Faculty Bibliography

Despite the emergence of a number of new classification systems, the diagnosis of cerebrovascular dementia remains controversial. Also controversial is the significance of periventricular and deep white matter alterations (WMA) as seen on magnetic resonance imaging (MRI). To further clarify this issue, MRI scans were used to regroup patients clinically diagnosed with Alzheimer's disease (AD) or subcortical ischemic vascular dementia (IVD) into cohorts presenting with either little versus significant WMA on MRI. These two groups were then compared to demented patients diagnosed with idiopathic Parkinson's disease (PD) using a comprehensive neuropsychological protocol. Neuropsychological assessment failed to distinguish between patients with PD and significant WMA. By contrast, both of these patient groups exhibited disproportionate impairment on tests of executive systems functioning, whereas patients with little WMA showed greater impairment on tests of declarative memory and semantic knowledge. These findings constitute further evidence that the pattern of cognitive impairment associated with significant WMA is distinctly different when compared to AD. These results are discussed within the context of a growing body of literature suggesting that elements of the underlying neuropathologies in AD and IVD are linked. Implications for the diagnosis of dementia are also discussed

In contrast to routine flexor tendon injuries, flexor tendon ruptures following blunt injury or re-ruptures following repair can be difficult to diagnose. The authors investigated the efficacy of using ultrasound to assist in the diagnosis. From 1996 to 1997, 8 patients underwent evaluation of the flexor tendons using an ATL HDI-3000 ultrasound machine with a high-resolution, 5 to 9-MHz hockey stick linear probe. Dynamic evaluation was performed in real time, simulating clinical symptoms. Six patients underwent surgical exploration. Sonographic diagnosis and intraoperative findings were correlated. Ultrasound was used to diagnose 3 patients with ruptured flexor digitorum profundus tendons. Mechanisms of injury included forceful extension, penetrating injury, and delayed rupture 3 weeks after tendon repair. Subsequent surgical exploration confirmed the ruptures and location of the stumps. Five patients had intact flexor tendons by ultrasound after forceful extension, penetrating injury, phalangeal fracture, crush injury, and unknown etiology. In 3 patients who underwent surgery for tenolysis, scar release, or arthrodesis, the flexor tendons were found to be intact, as predicted by ultrasound. The authors found ultrasound to be accurate in diagnosing the integrity of flexor tendons and in localizing the ruptured ends. They conclude that ultrasound is helpful in evaluating equivocal flexor tendon injuries

This research investigated whether subjects with Alzheimer's disease (AD) and ischaemic vascular dementia (IVD) associated with periventricular and deep white matter alterations can be dissociated on tests of declarative and procedural memory, as well as on MRI indices of white matter alterations and the size of the hippocampal formation. The California Verbal Learning Test (CVLT) and the Pursuit Rotor Learning Tests (PRLT) were used to measure declarative and procedural memory, respectively. Subjects with IVD obtained a higher score on the CVLT recognition discriminability index; however, on the PRLT total time on target, carry-over between trial blocks, and slope calculated for all test trials was low. Subjects with AD exhibited the opposite profile. MRI studies indicated that subjects with IVD had considerably greater white matter alterations, but larger hippocampal formations than subjects with AD. Higher scores on the CVLT recognition discriminability index were correlated with increased size of the body of the hippocampus and parahippocampal gyrus. By contrast, as the severity of white matter alterations increased the slope on the PRLT declined. In sum, subjects with AD and IVD can be dissociated on the basis of differing patterns of impairment on tests of declarative and procedural memory, and MRI indices of white matter alteration and the integrity of the hippocampal formation

This research examined the neuropsychological functioning of demented patients with periventricular and deep white matter alterations. Thirty-three outpatients with NINCDS-ADRDA probable Alzheimer's disease (AD) and 27 outpatients with probable/ possible ischaemic vascular dementia (IVD, Chui et al., 1992) associated with periventricular and deep white matter alterations matched for age, education, level of dementia, and functional disability were studied. White matter alterations were measured using a 40-point scale previously described by Junque et al. (1990). Subjects with cortical CVAs were excluded. On executive control tests, IVD subjects made more preservations on tests of mental control and response set, and produced fewer responses on phonemic controlled oral word association tests (letters: F,A,S). IVD subjects also made more preservations and graphomotor errors on clock drawings. On the California Verbal Learning Test the IVD group performed better than AD subjects on the short delay free recall test condition, the recognition discriminability index, and made fewer intrusion errors on both free and cued recall conditions. We conclude that neuropsychological assessment can differentiate AD from IVD associated with white matter alterations, and that the neuropsychological profile of demented subjects with significant periventricular and deep white matter alterations is similar to other subcortical dementing illnesses

The case of a 64-year-old white man with acquired immunodeficiency syndrome and ruptured abdominal aortic aneurysm infected with Salmonella is presented. Five points related to this case are addressed. It is feared that the vascular surgeon may face patients with acquired immunodeficiency syndrome and abdominal aortic aneurysms infected with Salmonella with increasing frequency in the future. This case raises medical, ethical, and moral questions