Cerebral Blood Flow in Dementia Vladimir C. Hachinski, MD, FRCP(C); Linnette D. Iliff, M Phil, PhD; Elias Zilhka, M Sc; George H. Du Victor L. McAllister, MB, DMRD, FFR; John Marshall, MD, FRCP (Edin), FRCP (Lond), DPM; Ralph W. Ross Russell, MA, MD, DM, FRCP; Lindsay Symon, FRCS (Edin), FRCS (Eng)
\s=b\ Twenty-four patients of comparable age, blood pressure, and degree of dementia were classified by an "Ischemic Score" based on clinical features into "multi-infarct" and "primary degenerative" dementia. Regional cerebral blood flow (CBF) was measured by the intracarotid xenon 133 method. Both groups showed a decreased proportion of rapidly clearing brain tissue (largely gray matter). Cerebral blood flow per 100 gm brain per minute was normal in the primary degenerative group but low in the multi-infarct group. This suggests the blood flow is adequate for metabolic needs of the brain in patients with primary degenerative dementia but inadequate for those with multi-infarct dementia. There was no correlation between degree of dementia and CBF in the primary degenerative group but an inverse relationship existed in the multi-infarct group. Reactivity of blood vessels to reduction of arterial carbon dioxide pressure was normal in both groups. (Arch Neurol 32:632-637, 1975)
Accepted
for publication Oct 28, 1974. From the Institute of Neurology and National Hospitals for Nervous Diseases, Queen Square, London. Dr. Hachinski is now at Sunnybrook Hospital, Toronto. Reprint requests to Graham MacLachlan
Stroke Unit, Sunnybrook Hospital, University of Toronto Clinic, 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada (Dr. Hachinski).
life expectancy in countries together with a low birth rate has greatly al¬ tered the age structure of population with a proportional increase in the older age groups. As a consequence, dementia, which affects many old people, has become an increasingly important medical and social prob¬ lem. It has been estimated that some 10% of people over the age of 65 years show some degree of organic de¬ mentia.1 Decrease in the total hemisphere blood flow in dementia of diverse ori¬ gin has been recognized since the 1950s.24 More recently, disturbance of regional blood flow, particularly in the frontal and temporal areas, has been emphasized.5·6 The present study is an attempt to relate the clinical type and severity of dementia to total hemisphere and regional cerebral blood flow (rCBF) and to study the re¬ activity of the cerebral blood vessels in this condition. Determination of the cause of de¬ mentia by clinical means is usually a simple matter in patients suffering the cerebral effect of trauma, tumors, syphilis, vitamin B,2 deficiency, and Huntington chorea. These diseases are, however, responsible for only a minority of cases; in the majority the underlying cause is obscure. The lat¬ ter fall into two main groups, which
increased Thedeveloped
Downloaded From: http://archneur.jamanetwork.com/ by a Monash University Library User on 07/18/2013
we
Boulay, MB, MRCP, FFR;
have labeled "multi-infarct" and
"primary degenerative." Pathological examination
of the
multi-infarct
group shows atherosclerotic disease of the vessels with multiple, small in-
farcts; the primary degenerative group is characterized by an excess of senile plaques and neurofibrillary tangles. Despite difficulties, there are cer¬
tain clinical features that enable a distinction to be made between the two groups, features that have been correlated with autopsy findings.7·8 It should be noted that no distinction can be made on grounds of age be¬ cause both multi-infarct and primary degenerative dementia may appear from the sixth decade onward. Sim¬ ilarly, there is no clear difference be¬ tween the primary degenerative de¬ mentia of the presenium (Alzheimer disease) and that of the senium (se¬ nile dementia) since both have the same pathological findings." Senile dementia must, however, be distin¬ guished from normal aging. While se¬ nile plaques and neurofibrillary tan¬ gles are found in both, the frequency of their occurrence distinguishes the two
groups.10·11 PATIENTS AND METHODS
Twenty-four patients (13 men and 11 women) were studied. The patients, who were living at home, were referred by psy-
chiatrists and others for investigation of the cause of dementia. Trauma, tumor, syphilis, vitamin BI2 deficiency, and Hunt¬ ington chorea as the causes of demen¬ tia were first excluded by the history, examination, and ancillary investigations including serological tests for syphilis, estimation of BI2, skull x-ray film, electroencephalogram, and brain scan. In one patient not included in the series a supratentorial tumor was found with the patient being much improved following surgery. Another patient had a small frontal subdural hematoma removed. When possible, the nature of the further investi¬ gation of angiography combined with mea8 (
O
< u.
°2 U
o
O
2
6
4
ISCHEMIC
8
IO
12
SCORE
Distribution of Ischemie Score: 4 and be¬ "primary degenerative de¬ and above "multi-infarct dementia." low labeled mentia"; 7
sûrement of rCBF was explained to the pa¬ tient and his consent obtained. When the patient was unable to appreciate the na¬ ture of the investigation, permission was obtained from the next of kin. Measurement of the degree of dementia is far from easy as so many aspects of ce¬ rebral function may be involved, many of which cannot be quantified. The main con¬ sequence of dementia, however, is im¬ paired ability to cope with the task of daily living. The degree of impairment was as¬ sessed by observation and by inquiry from the patient and relatives; one point was scored for each of a standard series of items, such as the ability to dress or to handle small change, that the patient was unable to perform (Table 1). This Dementia Score ranged from 0 to 27; the higher the score, the greater the degree of demen¬ tia.12 Other aspects of cerebral function mea¬ sured were general information, memory, and concentration. These were assessed by a standard series of tests, one point being awarded for each test satisfactorily com¬ pleted (Table 2). This Information Score has a range of from 0 to 37; the higher the score, the less the degree of dementia.12 To distinguish multi-infarct from pri¬ mary degenerative dementia clinically, we devised an Ischemie Score based on crite-
Table 1.—Dementia Score Feature
Changes in Performance of Everyday Activities perform household tasks
1. Inability to 2. Inability to cope with small sums of money 3. Inability to remember short list of items, eg, in shopping 4. Inability to find way about indoors 5. Inability to find way about familiar streets 6. Inability to interpret surroundings 7. Inability to recall recent events 8. Tendency to dwell in the past_ Changes in Habits 9. Eating
Messily with spoon only
1 1 1 1 1 1
1 1
1
Simple solids, eg, biscuits
2 3
Occasionally misplaced buttons, etc Wrong sequence, commonly forgetting items
1 2 3
Has to be fed 10. Dressing
Unable to dress 11. Sphincter control Occasional wet beds
Frequent wet beds Doubly incontinent Increased rigidity
12. 13. Increased egocentricity
Impairment of regard for feelings of others Coarsening of affect Impairment of emotional control Hilarity in inappropriate situations 18. Diminished emotional responsiveness 19. Sexual misdemeanor (appearing de novo in old age) 20. Hobbies relinquished 21. Diminished initiative or growing apathy 14.
15. 16. 17.
22.
Score
Purposeless
hyperactivity_
1 2 3 1 1 1 1 1 1 1 1 1 1 1
ria outlined by Mayer-Gross et al13 (Table 3). Features such as an acute onset, focal neurological signs, relative preservation of personality, and lability of mood, have
been shown
by clinicopathological studies changes in
to correlate well with ischemie
the brain. Each of a standard list of fea¬ present was scored positively by one of us (V.C.H.) so that the higher the score the greater was the probability of ischemie dementia. All medication was discontinued in the few patients who were receiving tures
drugs prior Regional
to
testing.
cerebral blood flow studies
made immediately prior to angiogra¬ phy with both being performed with the patient under the same general anesthetic. A short-acting barbiturate was used for were
induction and anesthesia was maintained by nitrous oxide and oxygen supplemented by neuroleptanalgesia.14 Regional cerebral blood flow was studied in 15 regions by the intracarotid xenon 133 injection method with the counting geometry arranged to obtain a high degree of collimation.15 The results from the 15 areas were processed by computer and averaged to give mean hemisphere flow. When determining the regional pattern of flow, the result in any area was only deemed abnormal when it differed by 3.3 standard deviations from the value of the equivalent area in a group of controls. The blood flow variables measured were as follows: Ff, flow through fast-clearing tissue, mainly gray matter; Fs, flow through slow-clearing tissue, mainly white matter; Wf, the portion of tissue clearing at the fast rate; F initial, flow measured from the slope of the first two minutes of the logarithmically displayed isotope clear¬ ance curve; F, weighted mean flow calcu¬ lated from the proportion of fast- and slow-clearing tissues and their respective flow rates. These are presented in the ta¬ bles in milliliters per 100 gm per minute at the arterial carbon dioxide pressure (Paco2) at which the measurement was made. Intracarotid arterial blood pressure and PacOj were measured at intervals throughout the procedure. In 17 patients, two 15 minute rCBF studies were per¬ formed, the first at normocapnia and the second at hypocapnia at least 9 mm Hg be¬ low the Paco2 at normocapnia. From these data the cerebrovascular reactivity to changing levels of Paco2 was estimated. The mean arterial blood pressure at nor¬ mocapnia varied between 80 and 125 mm Hg and did not change by more than 15 mm Hg with hypocapnia. In three patients not included in the series a preliminary film of the carotid bi¬ furcation showed substantial atheroscle¬ rosis so the study was abandoned. We re-
Downloaded From: http://archneur.jamanetwork.com/ by a Monash University Library User on 07/18/2013
gard
visualization of the bifurcation, before attempting to advance the catheter into the internal carotid in those patients with atherosclerosis, as an important pre¬ caution.
RESULTS
Application of the Ischemie Score patients fell clearly into two groups without any overlap (Fig¬ ure). Ten patients scoring 7 and above (mean, 8.1) were classed as hav¬ ing multi-infarct dementia and 14 pa¬ tients scoring 4 and below (mean, 2.3) were labeled as having primary degen¬ erative dementia. Details are given in Tables 4 and 5, respectively, together showed the
with their Dementia and Information Scores and cerebral blood flow (CBF)
results. The means of both the De¬ mentia and Information Scores did not differ significantly between the two groups, indicating that they were impaired to the same degree. Sim¬ ilarly, there was no significant differ¬ ence in the mean blood pressure. Mean Hemisphere Cerebral Blood Flow
The various parameters for mean hemisphere flow and for the propor¬ tion of fast- and slow-clearing tissue for each group of dementia in com¬ parison with controls are given in Table 6. The patients with multi-in¬ farct dementia show a significant de¬ crease in all CBF variables except Fs. By contrast, the patients with pri¬ mary degenerative dementia showed no significant decrease in flow.
Regional
Cerebral Blood Flow
The areas of abnormal flow present in each group of patients were marked on two skull outlines that showed the position of the detectors. Both groups had scattered areas of low flow together with a concentra¬ tion of low flow areas, particularly Fs, in the temporal lobe. In three pa¬ tients in the multi-infarct group, the site of the focal abnormalities could be related to persisting clinical de¬ fects such as hemiparesis. In all of these patients the angiograms showed early filling veins suggesting a recent cerebral infarct. Two other patients in the vascular group showed evidence of small vessel disease.
Table
2.—Information-Memory-Concentration Test Score
Feature
Information Name Time (hour) Time of day Day of week Date Month Season Year Place Name Street Town Type of place
(eg, home, hospital) Recognition of persons (cleaner, physician, nurse, patient, relative) Memory Personal Date of birth Place of birth School attended
Occupation Name of siblings Name of wife Name of any town where patient worked Name of employers
Nonpersonal
Date of World War I Date of World War II Name of monarch Name of Prime Minister Name and address (five-minute recall) Mr. John Brown, 42 West St, Gateshead Concentration Months of years backwards Counting from 1 to 20 Counting from 20 to 1
Areas of high flow were seen in both groups, particularly over the pri¬ mary motor and sensory areas. of Fast-Clearing Tissue (Wf)
Proportion
proportion of fast-clearing tis¬ significantly reduced in both groups (Table 6). When rCBF mea¬ The
sue was
done at two levels of Paco, there was a further decrease in the value of Wf with hypocapnia. This latter phenomenon has also been shown in a group of cerebrovascular patients by Iliff et al.16 surements
were
Cerebrovascular Reactivity
Cerebrovascular C02 reactivity was tested in most patients but not all. The percent change in mean hemi-
Downloaded From: http://archneur.jamanetwork.com/ by a Monash University Library User on 07/18/2013
Table 3.—Ischemie Score Feature
Abrupt onset Stepwise deterioration Fluctuating
course
Nocturnal confusion Relative preservation of personality
Depression
Somatic complaints Emotional incontinence History of hypertension History of strokes Evidence of associated atherosclerosis Focal neurological symptoms Focal neurological signs
Score 2 1 2 1
1 1 1 1 1 2 1 2 2
sphere flow in response to hypocapnia for nine patients from the multi-in¬ farct group and eight patients from the primary degenerative group is
Table 4.—Results in the Multi-infarct
Group Blood Flow Variables,
Patient
No./
Dementia Score 12 17 16 12 13
Age, yr
1/71 2/64 3/67 4/67 5/68 6/63 7/61 8/66 9/45 10/60
Information Score
Ischemie Score
Mean BP, mm Hg
26
125 100 90 93 95 120 95 100 95 120 103.3 13.1
12 13
22 21
10
Mean 63
16 15.3
12.0 5.1
SD
8.1
7.9
ml/100 gm/min
Pac02< mm
Ff
Fs
64 64 61 29 58 68 38 64 92 57 59.5 17.0
14 22 20 10 19 22 15 23 22 19 18.6 4.3
Hg
45 48 41 39 41 43 40 44 47 41 42.9 3.0
F initial 40 40 41 39 49 28 47 71 41 41.4 14.6
Wf, 31 39 36 18 35 42 27 43 48 37 35.4
% 32 40 41 44 42 45 53 50 37 48 42.7 6.4
Primary Degenerative Group
Table 5.—Results in
Blood Flow Variables,
Page No./ Age, yr 1/60
Dementia Score
2/73
15 10
6/67
14
7/70
25
8/62 9/67 10/60 11/68 12/53 13/45
13
Score 17
Score
15
Mean BP, mm
77! Table
85 95 80 95 105 95
21 28 15 28 33 11 29
10
28
11.6
18.4
5.4
11.7
125 80 125 93 95 105 85 97.1 14.7
2.3
6.—Comparison of Mean Hemisphere Multi-
Variables No. of patients
Age, yr
Pac02, mm Hg Ff, ml/100 gm/min Fs, ml/100 gm/min ml/100 gm/min F, ml/100 gm/min Wf, % F initial,
Hg
90
~
Mean 62
"so
Ischemie
13 15
3/68 4/65 5/64
14/55
Information
Group
mm
Ff
Hg
77
49 41 38 43
41 42 47 44
43 46 42 42 51 45 43.5 3.2
49 39 51 93 43 101 172 64 101 61 117 123 64 83.9 38.7
Cerebral Blood Flow
Primary Degenerative
infarct
ml/100 gm/min
Paco2.
Group
10 63 43 60* 19 41* 36*
14 63 43 84
43t
42f
24
57 49
Controls 43 41 91 24 68 56 49
*P
\s=b\ Twenty-four patients of comparable age, blood pressure, and degree of dementia were classified by an "Ischemic Score" based on clinical features into "multi-infarct" and "primary degenerative" dementia. Regional cerebral blood flow (CBF) was measured by the intracarotid xenon 133 method. Both groups showed a decreased proportion of rapidly clearing brain tissue (largely gray matter). Cerebral blood flow per 100 gm brain per minute was normal in the primary degenerative group but low in the multi-infarct group. This suggests the blood flow is adequate for metabolic needs of the brain in patients with primary degenerative dementia but inadequate for those with multi-infarct dementia. There was no correlation between degree of dementia and CBF in the primary degenerative group but an inverse relationship existed in the multi-infarct group. Reactivity of blood vessels to reduction of arterial carbon dioxide pressure was normal in both groups. (Arch Neurol 32:632-637, 1975)
Accepted
for publication Oct 28, 1974. From the Institute of Neurology and National Hospitals for Nervous Diseases, Queen Square, London. Dr. Hachinski is now at Sunnybrook Hospital, Toronto. Reprint requests to Graham MacLachlan
Stroke Unit, Sunnybrook Hospital, University of Toronto Clinic, 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada (Dr. Hachinski).
life expectancy in countries together with a low birth rate has greatly al¬ tered the age structure of population with a proportional increase in the older age groups. As a consequence, dementia, which affects many old people, has become an increasingly important medical and social prob¬ lem. It has been estimated that some 10% of people over the age of 65 years show some degree of organic de¬ mentia.1 Decrease in the total hemisphere blood flow in dementia of diverse ori¬ gin has been recognized since the 1950s.24 More recently, disturbance of regional blood flow, particularly in the frontal and temporal areas, has been emphasized.5·6 The present study is an attempt to relate the clinical type and severity of dementia to total hemisphere and regional cerebral blood flow (rCBF) and to study the re¬ activity of the cerebral blood vessels in this condition. Determination of the cause of de¬ mentia by clinical means is usually a simple matter in patients suffering the cerebral effect of trauma, tumors, syphilis, vitamin B,2 deficiency, and Huntington chorea. These diseases are, however, responsible for only a minority of cases; in the majority the underlying cause is obscure. The lat¬ ter fall into two main groups, which
increased Thedeveloped
Downloaded From: http://archneur.jamanetwork.com/ by a Monash University Library User on 07/18/2013
we
Boulay, MB, MRCP, FFR;
have labeled "multi-infarct" and
"primary degenerative." Pathological examination
of the
multi-infarct
group shows atherosclerotic disease of the vessels with multiple, small in-
farcts; the primary degenerative group is characterized by an excess of senile plaques and neurofibrillary tangles. Despite difficulties, there are cer¬
tain clinical features that enable a distinction to be made between the two groups, features that have been correlated with autopsy findings.7·8 It should be noted that no distinction can be made on grounds of age be¬ cause both multi-infarct and primary degenerative dementia may appear from the sixth decade onward. Sim¬ ilarly, there is no clear difference be¬ tween the primary degenerative de¬ mentia of the presenium (Alzheimer disease) and that of the senium (se¬ nile dementia) since both have the same pathological findings." Senile dementia must, however, be distin¬ guished from normal aging. While se¬ nile plaques and neurofibrillary tan¬ gles are found in both, the frequency of their occurrence distinguishes the two
groups.10·11 PATIENTS AND METHODS
Twenty-four patients (13 men and 11 women) were studied. The patients, who were living at home, were referred by psy-
chiatrists and others for investigation of the cause of dementia. Trauma, tumor, syphilis, vitamin BI2 deficiency, and Hunt¬ ington chorea as the causes of demen¬ tia were first excluded by the history, examination, and ancillary investigations including serological tests for syphilis, estimation of BI2, skull x-ray film, electroencephalogram, and brain scan. In one patient not included in the series a supratentorial tumor was found with the patient being much improved following surgery. Another patient had a small frontal subdural hematoma removed. When possible, the nature of the further investi¬ gation of angiography combined with mea8 (
O
< u.
°2 U
o
O
2
6
4
ISCHEMIC
8
IO
12
SCORE
Distribution of Ischemie Score: 4 and be¬ "primary degenerative de¬ and above "multi-infarct dementia." low labeled mentia"; 7
sûrement of rCBF was explained to the pa¬ tient and his consent obtained. When the patient was unable to appreciate the na¬ ture of the investigation, permission was obtained from the next of kin. Measurement of the degree of dementia is far from easy as so many aspects of ce¬ rebral function may be involved, many of which cannot be quantified. The main con¬ sequence of dementia, however, is im¬ paired ability to cope with the task of daily living. The degree of impairment was as¬ sessed by observation and by inquiry from the patient and relatives; one point was scored for each of a standard series of items, such as the ability to dress or to handle small change, that the patient was unable to perform (Table 1). This Dementia Score ranged from 0 to 27; the higher the score, the greater the degree of demen¬ tia.12 Other aspects of cerebral function mea¬ sured were general information, memory, and concentration. These were assessed by a standard series of tests, one point being awarded for each test satisfactorily com¬ pleted (Table 2). This Information Score has a range of from 0 to 37; the higher the score, the less the degree of dementia.12 To distinguish multi-infarct from pri¬ mary degenerative dementia clinically, we devised an Ischemie Score based on crite-
Table 1.—Dementia Score Feature
Changes in Performance of Everyday Activities perform household tasks
1. Inability to 2. Inability to cope with small sums of money 3. Inability to remember short list of items, eg, in shopping 4. Inability to find way about indoors 5. Inability to find way about familiar streets 6. Inability to interpret surroundings 7. Inability to recall recent events 8. Tendency to dwell in the past_ Changes in Habits 9. Eating
Messily with spoon only
1 1 1 1 1 1
1 1
1
Simple solids, eg, biscuits
2 3
Occasionally misplaced buttons, etc Wrong sequence, commonly forgetting items
1 2 3
Has to be fed 10. Dressing
Unable to dress 11. Sphincter control Occasional wet beds
Frequent wet beds Doubly incontinent Increased rigidity
12. 13. Increased egocentricity
Impairment of regard for feelings of others Coarsening of affect Impairment of emotional control Hilarity in inappropriate situations 18. Diminished emotional responsiveness 19. Sexual misdemeanor (appearing de novo in old age) 20. Hobbies relinquished 21. Diminished initiative or growing apathy 14.
15. 16. 17.
22.
Score
Purposeless
hyperactivity_
1 2 3 1 1 1 1 1 1 1 1 1 1 1
ria outlined by Mayer-Gross et al13 (Table 3). Features such as an acute onset, focal neurological signs, relative preservation of personality, and lability of mood, have
been shown
by clinicopathological studies changes in
to correlate well with ischemie
the brain. Each of a standard list of fea¬ present was scored positively by one of us (V.C.H.) so that the higher the score the greater was the probability of ischemie dementia. All medication was discontinued in the few patients who were receiving tures
drugs prior Regional
to
testing.
cerebral blood flow studies
made immediately prior to angiogra¬ phy with both being performed with the patient under the same general anesthetic. A short-acting barbiturate was used for were
induction and anesthesia was maintained by nitrous oxide and oxygen supplemented by neuroleptanalgesia.14 Regional cerebral blood flow was studied in 15 regions by the intracarotid xenon 133 injection method with the counting geometry arranged to obtain a high degree of collimation.15 The results from the 15 areas were processed by computer and averaged to give mean hemisphere flow. When determining the regional pattern of flow, the result in any area was only deemed abnormal when it differed by 3.3 standard deviations from the value of the equivalent area in a group of controls. The blood flow variables measured were as follows: Ff, flow through fast-clearing tissue, mainly gray matter; Fs, flow through slow-clearing tissue, mainly white matter; Wf, the portion of tissue clearing at the fast rate; F initial, flow measured from the slope of the first two minutes of the logarithmically displayed isotope clear¬ ance curve; F, weighted mean flow calcu¬ lated from the proportion of fast- and slow-clearing tissues and their respective flow rates. These are presented in the ta¬ bles in milliliters per 100 gm per minute at the arterial carbon dioxide pressure (Paco2) at which the measurement was made. Intracarotid arterial blood pressure and PacOj were measured at intervals throughout the procedure. In 17 patients, two 15 minute rCBF studies were per¬ formed, the first at normocapnia and the second at hypocapnia at least 9 mm Hg be¬ low the Paco2 at normocapnia. From these data the cerebrovascular reactivity to changing levels of Paco2 was estimated. The mean arterial blood pressure at nor¬ mocapnia varied between 80 and 125 mm Hg and did not change by more than 15 mm Hg with hypocapnia. In three patients not included in the series a preliminary film of the carotid bi¬ furcation showed substantial atheroscle¬ rosis so the study was abandoned. We re-
Downloaded From: http://archneur.jamanetwork.com/ by a Monash University Library User on 07/18/2013
gard
visualization of the bifurcation, before attempting to advance the catheter into the internal carotid in those patients with atherosclerosis, as an important pre¬ caution.
RESULTS
Application of the Ischemie Score patients fell clearly into two groups without any overlap (Fig¬ ure). Ten patients scoring 7 and above (mean, 8.1) were classed as hav¬ ing multi-infarct dementia and 14 pa¬ tients scoring 4 and below (mean, 2.3) were labeled as having primary degen¬ erative dementia. Details are given in Tables 4 and 5, respectively, together showed the
with their Dementia and Information Scores and cerebral blood flow (CBF)
results. The means of both the De¬ mentia and Information Scores did not differ significantly between the two groups, indicating that they were impaired to the same degree. Sim¬ ilarly, there was no significant differ¬ ence in the mean blood pressure. Mean Hemisphere Cerebral Blood Flow
The various parameters for mean hemisphere flow and for the propor¬ tion of fast- and slow-clearing tissue for each group of dementia in com¬ parison with controls are given in Table 6. The patients with multi-in¬ farct dementia show a significant de¬ crease in all CBF variables except Fs. By contrast, the patients with pri¬ mary degenerative dementia showed no significant decrease in flow.
Regional
Cerebral Blood Flow
The areas of abnormal flow present in each group of patients were marked on two skull outlines that showed the position of the detectors. Both groups had scattered areas of low flow together with a concentra¬ tion of low flow areas, particularly Fs, in the temporal lobe. In three pa¬ tients in the multi-infarct group, the site of the focal abnormalities could be related to persisting clinical de¬ fects such as hemiparesis. In all of these patients the angiograms showed early filling veins suggesting a recent cerebral infarct. Two other patients in the vascular group showed evidence of small vessel disease.
Table
2.—Information-Memory-Concentration Test Score
Feature
Information Name Time (hour) Time of day Day of week Date Month Season Year Place Name Street Town Type of place
(eg, home, hospital) Recognition of persons (cleaner, physician, nurse, patient, relative) Memory Personal Date of birth Place of birth School attended
Occupation Name of siblings Name of wife Name of any town where patient worked Name of employers
Nonpersonal
Date of World War I Date of World War II Name of monarch Name of Prime Minister Name and address (five-minute recall) Mr. John Brown, 42 West St, Gateshead Concentration Months of years backwards Counting from 1 to 20 Counting from 20 to 1
Areas of high flow were seen in both groups, particularly over the pri¬ mary motor and sensory areas. of Fast-Clearing Tissue (Wf)
Proportion
proportion of fast-clearing tis¬ significantly reduced in both groups (Table 6). When rCBF mea¬ The
sue was
done at two levels of Paco, there was a further decrease in the value of Wf with hypocapnia. This latter phenomenon has also been shown in a group of cerebrovascular patients by Iliff et al.16 surements
were
Cerebrovascular Reactivity
Cerebrovascular C02 reactivity was tested in most patients but not all. The percent change in mean hemi-
Downloaded From: http://archneur.jamanetwork.com/ by a Monash University Library User on 07/18/2013
Table 3.—Ischemie Score Feature
Abrupt onset Stepwise deterioration Fluctuating
course
Nocturnal confusion Relative preservation of personality
Depression
Somatic complaints Emotional incontinence History of hypertension History of strokes Evidence of associated atherosclerosis Focal neurological symptoms Focal neurological signs
Score 2 1 2 1
1 1 1 1 1 2 1 2 2
sphere flow in response to hypocapnia for nine patients from the multi-in¬ farct group and eight patients from the primary degenerative group is
Table 4.—Results in the Multi-infarct
Group Blood Flow Variables,
Patient
No./
Dementia Score 12 17 16 12 13
Age, yr
1/71 2/64 3/67 4/67 5/68 6/63 7/61 8/66 9/45 10/60
Information Score
Ischemie Score
Mean BP, mm Hg
26
125 100 90 93 95 120 95 100 95 120 103.3 13.1
12 13
22 21
10
Mean 63
16 15.3
12.0 5.1
SD
8.1
7.9
ml/100 gm/min
Pac02< mm
Ff
Fs
64 64 61 29 58 68 38 64 92 57 59.5 17.0
14 22 20 10 19 22 15 23 22 19 18.6 4.3
Hg
45 48 41 39 41 43 40 44 47 41 42.9 3.0
F initial 40 40 41 39 49 28 47 71 41 41.4 14.6
Wf, 31 39 36 18 35 42 27 43 48 37 35.4
% 32 40 41 44 42 45 53 50 37 48 42.7 6.4
Primary Degenerative Group
Table 5.—Results in
Blood Flow Variables,
Page No./ Age, yr 1/60
Dementia Score
2/73
15 10
6/67
14
7/70
25
8/62 9/67 10/60 11/68 12/53 13/45
13
Score 17
Score
15
Mean BP, mm
77! Table
85 95 80 95 105 95
21 28 15 28 33 11 29
10
28
11.6
18.4
5.4
11.7
125 80 125 93 95 105 85 97.1 14.7
2.3
6.—Comparison of Mean Hemisphere Multi-
Variables No. of patients
Age, yr
Pac02, mm Hg Ff, ml/100 gm/min Fs, ml/100 gm/min ml/100 gm/min F, ml/100 gm/min Wf, % F initial,
Hg
90
~
Mean 62
"so
Ischemie
13 15
3/68 4/65 5/64
14/55
Information
Group
mm
Ff
Hg
77
49 41 38 43
41 42 47 44
43 46 42 42 51 45 43.5 3.2
49 39 51 93 43 101 172 64 101 61 117 123 64 83.9 38.7
Cerebral Blood Flow
Primary Degenerative
infarct
ml/100 gm/min
Paco2.
Group
10 63 43 60* 19 41* 36*
14 63 43 84
43t
42f
24
57 49
Controls 43 41 91 24 68 56 49
*P
