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Specificity of Changes in Cerebral Blood Flow in J Neurol Neurosurg Psychiatry: First Published As 10.1136/Jnnp.57.7.790 on 1 July 1994 7907tournal ofNeurology, Neurosurgery, and Psychiatry 1994;57:790-796 Specificity of changes in cerebral blood flow in J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.57.7.790 on 1 July 1994. Downloaded from patients with frontal lobe dementia Sergio E Starkstein, Ricardo Migliorelli, Alejandra Teson, Liliana Sabe, Silvia Vazquez, Martin Turjanski, Robert G Robinson, Ramon Leiguarda Abstract ideas, distractibility, psychomotor agitation, Eight patients with a clinical diagnosis of and excessive involvement in pleasurable probable Alzheimer's disease, eight activities that have a high potential for painful patients with the clinical diagnosis of results. frontal lobe dementia, and eight controls In a consecutive series of patients admitted were examined with single photon emis- to a psychiatric unit with the diagnosis of sion tomography (SPECT) using "Tc- mania after a brain injury (stroke, tumour, or HMPAO. Patients with Alzheimer's closed head injury) we found a high frequency disease and those with frontal lobe of lesions involving the orbitofrontal cortex, dementia met DSM-III-R criteria for anterior temporal cortex, head of the caudate, mild dementia and were in the early and thalamus.5 In a recent study that included stages of the iflness. Compared with a new series of seven consecutive patients with patients with Alzheimer's disease, the mania after brain injury, four had lesions group with frontal lobe dementia had sig- involving the orbitofrontal or anterior temporal nificantly lower blood flow in the frontal cortex, and the remaining three patients had lobes (dorsolateral and orbital), the ante- single ischaemic lesions involving the right rior temporal cortex, and the basal gan- head of the caudate and the internal capsule.6 glia. Within the frontal lobe dementia A PET study with '8F-fluorodeoxyglucose group, blood flow was significantly lower (18FDG) showed significant hypometabolic in the orbital than in the dorsal frontal activity in the ipsilateral anterior temporal cortex, and in the anterior temporal than cortex in all three patients. Taken together, in the dorsal temporal cortex. The pre- these findings suggest that disinhibited behav- sent study shows the specificity of iour in patients with brain lesions may result changes in regional cerebral blood flow in from (direct or indirect) damage to the the diagnosis of different types of demen- orbitofrontal and anterior temporal cortices. tia, and supports the importance of It is possible that similar changes may underlie orbitofrontal, anterior temporal, and the psychiatric disturbances of patients with basal ganglia dysfunction in the produc- frontal lobe dementia, as recent studies have Department of tion of the psychiatric syndrome of shown significantly decreased blood flow in frontal lobe dementia. the frontal lobe of patients with a clinical diag- Behavioural http://jnnp.bmj.com/ Neurology nosis of frontal lobe dementia.7-'0 Whether S E Starkstein in cerebral blood flow R Migliorelli (J Neurol Neurosurg Psychiatry 1994;57:790-796) these changes pertain A Tes6n to the disinhibition syndrome of frontal lobe L Sabe dementia, however, rather than the cognitive Department of impairment of this disorder, and whether Nuclear Medicine Neary and coworkers described frontal lobe there are specific areas within the frontal lobes S E Starkstein S Vazquez dementia as a degenerative condition charac- that show blood flow deficits related to the M Turjanski terised by changes in personality, breakdown behavioural change has not, to our know- on September 25, 2021 by guest. Protected copyright. R Leiguarda in social conduct, disinhibition, impulsivity, ledge, been empirically examined. Department of unconcern, changes in eating conduct (hyper- For the present study we included a series Clinical Neurology of with mild dementia who also met Rasil Carrea Institute phagia), and stereotyped and perseverative patients of Neurological behaviour.' Disinhibited behaviour is often stringent criteria for disinhibited behaviour Research, Buenos found among patients with neurological disor- (the frontal lobe dementia group). To deter- Aires, Argentina ders such as closed head injuries and brain mine the severity, location, and specificity of S E Starkstein R Leiguarda tumours,2 and may manifest itself as motor blood flow deficits in frontal lobe dementia we matched control Department of disinhibition (for example, hyperactivity, pres- included both an age group Psychiatry, University sured speech, decreased need of sleep), intel- and a series of age matched patients with a of Iowa, Iowa City, lectual disinhibition (for example, flight of similar severity of dementia but no disinhibi- Iowa 52242, USA ideas, grandiose delusions, paranoia), and tion who met the National Institute of R G Robinson instinctive disinhibition (for example, hyper- Neurological and Communicative Disorder Correspondence to: Dr Sergio E Starkstein sexuality, hyperphagia).3 In some patients, and Stroke-Alzheimer's Disease and Related Department of Behavioural severe Disorders Association" criteria for probable Neurology, Raul Carrea disinhibited behaviour may be enough Institute of Neurological to fulfill DSM-III-R4 diagnostic criteria for Alzheimer's disease. Finally, to examine the Research, Ayacucho 2166, a of importance of ventral structures in the pro- 1 1 12 Buenos Aires, mania, which require distinct period Argentina. abnormally and persistently elevated, expan- duction of disinhibited behaviour, we com- Received 1 March 1993 sive, or irritable mood, and at least three of: pared blood flow changes in orbital v dorsal and in final revised form or decreased frontal areas, and anterior temporal v dorsal 2 September 1993. inflated self esteem grandiosity, Accepted 23 September 1993 need for sleep, pressured speech, flight of temporal areas. Specificity ofchanges in cerebral bloodflow in patients with frontal lobe dementia 791 Patients and methods on the Alzheimer's scale and >5 on the Pick's J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.57.7.790 on 1 July 1994. Downloaded from PATIENTS scale had a sensitivity and specificity of 100% Frontal lobe dementia group for the diagnosis of pathologically established The frontal lobe dementia group consisted of Pick's disease. On the other hand, scores <5 eight patients who met the following inclusion on the Pick's scale and >8 on the Alzheimer's criteria: (a) DSM-III-R diagnostic criteria for scale had a sensitivity and specificity of 100% mild dementia,4 (b) a score > 8 or more on for the diagnosis of pathologically established the Gustafson and Nilsson Pick scale,12 and a Alzheimer's disease. Thus in the present study score < 5 on the Gustafson and Nilsson patients included in the Alzheimer's group Alzheimer scale,'2 (c) no CT evidence of focal had a score < 5 on the Pick's scale and a score brain lesions, (d) normal results on routine >8 on the Alzheimer's scale, whereas patients laboratory tests, (e) a Hachinski ischaemic included in the frontal lobe dementia group score13 <5, and (f) no history of alcohol abuse had a score .5 on the Alzheimer's scale and or closed head injury. >8 on the Pick's scale (we decided to be more stringent on the Pick's scale score for the Alzheimer's disease group frontal lobe dementia group so as to maximise The Alzheimer's disease group consisted of the chance of including patients with severe eight patients who met the following inclusion disinhibition) (table 1). criteria: (a) DSM-III-R diagnostic criteria of mild dementia, (b) a score on the Gustafson NEUROPSYCHOLOGICAL EXAMINATION and Nilsson Alzheimer scale >8, and a score Patients with Alzheimer's disease and patients on the Gustafson and Nilsson Pick scale <5, with frontal lobe dementia had a comprehen- (c) no CT evidence of focal brain lesions, (d) sive neuropsychological evaluation that was normal laboratory tests, (e) a Hachinski carried out within two weeks of the SPECT Ischaemic score <5, and (f) no history of alco- study and included the following tasks: hol abuse or closed head injury. Wechsler adult intelligence scale-revised Control group (WAIS-R) The control group comprised four normal The WAIS-R is a measure of general intellec- volunteers from our Institute and four people tual ability. who complained of dizziness. All had a nor- mal brain CT, a normal neurological evalua- Wisconsin card sorting test tion, and no history of psychiatric disorders. This test measures the ability to develop new concepts and shift sets, and also requires the NEUROPSYCHIATRIC EXAMINATION subject to suppress a previously correct The neuropsychiatric evaluation consisted of response and produce a new one.'6 the following: Controlled word association test Mini-mental state examination (MMSE) This test examines access to semantic infor- The MMSE is an 11 item examination reli- mation with time constraint.'7 able and valid in assessing a limited range of functions.14 Trail making test http://jnnp.bmj.com/ cognitive This test examines visual, conceptual, and Gustafson and Nilsson rating scales for diagnosis visuomotor tracking.'8 ofAlzheimer's disease and Pick's disease Digit span This is a 16 item scale that scores the fre- This test examines auditory attention.'9 quency of intellectual deficits (early amnesia, early disorientation, apraxia, aphasia, and Buschke selective reminding test motor signs muscular agnosia), (increased This test measures verbal learning and mem- on September 25, 2021 by guest. 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