379
ANZJP Correspondence
Communicating hydrocephalus with reversible cognitive impairment Brad Hayhow1,2, Firuz Begic2, Andrew Evans3, Dennis Velakoulis1,2 and Frank Gaillard4 1Melbourne
Neuropsychiatry Centre, University of Melbourne and Melbourne Health, Parkville, Australia 2Neuropsychiatry Unit, Royal Melbourne Hospital, Parkville, Australia 3Department of Neurology, Royal Melbourne Hospital, Parkville, Australia 4Department of Radiology, Royal Melbourne Hospital, Parkville, Australia Corresponding author: Brad Hayhow, Level 2, John Cade Building, Royal Melbourne Hospital, Parkville, VIC 3050, Australia. Email: [email protected] DOI: 10.1177/0004867413511547
To the Editor
On magnetic resonance imaging (MRI), a T2-weighted midline sagittal image (Figure 1A) demonstrated a prominent flow void in the aqueduct of Sylvius (arrow) and outward bowing of the supraoptic and infundibular recesses (star) of the third ventricle. In addition, the corpus callosum was upwardly bowed and the septum pellucidum fenestrated. T2-weighted axial (Figure 1B) and T1-weighted coronal (Figure 1C) images demonstrated characteristic ventriculomegaly with box-shaped frontal horns of the lateral ventricles. The patient proceeded promptly to surgery and a postoperative noncontrast computed tomo graphy (CT) scan demonstrated appropriate placement of a right occipitoparietal shunt (Figure 1D). Within a week of surgery, the patient demonstrated a significant improvement in continence, mobility
and cognition, with normalization of visual construction, memory and executive function. While ventriculoperitoneal shunting does not always improve the clinical syndrome associated with idiopathic NPH, the presence of an increased cerebrospinal fluid (CSF) stroke volume and aqueductal flow void on MRI may predict a favourable outcome (Bradley et al., 1996). Other predictors may include shorter duration of illness (Caruso et al., 1997) and a temporary symptomatic response to the removal of 40 mL CSF by lumbar puncture (Sand et al., 1994). The appropriate assessment and treatment of this patient averted both a misdiagnosis of young-onset dementia and premature nursing home placement, demonstrating the utility of seeking potentially reversible causes of neuro-cognitive
Figure 1. MRI and CT Brain.
A 54-year-old woman with a 13-year history of bipolar affective disorder presented with a 3-year history of urinary incontinence, falls and progressive short-term memory impairment. There was no history of head injury. On mental state examination she presented as mildly disheveled with a ‘magnetic’ wide-based gait. Although she exhibited some psychomotor slowing, her mood was euthymic and there was no evidence of thought disorder or hallucinations. Her speech was prosodic and in conversation she was appropriately concerned about the looming threat of nursing home placement. Following bedside cognitive testing she demonstrated impairments of attention, visual construction, memory and executive function. Language function was unimpaired. Except for her gait, her neurological examination was unremarkable and a differential diagnosis of idiopathic normal pressure hydrocephalus (NPH) was proposed. Australian & New Zealand Journal of Psychiatry, 48(4)
Downloaded from anp.sagepub.com at UNIV OF ILLINOIS URBANA on March 9, 2015
380 impairment and avoiding the attribution of functional decline to mental illness in an otherwise well-treated individual. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Synaesthesia, reflex hallucinations and Mitempfindung - one of the same or different entities? Birinder Narang1, Rohan Dhillon1,2, Prashant Tibrewal1,2 and Liz Coventry1 1The
Queen Elizabeth Hospital, Adelaide, Australia 2The University of Adelaide, Adelaide, Australia Corresponding author: Birinder Narang, Cramond Clinic, The Queen Elizabeth Hospital, 28 Woodville Road, Adelaide, SA 5011, Australia. Email: [email protected] DOI: 10.1177/0004867413512689
To the Editor Synaesthesia, first reported in the late 19th century, consists of a stimulation in one sensory pathway leading to perceptual experiences in a second sensory pathway (Hubbard and Ramachandran, 2005). Another similar phenomenology previously identified yet poorly defined was reflex hallucinations. Cutting (1997) described reflex hallucinations as occurring when a precipitating stimulus was experienced in a different modality from that of the hallucination. A related phenomenology was Mitempfindung, which was described as a stimulus applied in one region of the body being felt as a tactile sensation in another region. A small study
ANZJP Correspondence Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Bradley WG, Scalzo D, Queralt J, et al. (1996) Normal-pressure hydrocephalus: Evaluation with cerebrospinal fluid flow measurements at MR imaging. Radiology 198: 523–529.
of 20 digit-colour synaesthetes found that Mitempfindung was reported in 40% of synaesthetes with only 10% reported incidence in two matched control groups. The authors of this study presented multiple similarities between synaesthesia and Mitem pfindung (Burrack et al., 2006). The various terms used in the psychiatric literature to report such overlapping phenomenon was confusing because historical descriptions have not caught up with research findings. We present a case highlighting these complexities and provide discussion about how these various terms can be better understood utilizing modern nomenclature. Ms AT is a 38-year-old woman with a schizoaffective disorder – bipolar type. Her recent admission was the result of an acute psychotic relapse. At admission she complained of an ongoing vibrating sensation in her genitalia caused by her mother opening and shutting doors and by the sound of her clicking her nails. Her psychosis improved with a short course of electroconvulsive therapy (ECT), in conjunction with lithium and risperidone. Ms AT’s symptoms were a type of reflex hallucination. Having similarities with synaesthesia, these two phenomena might share more in common rather than be separate entities. We propose that synaesthesia, reflex hallucinations and Mitempfindung share their pathophysiological basis and fall within the same dimensional framework, with synaesthesia representing a non-morbid phenotype.
Caruso R, Cervoni L, Vitale AM, et al. (1997) Idiopathic normal-pressure hydrocephalus in adults: Results of shunting correlated with clinical findings in 18 patients and review of the literature. Neurosurgical Review 20: 104–110. Sand T, Bovim G, Grimse R, et al. (1994) Idiopathic normal pressure hydrocephalus: The CSF tap-test may predict the clinical response to shunting. Acta Neurologica Scandinavia 89: 311–316.
Even though Ms AT experiences did not represent Mitempfindung, the nature of the phenomenology shared some common ground with reflex hallucinations and synaesthesia. This case illustrates the potential confusion of various terms used in the literature; we propose that narrowing the definition may potentially lead to a further recognition and increased reporting of these unusual phenomena. It is possible that the presence of one might increase the probability of another in the same person. With further research in this area, a revised terminology and classification will emerge shedding new light on historical phenomenology that have been reported in clinical practice for over a century. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Burrack A, Knoch D and Brugger P (2006) Mitempfindung in synaesthetes: co-incidence or meaningful association? Cortex 42: 151–154. Cutting J (1997) Principles of Psychopathology: Two Worlds - Two Minds - Two Hemispheres. Oxford, England: Oxford Univeristy Press. Hubbard EM and Ramachandran VS (2005) Neurocognitive mechanisms of synesthesia. Neuron 48: 509–520.
Australian & New Zealand Journal of Psychiatry, 48(4) Downloaded from anp.sagepub.com at UNIV OF ILLINOIS URBANA on March 9, 2015
ANZJP Correspondence
Communicating hydrocephalus with reversible cognitive impairment Brad Hayhow1,2, Firuz Begic2, Andrew Evans3, Dennis Velakoulis1,2 and Frank Gaillard4 1Melbourne
Neuropsychiatry Centre, University of Melbourne and Melbourne Health, Parkville, Australia 2Neuropsychiatry Unit, Royal Melbourne Hospital, Parkville, Australia 3Department of Neurology, Royal Melbourne Hospital, Parkville, Australia 4Department of Radiology, Royal Melbourne Hospital, Parkville, Australia Corresponding author: Brad Hayhow, Level 2, John Cade Building, Royal Melbourne Hospital, Parkville, VIC 3050, Australia. Email: [email protected] DOI: 10.1177/0004867413511547
To the Editor
On magnetic resonance imaging (MRI), a T2-weighted midline sagittal image (Figure 1A) demonstrated a prominent flow void in the aqueduct of Sylvius (arrow) and outward bowing of the supraoptic and infundibular recesses (star) of the third ventricle. In addition, the corpus callosum was upwardly bowed and the septum pellucidum fenestrated. T2-weighted axial (Figure 1B) and T1-weighted coronal (Figure 1C) images demonstrated characteristic ventriculomegaly with box-shaped frontal horns of the lateral ventricles. The patient proceeded promptly to surgery and a postoperative noncontrast computed tomo graphy (CT) scan demonstrated appropriate placement of a right occipitoparietal shunt (Figure 1D). Within a week of surgery, the patient demonstrated a significant improvement in continence, mobility
and cognition, with normalization of visual construction, memory and executive function. While ventriculoperitoneal shunting does not always improve the clinical syndrome associated with idiopathic NPH, the presence of an increased cerebrospinal fluid (CSF) stroke volume and aqueductal flow void on MRI may predict a favourable outcome (Bradley et al., 1996). Other predictors may include shorter duration of illness (Caruso et al., 1997) and a temporary symptomatic response to the removal of 40 mL CSF by lumbar puncture (Sand et al., 1994). The appropriate assessment and treatment of this patient averted both a misdiagnosis of young-onset dementia and premature nursing home placement, demonstrating the utility of seeking potentially reversible causes of neuro-cognitive
Figure 1. MRI and CT Brain.
A 54-year-old woman with a 13-year history of bipolar affective disorder presented with a 3-year history of urinary incontinence, falls and progressive short-term memory impairment. There was no history of head injury. On mental state examination she presented as mildly disheveled with a ‘magnetic’ wide-based gait. Although she exhibited some psychomotor slowing, her mood was euthymic and there was no evidence of thought disorder or hallucinations. Her speech was prosodic and in conversation she was appropriately concerned about the looming threat of nursing home placement. Following bedside cognitive testing she demonstrated impairments of attention, visual construction, memory and executive function. Language function was unimpaired. Except for her gait, her neurological examination was unremarkable and a differential diagnosis of idiopathic normal pressure hydrocephalus (NPH) was proposed. Australian & New Zealand Journal of Psychiatry, 48(4)
Downloaded from anp.sagepub.com at UNIV OF ILLINOIS URBANA on March 9, 2015
380 impairment and avoiding the attribution of functional decline to mental illness in an otherwise well-treated individual. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Synaesthesia, reflex hallucinations and Mitempfindung - one of the same or different entities? Birinder Narang1, Rohan Dhillon1,2, Prashant Tibrewal1,2 and Liz Coventry1 1The
Queen Elizabeth Hospital, Adelaide, Australia 2The University of Adelaide, Adelaide, Australia Corresponding author: Birinder Narang, Cramond Clinic, The Queen Elizabeth Hospital, 28 Woodville Road, Adelaide, SA 5011, Australia. Email: [email protected] DOI: 10.1177/0004867413512689
To the Editor Synaesthesia, first reported in the late 19th century, consists of a stimulation in one sensory pathway leading to perceptual experiences in a second sensory pathway (Hubbard and Ramachandran, 2005). Another similar phenomenology previously identified yet poorly defined was reflex hallucinations. Cutting (1997) described reflex hallucinations as occurring when a precipitating stimulus was experienced in a different modality from that of the hallucination. A related phenomenology was Mitempfindung, which was described as a stimulus applied in one region of the body being felt as a tactile sensation in another region. A small study
ANZJP Correspondence Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Bradley WG, Scalzo D, Queralt J, et al. (1996) Normal-pressure hydrocephalus: Evaluation with cerebrospinal fluid flow measurements at MR imaging. Radiology 198: 523–529.
of 20 digit-colour synaesthetes found that Mitempfindung was reported in 40% of synaesthetes with only 10% reported incidence in two matched control groups. The authors of this study presented multiple similarities between synaesthesia and Mitem pfindung (Burrack et al., 2006). The various terms used in the psychiatric literature to report such overlapping phenomenon was confusing because historical descriptions have not caught up with research findings. We present a case highlighting these complexities and provide discussion about how these various terms can be better understood utilizing modern nomenclature. Ms AT is a 38-year-old woman with a schizoaffective disorder – bipolar type. Her recent admission was the result of an acute psychotic relapse. At admission she complained of an ongoing vibrating sensation in her genitalia caused by her mother opening and shutting doors and by the sound of her clicking her nails. Her psychosis improved with a short course of electroconvulsive therapy (ECT), in conjunction with lithium and risperidone. Ms AT’s symptoms were a type of reflex hallucination. Having similarities with synaesthesia, these two phenomena might share more in common rather than be separate entities. We propose that synaesthesia, reflex hallucinations and Mitempfindung share their pathophysiological basis and fall within the same dimensional framework, with synaesthesia representing a non-morbid phenotype.
Caruso R, Cervoni L, Vitale AM, et al. (1997) Idiopathic normal-pressure hydrocephalus in adults: Results of shunting correlated with clinical findings in 18 patients and review of the literature. Neurosurgical Review 20: 104–110. Sand T, Bovim G, Grimse R, et al. (1994) Idiopathic normal pressure hydrocephalus: The CSF tap-test may predict the clinical response to shunting. Acta Neurologica Scandinavia 89: 311–316.
Even though Ms AT experiences did not represent Mitempfindung, the nature of the phenomenology shared some common ground with reflex hallucinations and synaesthesia. This case illustrates the potential confusion of various terms used in the literature; we propose that narrowing the definition may potentially lead to a further recognition and increased reporting of these unusual phenomena. It is possible that the presence of one might increase the probability of another in the same person. With further research in this area, a revised terminology and classification will emerge shedding new light on historical phenomenology that have been reported in clinical practice for over a century. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Burrack A, Knoch D and Brugger P (2006) Mitempfindung in synaesthetes: co-incidence or meaningful association? Cortex 42: 151–154. Cutting J (1997) Principles of Psychopathology: Two Worlds - Two Minds - Two Hemispheres. Oxford, England: Oxford Univeristy Press. Hubbard EM and Ramachandran VS (2005) Neurocognitive mechanisms of synesthesia. Neuron 48: 509–520.
Australian & New Zealand Journal of Psychiatry, 48(4) Downloaded from anp.sagepub.com at UNIV OF ILLINOIS URBANA on March 9, 2015
