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[Progressive primary aphasia associated with corticobasal degeneration].

INTRODUCTION: Progressive primary aphasia generally progresses to global cognitive deterioration of Alzheimer type, although occasionally it remains unchanged. The neuropathological findings are varied: Alzheimer, spongiform etc. The case we describe followed a very unusual course. Initially there was a clinical picture of progressive primary aphasia with which that of corticobasal degeneration was later associated. CASE REPORT: The patient, who had no relevant previous clinical history apart from chronic obstructive pulmonary disease presented with gradually deteriorating oral expression, with no loss of memory and maintenance of autonomy in everyday activities. This condition was later associated with slowing of voluntary movements, hypertonia of the right limbs, difficulty in manipulation with the right hand and myoclonic jerks. Neuro imaging on cranial CT showed global cerebral atrophy, most marked on the right and cerebral SPECT showed reduced fronto temporal uptake. No other significant alterations were found in the investigations done. On neuropsychological examination there was alteration of language in the form of mutism and reduction in denomination, repetition, fluency and comprehension (except for simple orders). However, copies of drawings were done correctly with absence of apraxia of ideas or ideomotor initiation. Handwriting was also normal. CONCLUSION: . The unusual aspect of our case was the simultaneous presentation of an aphasic disorder and corticobasal degeneration.

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Evidence of bilateral temporal lobe involvement in primary progressive aphasia: a SPECT study.

UNLABELLED: Primary progressive aphasia (PPA) is rare. Only limited series have been reported with SPECT or PET. Moreover, in the majority of studies, the left-to-right asymmetry ratio was used, leading to difficulties in right hemisphere analyzes. METHODS: Twenty-nine patients with clinical criteria of PPA (Mesulam and Weintraub) were included and compared with 12 control subjects. Complete language examination was performed in all patients. SPECT was performed on a double-head gamma camera after intravenous injection of hexamethylpropyleneamine oxime (22 patients and 12 control subjects) or ethylcysteinate dimer (7 patients). Nineteen regions of interest (ROIs) were drawn on each hemisphere in all patients using the Talairach atlas. The perfusion index (PI = cortex-to-cerebellum ratio) was calculated for each ROI. Atrophy was quantified on MRI by consensus of 3 observers in 16 cortical ROIs. ANOVAs were used to compare the PI between (a). patients and control subjects, (b). patients with (n = 15) or without (n = 14) lexicosemantic abnormalities (LS+ vs. LS-) and patients with (n = 19) or without (n = 10) arthric disorders (A+ vs. A-), and (c). patients with or without atrophy. RESULTS: In the 29 patients, the PI was significantly lower in the left temporopolar, left lateral temporal, left Wernicke, left parietal, and right lateral temporal cortex when compared with control subjects (P < 0.001). In LS+ patients versus control subjects, the PI significantly decreased in the left temporal cortex (lateral temporal; medial temporal; temporopolar; Wernicke), left Broca, left parietal, and right lateral temporal cortex (P < 0.001). In addition, LS+ versus LS- comparison showed a significant decrease in the left lateral, left medial temporal, and left Broca cortex (P < 0.001). In comparison with control subjects, the PI was not significantly different in A+ patients, whereas in A- patients the PI was significantly decreased in the left and right lateral temporal cortex, left Wernicke, and left parietal cortex. Moreover, the PI significantly decreased in the left lateral temporal region in A+ patients compared with A- patients. Finally, in patients without atrophy, the PI significantly decreased in the right and left lateral temporal cortex and the left parietal cortex (P < 0.01). CONCLUSION: Our study demonstrates that right-handed patients with PPA present a decreased perfusion in the bilateral temporal cortex. Moreover, in these regions, morphologic abnormalities are preceded by perfusion abnormalities. Finally, our results show that large left temporal dysfunction occurs in patients with LS disorders.

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Different patterns of Mini Mental Status Examination responses in primary progressive aphasia and Alzheimer's disease.

Primary progressive aphasia (PPA) syndrome is frequently misdiagnosed--particularly in favour of Alzheimer's disease (AD). Misdiagnosis is related to the heterogeneity of language disorders at onset, variability in the rate of clinical progression and the low prevalence of PPA syndrome, compared with AD. The aim of this study was to determine whether a patient's first Mini Mental Status Examination (MMSE) might provide insight into differentiating between PPA and AD. We compared item scores for the first, complete MMSE in consecutive patients with PPA versus matched patients with AD. Word recall and constructional praxis were significantly better in patients subsequently diagnosed as suffering from PPA. Patients with AD performed significantly better in terms of word registration, object naming, repetition and verbal direction. Our findings indicate that the various MMSE item scores may be helpful in differentiating PPA and AD in the first few years of the disease.

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Primary progressive aphasia: analisys of 16 cases.

Primary progressive aphasia (PPA) is an intriguing syndrome, showing some peculiar aspects that differentiate it from classical aphasic pictures caused by focal cerebral lesions or dementia. The slow and progressive deterioration of language occurring in these cases provides an interesting model to better understand the mechanisms involved in the linguistic process. We describe clinical and neuroimaging aspects found in 16 cases of PPA. Our patients underwent language and neuropsychological evaluation, magnetic resonance imaging (MRI) and single photon emission computerized tomography (SPECT). We observed a clear distinction in oral expression patterns; patients were classified as fluent and nonfluent. Anomia was the earliest and most evident symptom in both groups. Neuroimaging pointed to SPECT as a valuable instrument in guiding the differential diagnosis, as well as in making useful clinical and anatomical correlations. This report and a comparison to literature are an attempt to contribute to a better understanding of PPA.

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A clinical profile of corticobasal degeneration presenting as primary progressive aphasia.

We report a patient with primary progressive aphasia who first presented with amnesic aphasia that developed over the course of 3 years into nonfluent aphasia with buccofacial apraxia, followed in the next year by cognitive impairment and parkinsonism. Pathological findings were typical for corticobasal degeneration except for the distribution of cortical atrophy. This case suggests that corticobasal degeneration should be included in the differential diagnosis of primary progressive aphasia, especially in association with parkinsonism.

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Profiles of language impairment in primary progressive aphasia.

OBJECTIVE: The profile of language impairment in patients with primary progressive aphasia in comparison with the language impairment in patients with Alzheimer's disease and after stroke. DESIGN: The Western Aphasia Battery and the Mattis Dementia Rating Scale evaluated the language and cognitive impairment. Follow-up studies were done 1 to 5 years after the initial testing in seven of 10 patients with primary progressive aphasia, and a postmortem examination of the brain was done in two patients. SETTING: All 10 patients with primary progressive aphasia were previously healthy, community-dwelling persons when first tested. PATIENTS AND OTHER PARTICIPANTS: All patients with primary progressive aphasia reported at least a 2-year history of slowly progressive aphasia without other signs of global dementia. The initial Western Aphasia Battery results of the 10 patients with primary progressive aphasia were compared with those of a sample of 10 patients with probable Alzheimer's disease and with those of a sample of 10 patients with aphasia due to a left hemispheric stroke. Both reference samples were matched for age and sex; the sample with stroke-caused aphasia was additionally matched for the aphasia type. RESULTS: Expressive language disability with reduced speech fluency and anomia but preserved language comprehension and nonverbal cognition were typical features in early stages of primary progressive aphasia. Spontaneous speech was significantly more impaired in patients with primary progressive aphasia in comparison with those with aphasia after left hemisphere stroke and with language impairment in patients with Alzheimer's disease. Follow-up examinations revealed continuous, often rapid deterioration of language impairment. The neuropathological examination showed Alzheimer's disease in one patient and Pick's disease in the other. CONCLUSION: The profile of aphasia suggests that primary progressive aphasia tends to affect anterior parts of the language-dominant cortex first.

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Primary progressive aphasia: PPA and the language network.

Primary Progressive Aphasia (PPA) is a behaviorally focal dementia syndrome with deterioration of language functions but relative preservation of other cognitive domains for at least the first two years of disease. In this study, PPA patients with impaired word finding but intact comprehension of conversational speech and their matched control subjects were examined using voxel-based morphometry (VBM) and functional magnetic resonance imaging (fMRI). fMRI compared signal changes during phonological and semantic language tasks with those during a control task (matching letters). PPA patients showed longer reaction times and reduced accuracy versus controls on the language tasks, but no performance differences on the control task. VBM demonstrated reduced gray matter in left superior temporal and inferior parietal regions in the PPA group. However, these patients showed a normal pattern of activation within the classical language regions. In addition, PPA patients showed activations, not seen in normals, in fusiform gyrus, precentral gyrus, and intra-parietal sulcus. These activations were found to correlate negatively with measures of naming and task performance. The additional activations in PPA may therefore represent a compensatory spread of language-related neural activity or a failure to suppress activity in areas normally inhibited during language tasks.

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The role of brain single photon emission computed tomography in the diagnosis of primary progressive aphasia.

We present two cases of primary progressive aphasia studied with neuropsychologic measures, computed tomography or magnetic resonance imaging, and single-photon emission computed tomography with technetium Tc99m-labeled hexamethylpropyleneamine oxime. Clinical and neuropsychologic observations revealed a marked, progressive loss of language functions over time with relative preservation of nonlanguage cognitive functions in both patients. The brain single-photon emission computed tomographic scan revealed marked left frontal and minimal left temporal and parietal hypoperfusion in case 1 and marked left posterior frontal and minimal left temporal hypoperfusion in case 2. The value of brain single-photon emission computed tomography in distinguishing primary progressive aphasia from Alzheimer's disease is described.

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Primary progressive aphasia: a case report.

We report a 69-year-old male patient whose motor aphasia started at the age of 61. The language disability remained isolated and progressed over a period of eight years without any additional cognitive deficits. Computed tomography (CT) and magnetic resonance imaging (MRI) showed moderate cortical atrophy with frontal dominance. Single photon emission tomography (SPECT) showed hypoperfusion in the frontotemporoparietal region, positron emission tomography (PET) demonstrated a global cortical reduction of glucose utilization with a lesser decrement in the occipital lobes. The clinical symptoms and the neuropsychological findings fit the diagnosis of primary progressive aphasia.

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A case of primary progressive aphasia. A 14-year follow-up study with neuropathological findings.

Primary progressive aphasia has been clinically defined as a progressive language deficit leading to the dissolution of almost all language functions with relative preservation of other cognitive functions until late in the course of the disease. Two types of language impairment have been described for primary progressive aphasia, which differ with respect to the degree of fluency of spontaneous speech. Whereas some authors have emphasized non-fluency as a defining characteristic of primary progressive aphasia, others have proposed that phonemic rather than semantic paraphasias in naming, both in the fluent and the non-fluent subtype, should be used as a criterion to distinguish primary progressive aphasia from slowly progressive aphasia in other forms of degenerative brain disease. Patients with fluent speech and semantic dementia, as typically seen in Alzheimer's disease, produce semantic paraphasias and circumlocutions rather than phonemic errors in naming. This paper reports the long-term follow-up of a patient with fluent aphasic speech, whose language profile over a decade was similar to that of patients with semantic dementia. Neuropathological examination revealed no evidence of Alzheimer's disease. Pick's disease or Pick variant, but showed spongiform changes of cortical layers (II and III) in temporal and, less severely, in frontal gyri. The present case indicates that semantic dementia is not a reliable indicator of probable Alzheimer's disease and supports the notion that there are different subtypes of primary progressive aphasia which cannot be defined by fluency or by the presence of phonemic paraphasia. Progress in identifying the neuropathological correlates of these subtypes in cases with lobar atrophy and spongiform changes should be expected from hereditary variants of progressive disorder.

Aphasia, Primary Progressive↗

[A case of corticobasal degeneration that progressed from primary progressive aphasia].

A 65-year-old woman began to experience slowly progressive speech disturbance from 2001. She was admitted to our hospital for examination on May 2003. She had dysprosody, paragraphia, and mild disturbance in comprehension of spoken language. Repetition was preserved. No clear paraphasia was found. Calculation was disturbed, but there were no other neurological abnormalities including apraxia and agnosia. Brain MRI showed atrophy of the left frontal and parietal lobes. 99mTc-ECD SPECT showed decreased blood flow in the left frontal lobe and parietal lobe, especially in the Broca area and supplemental motor cortex. Primary progressive aphasia was diagnosed, because aphasia lasted for 2 years without other neurological deficits, and her daily activity was well preserved. During follow up, facial apraxia appeared from December 2003, and limb apraxia appeared from May 2004, followed by rigidity predominantly in the right upper limb and dementia. She was diagnosed as having corticobasal degeneration (CBD). The second SPECT on December 2004 showed progression of the decrease in cerebral flow at the same area showed by the first SPECT. SPECT is useful examination to predict the progress of the disease because the decrease of blood flow was recognized before the progression to CBD.

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Natural history of primary progressive aphasia.

OBJECTIVE: To characterize the natural history of primary progressive aphasia (PPA). METHODS: Forty-nine patients (28 women) with newly diagnosed with PPA presenting to a memory disorders clinic between 1992 and 2001 were prospectively evaluated. RESULTS: Median age at onset was 62 years (range 49 to 73 years) and at first visit was 66 years (52 to 80 years). The median duration of follow-up was 4 years (1 to 11 years). Impairments in activities of daily living developed a median of 6 to 7 (2 to 12) years post onset. Seventy-five percent of patients eventually met clinical diagnostic criteria for frontotemporal dementia (FTD), 14% met diagnostic criteria for dementia with Lewy bodies, and 8% developed signs of corticobasal degeneration; 60% of the patients died after a median course of 7 years (3 to 17 years) at a median age of 71 years (56 to 81 years). Patients showing high Mini-Mental State Examination scores, moderate aphasia, and fluent language at first visit subsequently retained greater autonomy in daily life. CONCLUSIONS: Although activities of daily living are well maintained during the first years of the disease, patients with primary progressive aphasia (PPA) may lose autonomy 6 to 7 years after onset. The majority of patients with PPA in the current study developed frontotemporal dementia.

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Progranulin mutations in primary progressive aphasia: the PPA1 and PPA3 families.

BACKGROUND: Primary progressive aphasia (PPA) is a language-based dementia characterized by fluent or nonfluent language disorder as its principal feature. OBJECTIVE: To describe progranulin gene mutations in 2 families with PPA. DESIGN: Report of affected families. SETTING: Academic research. PATIENTS: Two families, PPA1 and PPA3, were studied. Genomic DNA was isolated from 3 of 4 siblings in PPA1, from all 3 siblings in PPA3, and from more than 200 control subjects. MAIN OUTCOME MEASURES: All 12 coding exons of the progranulin gene and the 5" and 3" untranslated regions were amplified by polymerase chain reaction and were sequenced in both directions using relevant primers. RESULTS: Both affected members of PPA1 for whom DNA was available and both affected sisters of PPA3 had a progranulin gene mutation not found in the unaffected siblings or in the controls. The mutations likely cause a null allele and a reduction in the level of functional progranulin protein. Both affected members of PPA1 with autopsies had frontotemporal lobar degeneration with tau-negative ubiquinated inclusions. CONCLUSIONS: To our knowledge, these are the only known families in which affected members display phenotypical homogeneity for PPA in the initial stages of the disease. In both families, the disease segregated with progranulin gene mutations. Whether progranulin dysfunction also extends to sporadic PPA and how it affects the initial anatomical specificity of neurodegeneration remain to be determined.

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[Writing disorders in primary progressive aphasia].

We investigated longitudinally three patients with primary progressive aphasia (PPA) who exhibited fluent aphasia at the early stage, in terms of writing disorders. The writing disorders were the most striking during the aphasia quotient (AQ) was 50-60 for all these patients. The characteristic features were as follows: (i) several types of perseverative errors, especially on spontaneous writing rather than on dictation (ii) confusion between letters and pictures (iii) preserved copying ability and (iv) total loss of writing ability at the final stage. Additionally, through the progression, linguistic level of the perseverative errors changed from sentence to word and finally to phoneme. The results suggest that the fluent type PPA patients have difficulty to recall proper letters and to arrange them in correct order following the writing plan, in addition to disinhibition and lexical stereotyping which were commonly observed in perseverative patients. The results also suggest that their writing disorders seem to be based on difficulty of letter manipulation as symbols.

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Pick Complex: an integrative approach to frontotemporal dementia: primary progressive aphasia, corticobasal degeneration, and progressive supranuclear palsy.

BACKGROUND: Frontotemporal dementia (FTD) is a new label for clinical Pick's disease (PiD) because the eponymic term is increasingly restricted to the pathologic finding of Pick bodies. This restriction created the impression that PiD is rare and that is it difficult to diagnose. FTD is also a term most often used for behavioral and personality alterations. Primary progressive aphasia (PPA) and corticobasal degeneration (CBD), formerly the extrapyramidal variety of PiD, are also part of the syndrome. Recently, chromosome 17 localization and tau mutations were discovered in familial forms of the disease. REVIEW SUMMARY: FTD consists of behavioral and personality changes, often beginning with apathy and disinterest, which may be mistaken for depression. Disinhibition and perseverative, compulsive behavior often appear at the same time. A quantifiable frontal behavioral inventory is useful in the diagnosis beyond a checklist. The second type of presentation is progressive language loss (PPA). A less common variety is semantic dementia: the meaning of nouns and objects is lost. As the disease progresses, all components tend to overlap. CBD and progressive supranuclear palsy (PSP), although described as distinct entities, show a great deal of clinical, pathologic, genetic, and biochemical overlap. The evidence suggests they also belong to the complex. The association of motor neuron disease (MND) with FTD and other varieties of the complex is also reviewed. CONCLUSIONS: Clinical Pick's disease or Pick Complex includes the overlapping syndromes of FTD, PPA, CBD, PSP, and FTD-MND. The neuropathological and genetic spectrum should be viewed with emphasis on the commonalities rather than the differences, allowing the recognition of the relatively high frequency of this presenile syndrome.

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Progressive supranuclear palsy presenting with primary progressive aphasia--clinicopathological report of an autopsy case.

We report a Japanese autopsy case of progressive supranuclear palsy (PSP). The male patient was 74 years old at the time of death. At age 64, he developed non-fluent aphasia that progressed slowly over 8 years, eventually associated with behavioral abnormality, postural instability, and dysphagia at 2 years prior to his death. Magnetic resonance imaging of the brain at age 73 demonstrated marked atrophy of the frontal lobes, particularly on the left side. Neuropathological examination revealed the typical pathology of PSP: loss of neurons, gliosis, occurrence of neurofibrillary tangles, oligodendroglial coiled bodies, and tuft-shaped astrocytes in the frontal cortex, associated with argyrophilic threads in the underlying white matter, in the basal ganglia, including the thalamus, globus pallidus, and subthalamic nucleus, and in the brainstem nuclei, including the substantia nigra, pontine nucleus, and inferior olivary nucleus. No astrocytic plaques or ballooned neurons were observed. Protein analysis revealed accumulation of hyperphosphorylated tau of 68 and 64 kDa consisting of the four repeat tau isoforms. We conclude that the present case represented PSP with an 8-year history of primary progressive aphasia (PPA). Although focal cortical symptoms in PSP are rare or absent, we should keep in mind the possibility of atypical PSP in which cortical pathology is predominant, particularly in the frontal lobe, and could result in PPA.

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False recognition of incidentally learned pictures and words in primary progressive aphasia.

Recognition memory was tested in patients with primary progressive aphasia (PPA), a language based dementia with relative preservation of memory for at least the first 2 years. The goal of the study was two-fold: (1) to compare true and false recognition rates for words versus pictures in patients with PPA and cognitively intact controls and (2) to determine if the semantic relatedness of distracters-to-targets influences recognition memory performance. Overall, performance of PPA patients was worse for words than pictures. PPA patients and healthy elderly controls showed similar recognition rates for studied items. However, the patients had significantly more false alarms than controls, particularly to semantically related items. This suggests that the aphasia in PPA patients contributes to their difficulty in selecting among items within a semantic class.

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Primary progressive aphasia: a review of 112 cases.

Primary progressive aphasia (PPA) was first recognized by Mesulam in 1982. Although dozens of cases have since been described, it has been difficult to place these cases into a coherent framework due to the wide variation in measures which have been reported. We review 170 contacts with 112 patients to provide a clinical, neuroanatomical, and neuropsychological profile of patients with the disorder. The progression of the disease is analyzed over a 10-year reporting period starting from symptom onset to show how progression affects five general linguistic skills: oral and written naming, reading, repetition, and general comprehension. The pattern of functional and neurological deficits in PPA is heterogeneous. Differences in the distribution of neurological anomalies between patients with bilateral and unilateral changes suggest that there may be two separate disease processes involved.

Aphasia↗