Diagnóstico diferencial das demências

Dementia is a syndrome characterized by progressive impairment of cognitive functions, particularly in memory, which affects social and occupational activities. The differential diagnosis must, firstly, identify potentially treatable causes of cognitive impairment, addressing the different etiologies of reversible dementia such as metabolic alterations, intoxications, CNS infections, and nutritional deficiencies. The correct and early diagnosis of primary degenerative dementia carries therapeutic and prognostic implications, which may attenuate the inevitable cognitive and behavioral deficits. Definitive diagnoses of most primary dementia syndromes rely on post-mortem neuropathological examination. However, a thorough clinical evaluation, including a detailed clinical history, physical and neurological examination, combined with biochemical determinations and neuroimaging, provide a more accurate differential diagnosis. Technological innovations making use of both structural and functional neuroimaging methods, as well molecular biology and molecular genetic techniques, have presented in the recent literature a strong perspective for the early diagnosis of dementia, especially of Alzheimer disease. The different etiologies involved in the development of dementia syndromes, as well as the respective diagnostic conduct, will be reviewed in this article.As síndromes demenciais são caracterizadas pela presença de déficit progressivo na função cognitiva, com maior ênfase na perda de memória, e interferência nas atividades sociais e ocupacionais. O diagnóstico diferencial deve, primeiramente, identificar os quadros potencialmente reversíveis, de etiologias diversas, tais como alterações metabólicas, intoxicações, infecções, deficiências nutricionais etc. Nas demências degenerativas primárias e nas formas seqüelares, o diagnóstico etiológico carrega implicações terapêuticas e prognósticas. Sabe-se que o diagnóstico definitivo da maioria das síndromes demenciais depende do exame neuropatológico. Entretanto, uma avaliação clínica cuidadosa incluindo anamnese detalhada, exames físico e neurológico, associado a determinações bioquímicas e de neuroimagem, podem possibilitar maior acurácia no diagnóstico diferencial. Inovações tecnológicas servindo-se de métodos de neuroimagem estrutural e funcional, bem como de técnicas de biologia e genética molecular, têm apresentado perspectivas para o diagnóstico precoce das demências, particularmente da doença de Alzheimer. As diversas etiologias implicadas no desenvolvimento de síndromes demenciais, bem como as respectivas condutas diagnósticas, serão revistas neste artigo

Transtornos mentais associados à epilepsia

Epilepsia é o mais freqüente transtorno neurológico sério, atingindo 50 milhões de pessoas no mundo, 40 milhões delas em países em desenvolvimento. Embora seja um problema predominantemente tratável, nestes países a maioria dos pacientes permanece sem tratamento. Provavelmente uma das principais causas para isto seja o estigma que atinge as pessoas com epilepsia. Tal fato se agrava ainda mais quando à epilepsia se associam transtornos mentais, que ocorrem com prevalência aumentada. Os pacientes com epilepsia e transtornos mentais sofrem o que se chama de "duplo estigma", que freqüentemente os deixa sem tratamento. É provável, particularmente em países em desenvolvimento, que psiquiatras se defrontem com pacientes com epilepsia nos diferentes locais de atendimento. Os autores revisam diferentes aspectos dos principais transtornos mentais associados à epilepsia.Epilepsy is the most common serious neurological disorder. Worldwide, around 50 million people have epilepsy, 40 million of which in developing countries. Though epilepsy is predominantly treatable, most patients in these countries remain without treatment. It is likely that one of the main reasons is the stigma associated with epilepsy. This problem increases when mental disorders are associated with epilepsy, a fairly frequent occurrence. Patients with epilepsy and mental disorders are exposed to a "double stigma", which frequently leads to complete absence of treatment. It is probable that, particularly in developing countries, psychiatrists will be involved with the treatment of people with epilepsy. The authors review different aspects of the most important mental disorders associated with epilepsy

The SPECT in the differential diagnosis between epileptic and nonepileptic seizures

O presente estudo comparou o fluxo sanguíneo cerebral regional avaliado através da tomografia por emissão de fóton simples (SPECT) de pacientes com crises epilépticas temporais com pacientes com crises não epilépticas psicogênicas (CNEP). Todos os SPECT foram realizado no período ictal, tendo as CNEP sido induzidas por métodos sugestivos e de hipnose. Os grupos de pacientes com epilepsia e CNEP foram ainda comparados com um terceiro grupo, denominado grupo de sujeitos saudáveis. As comparações dos SPECT foram feitas através da análise visual (radiologista cego ao estudo) e semiquantitativa pelo programa Statistical Parametric Mapping (SPM). Os objetivos do estudo foram: (1) estabelecer a sensibilidade e a especificidade do SPECT ictal para o diagnóstico diferencial entre CNEP e crises epilépticas parciais complexas em pacientes com epilepsia do lobo temporal, em comparação com o VEEG associado a técnicas de hipnose; (2) avaliar através da análise quantitativa voxel a voxel do SPECT as alterações de perfusão cerebral dos pacientes com CNEP em relação aos pacientes com epilepsia, dos pacientes com CNEP em relação a um grupo controle de sujeitos normais e dos pacientes com epilepsia em relação a um grupo controle de sujeitos saudáveis. Foram estudados 30 pacientes no grupo com CNEP, 22 pacientes no grupo com epilepsia e 29 sujeitos saudáveis. Os resultados mostram que os SPECT ictais dos pacientes do grupo CNEP foram diferentes dos SPECT ictais dos pacientes com epilepsia. Na análise visual o SPECT ictal apresentou sensibilidade de 50% e especificidade de 91% para o diagnóstico de CNEP . Na análise comparativa voxel a voxel entre os grupos os resultados revelaram que: (a) houve aumento de perfusão cerebral em lobo temporal esquerdo e tronco cerebral nos pacientes do grupo epilepsia em relação ao grupo controle normal; (b) houve diminuição de perfusão cerebral no lobo frontal esquerdo e córtex anterior do cíngulo nos pacientes do grupo epilepsia em relação ao grupo controle normal; (c) houve aumento de perfusão cerebral no giro do cíngulo e precuneus á direita nos pacientes do grupo CNEP em relação ao grupo epilepsia; (d) houve diminuição perfusão cerebral em amígdala direita nos pacientes do grupo CNEP em relação ao grupo epilepsia; (e) houve aumento de perfusão cerebral na cauda do núcleo caudado esquerdo, giro précentral esquerdo e tálamo direito nos pacientes do grupo CNEP em relação ao grupo controle normal. Desta forma, após a análise estatística dos resultados concluímos que na análise visual, um SPECT ictal positivo em um paciente com suspeita de CNEP não confirma nem afasta tal suspeita, já que a sensibilidade do método foi baixa (50%). Na análise visual, um SPECT ictal negativo em um paciente com suspeita de CNEP afasta a possibilidade de epilepsia do lobo temporal com 91% de acerto (especificidade do método). O resultado da análise visual do SPECT ictal de CNEP revelou valor de sensibilidade abaixo do encontrado na literatura, e valor de especificidade superior ao encontrado na literatura. A análise quantitativa dos SPECT de crise epiléptica em comparação com os de sujeitos saudáveis em repouso, mostrou concordância com a análise visual em relação à lateralidade. Tal comparação revelou ainda ativação de áreas compatíveis com o que se encontra na literatura. A análise quantitativa dos SPECT ictais do grupo CNEP em comparação com os do grupo epilepsia revelou ativação de estruturas cerebrais posteriores (precuneus e giro cíngulo), não havendo comparação semelhante na literatura. A análise quantitativa dos SPECT ictais do grupo CNEP em comparação com os de sujeitos saudáveis em repouso, mostrou ativação do sistema estriatotalamocortical, achado em concordância com a literatura. A ativação do sistema estriatotalamocortical nos pacientes com CNEP mostrou ser um correlato neuroanatômico clinicamente relevante, com forte associação estatística.The study compared regional cerebral blood flow assessed by positron emission tomography single photon (SPECT) in patients with temporal lobe epilepsy and patients with psychogenic nonepileptic seizures (PNES). All SPECT were performed in the ictal period, PNES having been induced by and suggestive methods of hypnosis. The groups of patients with epilepsy and PNES were compared with a third group, called group of healthy subjects. SPECT comparisons were made by visual analysis (radiologist blinded to the study) and semiquantitative analysis by Statistical Parametric Mapping (SPM). The study objectives were: (1) to establish the sensitivity and specificity of ictal SPECT for the differential diagnosis between PNES and complex partial seizures in patients with temporal lobe epilepsy, compared with VEEG associated with hypnosis techniques, (2) to assess by quantitative analysis of SPECT voxel to voxel changes in cerebral perfusion of patients with PNES compared to patients with epilepsy, patients with PNES compared to a control group of normal subjects and patients with epilepsy compared to a control group of healthy subjects. We studied 30 patients in the PNES group, 22 patients in the group with epilepsy and 29 healthy subjects. The results show that ictal SPECT of patients in the PNES group were different from the ictal SPECT of patients with epilepsy. The visual analysis of ictal SPECT had a sensitivity of 50% and specificity of 91% for the diagnosis of PNES. In the voxel voxel comparative analysis between the groups the results showed that: (a) increased cerebral perfusion in the left temporal lobe and brain stem in patients of epilepsy group compared to normal control group, (b) a decrease in cerebral perfusion in the left frontal lobe and anterior cingulate cortex in patients of epilepsy group compared to normal control group, (c) increased cerebral perfusion in the cingulate gyrus and precuneus in the right group of PNES patients compared to epilepsy group, (d) decreased cerebral perfusion in the right amygdala in patients PNES group compared to the epilepsy group, (e) increased cerebral perfusion in the left tail of the caudate nucleus, left pre-central gyrus and right thalamus in patients in the PNES group compared to group normal control. Therefore, after statistical analysis of the results we conclude that in visual analysis, a positive ictal SPECT in a patient with suspected PNES neither confirms nor removes the suspicion, since the sensitivity was low (50%). In visual analysis, a negative ictal SPECT in a patient with suspected PNES rules out the possibility of temporal lobe epilepsy with 91% accuracy (specificity of the method). The result of visual analysis of ictal SPECT of PNES revealed sensitivity value below that found in the literature and specificity value higher than that found in the literature. The quantitative analysis of SPECT of seizures compared with those of healthy subjects at rest, showed agreement with visual analysis in relation to laterality. This comparison also revealed activation in areas consistent with that found in the literature. The quantitative analysis of SPECT ictal PNES group compared with the epilepsy group showed activation of posterior brain structures (cingulate gyrus and precuneus), with no similar comparison in the literature. The quantitative analysis of SPECT ictal PNES group compared to healthy subjects at rest, showed activation of the estriatotalamocortical, a finding in agreement with the literature. The activation of the estriatotalamocortical circuit in patients with PNES proved to be a neuroanatomical correlate clinically relevant, with strong statistical associatio

Electroconvulsive therapy for treating patients with agitation and related behavioral disorders due to dementia: a systematic review

ABSTRACT Behavioral disturbances are clinically relevant in patients with dementia, and pharmacological regimens to mitigate these symptoms have provided limited results. Proven to be effective in several psychiatric conditions, electroconvulsive therapy is a potentially beneficial strategy for treating severe agitation due to dementia. Objective: This review aimed to examine the publications on the efficacy, safety and tolerability of electroconvulsive therapy in treating patients with agitation due to dementia. Methods: We performed a systematic analysis on the electroconvulsive therapy to treat patients with dementia and coexisting severe agitation. Articles were classified according to the level of evidence based on methodological design. Patients received an acute course of electroconvulsive therapy, often followed by maintenance intervention. Results: We selected 19 studies (156 patients; 64.1% women; 51–98 years old), which met the inclusion criteria: one case-control study by chart analysis (level of evidence 2); one open-label study (level of evidence 3); three historical/retrospective chart analyses (level of evidence 4); and 14 case series/reports (level of evidence 5). No randomized, sham-controlled clinical trials (level of evidence 1) were identified, which represents the main methodological weakness. Some patients had postictal delirium, cardiovascular decompensation and cognitive changes, lasting for a short time. Conclusions: Overall, patients achieved significant improvement in agitation. However, the main finding of the present review was the absence of methodological design based on randomized and sham-controlled clinical trials. Despite methodological limitations and side effects requiring attention, electroconvulsive therapy was considered a safe and effective treatment of patients with severe agitation and related behavioral disorders due to dementia

Escala de Depressão de Hamilton (HAM-D): revisão dos 40 anos de sua utilização

O termo depressão é utilizado para caracterizar uma síndrome clínica, onde encontram-se vários sinais e sintomas particulares. A depressão pode ocorrer como manifestações primárias do humor; associada a doenças médicas sistêmicas, a outros transtornos psiquiátricos ou a transtornos decorrentes o uso de substâncias psicoativas

Psychiatric diagnoses of patients with psychogenic non-epileptic seizures

Objective: Our purpose was to present and discuss the psychiatric diagnoses of patients who presented psychogenic non-epileptic seizures (PNES) during video-electroencephalographic monitoring (VEEG). Methods: Out of 98 patients, a total of 28 patients presented PNES during the diagnostic procedure. In those cases in which the PNES that occurred during VEEG were validated by clinical history (clinical validation), and by showing the recorded event on video to an observer close to the patient (observer validation), was defined psychogenic non-epileptic seizure disorder (PNESD). Psychiatric diagnoses were made according to DSM-IV. Results: In 27, psychogenic non-epileptic seizures disorder was diagnosed. Fourteen patients presented only with psychogenic non-epileptic seizure disorder, 13 with both psychogenic non-epileptic seizures disorder and epilepsy, and one patient with epilepsy only. Psychiatric diagnoses were: 17 (63%) patients with conversion disorder, five (19%) with somatization disorder, two (7%) with dissociative disorder NOS, two (7%) with post-traumatic stress disorder and one (4%) with undifferentiated somato-form disorder. Conclusions: Dissociative-conversion non-epileptic seizures are the most frequent finding, representing the pseudoneurological manifestation of mental disorders that have these symptoms as a common feature. Provisionally, they may be defined as dissociative-conversion non-epileptic seizure disorders. (C) 2007 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved

Robotic‐assisted approaches to urachal carcinoma: A comprehensive systematic review of the safety and efficacy outcomes

Abstract Introduction Surgical intervention is the treatment of choice in patients with urachal carcinoma. Due to complications and to reduce hospital stay from open surgery, minimally invasive approaches are desirable. Nowadays, robotic‐assisted surgery has become increasingly popular, and robot‐assisted cystectomy can be performed in patients with urachal carcinoma with low complication rates. Methods We performed a systematic review to search for studies that evaluated patients who underwent robotic‐assisted surgery for urachal carcinoma. The outcomes of interest were the type of cystectomy performed, whether there was umbilicus resection, total operative time, console time, intraoperative complications, estimated blood loss, postoperative complications, time of hospitalisation, positive surgical margins and the presence of documented tumour recurrence. Results In this study, we evaluated three cohorts comprising a total of 21 patients. The median follow‐up period ranged from 8 to 40 months. Medium age was between 51 and 54 years, with a majority (63.1%) being male. One patient (5.2%) underwent a radical cystectomy, and 19 patients (94.7%) underwent to partial cystectomy. Umbilical resections were performed in all cases, and pelvic lymphadenectomy in 14 cases (73.6%). Recurrence occurred in three patients at a median of 17 months postoperation, two cases in the trocar insertion site. Additionally, there was one death, which was attributed to postoperative cardiovascular complications. Conclusion Robotic‐assisted partial cystectomy has a low incidence of adverse outcomes in patients with urachal carcinoma. Controlled studies, ideally randomised, are warranted to establish the comparative efficacy and safety of the robotic‐assisted cystectomy approach relative to open surgery

A study protocol for an ongoing multi-arm, randomized, double-blind, sham-controlled clinical trial with digital features, using portable transcranial electrical stimulation and internet-based behavioral therapy for major depression disorders : the PSYLECT study

Background Transcranial electrical stimulation (tES) is considered effective and safe for depression, albeit modestly, and prone to logistical burdens when performed in external facilities. Investigation of portable tES (ptES), and potentiation of ptES with remote psychological interventions have shown positive, but preliminary, results. Research design We report the rationale and design of an ongoing multi-arm, randomized, double-blind, sham-controlled clinical trial with digital features, using ptES and internet-based behavioral therapy (iBT) for major depressive disorder (MDD) (NCT04889976). Methods We will evaluate the efficacy, safety, tolerability and usability of (1) active ptES + active iBT ('double-active'), (2) active ptES + sham iBT ('ptES-only'), and (3) sham ptES + sham iBT ('double-sham'), in adults with MDD, with a Hamilton Depression Rating Scale - 17 item version (HDRS-17) score >= 17 at baseline, during 6 weeks. Antidepressants are allowed in stable doses during the trial. Results We primarily co-hypothesize changes in HDRS-17 will be greater in (1) 'double-active' compared to 'ptES-only,' (2) 'double-active' compared to 'double-sham,' and (3) 'ptES-only' compared to 'double-sham.' We aim to enroll 210 patients (70 per arm). Conclusions Our results should offer new insights regarding the efficacy and scalability of combined ptES and iBT for MDD, in digital mental health