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Nicola Wolfe, PhD; Viken L. Babikian, MD; Richard T. Linn, PhD; Janice E. Knoefel, MD; Mark D'Esposito, MD; Martin L. Albert, MD

Arch Neurol. 1994;51(2):211-215.

Abstract
Objective
The goal of this study was to characterize the cumulative effects of multiple strokes on cognition.

Design
We conducted a prospective, longitudinal case study with neuropsychological, neurological, and radiological evaluations.

Setting
Research was conducted at the Boston (Mass) Veterans Administration Medical Center, Neurology Service, on successive inpatient hospital admissions.

Patient
We followed up a 66-year-old right-handed man with multiple subcortical lacunae during a 3.5-year period during which he suffered two additional cortical infarctions.

Main Outcome Measures
Each evaluation included approximately 3 hours of neuropsychological testing spanning a range of cognitive domains (attention, language, memory, visuospatial functions, response inhibition, and mental flexibility), full neurological examination, and computed tomographic scan.

Results
The patient's stepwise cognitive decline was characterized by unexpected exacerbation of "frontal" neurobehavioral features following the occurrence of two posterior cortical lesions. At initial evaluation, the computed tomographic scan showed bilateral subcortical lacunae in basal ganglia and periventricular white matter, and symptoms included dysarthria and perseveration. The second evaluation, following a left posterior parietal lesion, revealed a range of new frontal features, including impulsivity, pull-to-stimulus, and difficulty shifting set. Following a subsequent right occipital infarct, further frontal lobe impairments emerged: forced grasp reflex and incontinence.

Conclusions
We hypothesize that the cumulative effects of infarcts were synergistic. That is, the posterior cortical infarcts elicited frontal features that would not be expected from a simple sum of these lesions' effects.

Author Affiliations
From the Department of Neurology, University of California at Davis, School of Medicine, and the Northern California Alzheimer's Disease Center, Berkeley (Dr Wolfe); Department of Neurology, Boston (Mass) University School of Medicine and Boston Veterans Administration Medical Center (Drs Babikian, Knoefel, D'Esposito, and Albert); and the Department of Psychiatry, State University of New York at Buffalo, School of Medicine (Dr Linn).

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