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The coronavirus disease of 2019 or COVID-19 was first identified in Hubei Province in China in November of 2019 and quickly spread to become a global pandemic. The virus, SARS-Coronavirus-2, is particularly virulent in the elderly who can develop symptoms and become mortally ill within days of contracting the virus. The virus is easily transmitted by droplets (e.g., sneezing and coughing) and communal living settings such as personal care homes can be vulnerable to the spread of the virus. Identifying patients early in the disease process is important to providing appropriate medical interventions. To date, most of the medical literature, including Center for Disease Control guidelines, has relied on three necessary symptoms in making the diagnosis of COVID-19: fever, cough, and shortness of breath. We present four cases of elderly patients who developed altered mental status as their presenting symptom without associated fever or respiratory symptoms., (Copyright © 2020. Published by Elsevier Inc.)

Objectives: The objective of this article is to present safety and tolerability data from the long-term extension phase of a core study conducted in patients with Alzheimer's disease (AD) who were immediately switched to rivastigmine., Method: This was a 26-week open-label extension (OLE) of a prospective, 26-week, open-label, single-arm, multicenter study conducted in the United States from October 2003 to January 2005. Patients had a diagnosis of Alzheimer's disease according to DSM-IV-TR and National Institute of Neurologic and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association criteria. Safety and tolerability of rivastigmine were monitored through monthly telephone contacts. At week 52, patients or caregivers were contacted by telephone to evaluate the patient's well-being., Results: 146 patients (approximately 79% of patients who completed the core phase) entered this OLE. Most patients (N = 115, 78.8%) completed the full 26 weeks of the extension phase, during which time they received a mean rivastigmine dosage of 10.5 mg/day. The number of patients reporting newly occurring or worsening adverse events decreased considerably during the OLE (N = 84, 57.5%) compared with the core phase (the first 26 weeks; N = 116, 79.5%). Most patients reported adverse events that were mild or moderate in severity. At the end of the OLE, the majority of patients (128/146; 87.7%) were still receiving treatment with rivastigmine. At week 52, most caregivers expressed satisfaction with rivastigmine treatment (77.4%) and with the changes observed in the patient's behavior during the study (71.9%)., Conclusions: For patients not tolerating or not responding to donepezil, treatment with rivastigmine was safe and well tolerated for at least 52 weeks.

Objective: Switching patients with Alzheimer's disease from one cholinesterase inhibitor to another represents a viable option for patients not responding to current therapy. The objective of this large U.S.-based study was to evaluate the safety and efficacy of a treatment switch to rivastigmine in patients not responding adequately to or declining on treatment with donepezil., Method: In this 26-week, prospective, open-label, single-arm, multicenter study conducted from April 24, 2003, to June 25, 2004, patients with mild-to-moderate Alzheimer's disease (DSM-IV-TR criteria) who were not responding to donepezil were treated with rivastigmine 3-12 mg/day. Safety and tolerability were measured by the occurrence of adverse events and patient disposition. Treatment effects on global functioning were assessed using the Clinical Global Impression of Change (CGIC) scale., Results: Two hundred seventy patients with a mean age of 78.5 (SD = 7.56) years and a mean duration of dementia of 3.5 (SD = 2.06) years were included in the study. Sixty-nine percent of patients completed the study with 17.8% discontinuing due to adverse events. Eighty-three percent of patients reported at least 1 adverse event, with the most frequently occurring adverse events affecting the gastrointestinal system (54%). The majority of patients were reported to have either improvement or no decline on the CGIC. A limitation of the study is that the interpretation of the results is based on an overall completion rate of 69%., Conclusion: Immediately switching patients from donepezil to rivastigmine without a washout period was safe and well tolerated in the current study. Additionally, these results suggest that patients not responding adequately to or declining while taking donepezil may improve or stabilize after switching to rivastigmine.

Inhibition of return is a bias in attention that reduces the likelihood of returning attention to previously viewed locations. This attention bias develops during the first 6 months of life and is putatively mediated by midbrain structures. The present study evaluated the effects of perinatal lesions on the development of inhibition of return. Thirty-three children with perinatal injury resulting in spastic diplegic cerebral palsy were grouped based on magnetic resonance exams. Children with anterior (n = 5), posterior (n = 12), diffuse (n = 8), or no apparent (n = 8) lesions were compared with a group of age-matched children without neurologic injury (n = 39) on an orienting task designed to elicit inhibition of return. Short-delay trials demonstrated grossly intact facilitation of attention for all groups. Long-delay trials that produced inhibition of return in the control and posterior injury groups indicated a disruption of inhibition of return in the groups with anterior and diffuse lesions. The findings are consistent with previous reports that anterior regions are important for the developing attention system, and that bilateral injury can result in unilateral disruption of visual attention.

Background: To examine the magnetic resonance (MR) images of bipolar patients across a wide age range for the presence of hyperintense lesions compared to age- and gender-matched control subjects., Methods: Consecutive admissions to a mood disorders unit over a 2-year period were evaluated retrospectively for the presence of bipolar disorder by DSM-III-R criteria and whether they received an MR scan. Bipolar patients (n = 70, mean age = 49.9 +/- 19.7 years) were age- and gender-matched to control subjects (n = 70, mean age = 53.2 +/- 18.1 years) and the MR scans were rated to assess for the presence of hyperintensites., Results: Compared to control subjects, the bipolar patients demonstrated hyperintense lesions in the subependymal region, subcortical gray nuclei, and the deep white matter., Conclusions: Hyperintense lesions in bipolar patients are found in both the subcortical white matter and gray nuclei and may play an important role in the etiology of bipolar illness.

Rapid-rate transcranial magnetic stimulation (rTMS) allows for the noninvasive examination of the cerebral cortex. Recent studies have begun to investigate whether rTMS may be therapeutic for the treatment of depression. In the present study, the authors report on the safety and efficacy of rTMS in treating 50 patients with refractory depression. Overall, there were 21 responders (42%). Interestingly, 56% of the young patients responded, but only 23% of the elderly patients responded to rTMS. Overall, rTMS was well tolerated in all patients. Specifically, no patient developed a new onset of seizures during rTMS. The authors discuss the extant literature on rTMS for the treatment of depression along with future areas of research.

Cognitive and clinical changes during hospitalization were examined in 48 elderly patients with major depression treated with electroconvulsive therapy (ECT) and 55 elderly depressed patients not treated with ECT. Cognitive changes with ECT involved orientation, attention and calculation, and recall. The maximal decrement during ECT averaged 3 points on the Mini-Mental State Examination and occurred after two thirds of the treatments were administered. Baseline cognitive values returned by time of discharge. The affective symptoms improved throughout the course of treatment and remained improved while cognition returned to normal. Patients not receiving ECT showed slightly improved cognitive performance during hospitalization and small, gradual, clinical improvement.

Magnetic resonance imaging was used to examine cerebral anatomy in 48 inpatients with severe depression who were referred for electroconvulsive therapy and in 76 normal control subjects. The magnetic resonance imaging measures included determinations of regional cerebral volumes and ratings of the frequency and severity of cortical atrophy, lateral ventricular enlargement, and subcortical hyperintensity. The mean total frontal lobe volume was found to be 7% smaller in the inpatients with severe depression (235.88 mL) than in the normal control subjects (254.32 mL)--a difference that was statistically significant even after adjusting for the effects of age, sex, education, and intracranial size. No group differences were observed in the volumes of the cerebral hemispheres, the temporal lobes, or the amygdala-hippocampal complex, nor in the frequency of cortical atrophy. Neither did the groups differ with respect to the total volumes of the lateral and third ventricles, nor in the frequency of lateral ventricular enlargement. Patients with depression had a significantly higher frequency of subcortical hyperintensity in the periventricular white matter, with an odds ratio of 5.32.

Purpose: To assess the effects of age and gender on the interuncal distance measured from MR images., Methods: High-field strength MR images (axial) of 75 volunteers, 21-82 years old and free of neurologic disorders, were used to measure the interuncal distance., Results: The interuncal distance increased with age (r = 0.66, P < .0001). The mean (SD) interuncal distance for all subjects was 21.4 (4) mm with a range of 12 to 29 mm., Conclusions: The interuncal distance in healthy subjects is unlikely to exceed 30 mm. Our data may be of clinical significance in view of a previous report stating that the interuncal distance may be enlarged in pathologic hippocampal degeneration, such as in patients with Alzheimer disease.

Serious cardiac complications have been reported to occur in elderly depressed patients during a course of electroconvulsive therapy (ECT). As a result, cardiac medications are being used more often to dampen the cardiovascular response that occurs during an ECT treatment. Specifically, labetalol (a mixed alpha- and beta-blocker) has been shown to effectively control the heart rate during ECT. However, on occasion, patients may still exhibit sustained elevations of blood pressure during ECT when receiving labetalol. The optimum clinical management of these patients is unclear. The authors report on the safety and efficacy of combining nifedipine with labetalol to control blood pressure during ECT in ten elderly patients whose blood pressures were not adequately controlled by labetalol alone. No adverse effects were noted, nor did nifedipine appear to shorten seizure duration.

The etiology of depression in the elderly is poorly understood. In this study, magnetic resonance imaging was used to evaluate the role of subcortical structures in the pathophysiology of depression in the elderly. Elderly depressed patients were found to have smaller caudate nuclei, smaller putaminal complexes and in increased frequency of subcortical hyperintensities compared with normal, healthy controls. These findings were more pronounced in patients with late-onset depression. Based on these findings, the authors discuss the role of the basal ganglia in the pathophysiology of depression in the elderly.

Purpose and Methods: High-field MR images at 1.5 T were used to characterize the effects of age and gender on pituitary size and shape in a sample of 71 adult volunteers (40 females), aged 21 to 82 years., Findings: For all subjects, age was inversely correlated with pituitary height (r = -.43, P less than .0002) and cross-sectional area (r = -.35, P less than .0028). Age-specific gender differences were also present in pituitary height and area. A convex upper pituitary margin was more common in females (P = .002) and younger subjects (P = .009)., Conclusions: This study confirms that aging is accompanied by gender-specific changes in pituitary size and shape, and provides normative data that may facilitate evaluation of the pituitary gland in neuroendocrine disorders.

A role of the caudate nucleus in depression has been suggested from relevant clinical conditions, such as patients with Huntington's disease or caudate infarcts, as well as animal studies. Correlations of caudate nucleus disease with depressive symptoms have been limited to autopsy studies and cases of gross pathological disorder, such as large infarcts. We used serial axial high-field magnetic resonance images and an unbiased stereological technique to estimate the volumes of the caudate nuclei in 50 patients who met DSM-III criteria for major depression (23 men, 48.3 +/- 17 years old) in comparison with 50 age- and gender-matched normal controls free of major neurological and psychiatric disorders. Depressed patients had smaller caudate nucleus volumes (5.2 +/- 1.6 cm3) compared with controls (6.2 +/- 1.7 cm3). Right and left caudate nucleus volumes were smaller in depressed patients compared with controls. Age was negatively correlated with caudate nucleus volumes in depressed patients as well as in controls. Caudate nucleus volumes in depressed patients were inversely correlated with the bicaudate and bifrontal indices. These results may be the first demonstration of diminished caudate nucleus volumes in depression and suggest a role for the caudate nucleus in the pathogenesis of major depression.

High-field magnetic resonance (MR) images were used to study posterior fossa morphology in 27 patients with major depression and 36 normal control subjects. Depressed patients demonstrated smaller brain stem and cerebellar vermis than controls. These differences were highly significant for the anterior cerebellar vermis and medulla. There was also a striking age-related decline in midbrain size in depressed patients as well as in controls. Our results are consistent with several lines of evidence implicating a role for the cerebellar vermis in affective disorders and, in addition, provide the first MR documentation of the differential effects of aging on posterior fossa morphology in normal subjects compared with patients with major depression.

Electroconvulsive therapy (ECT) has been used effectively in treating depressed patients with multiple sclerosis (MS). However, several reports have observed that some patients with MS may suffer neurological deterioration during ECT. The authors describe the outcomes of 3 depressed patients with MS who were treated with ECT. Consistent with previous works, ECT effectively treated the psychiatric symptoms; however, 1 patient deteriorated neurologically during ECT. The brain MRI findings and clinical courses of all 3 patients are discussed, along with the possible value of gadolinium-contrast MRI scans for identifying high-risk patients.

There is increasing evidence for structural differences in the brains of patients with affective disorders. Recent magnetic resonance imaging (MRI) studies have reported focal signal hyperintensities in the deep white matter of bipolar patients. These previous reports had focused on adult patients with prior episodes of illness. In this case report, the authors discuss a young adolescent patient during her first episode of mania and the finding of subcortical focal signal hyperintensities on brain MRI. The etiology, pathophysiology, and clinical correlates of these lesions will be reviewed.

Seventy-six healthy adults underwent magnetic resonance imaging (1.5 T) to investigate the effects of age on regional cerebral volumes and on the frequency and severity of cortical atrophy, lateral ventricular enlargement, and subcortical hyperintensity. Increasing age was associated with (1) decreasing volumes of the cerebral hemispheres (0.23% per year), the frontal lobes (0.55% per year), the temporal lobes (0.28% per year), and the amygdala-hippocampal complex (0.30% per year); (2) increasing volumes of the third ventricle (2.8% per year) and the lateral ventricles (3.2% per year); and (3) increasing odds of cortical atrophy (8.9% per year), lateral ventricular enlargement (7.7% per year), and subcortical hyperintensity in the deep white matter (6.3% per year) and the pons (8.1% per year). Many elderly subjects did not exhibit cortical atrophy or lateral ventricular enlargement, however, indicating that such changes are not inevitable consequences of advancing age. These data should provide a useful clinical context within which to interpret changes in regional brain size associated with "abnormal" aging.

Background: Major depression and panic disorder commonly occur together. Patients with simultaneous depression and panic disorder may have a higher lifetime rate of suicide attempts and an overall worse prognosis than patients with either depression or panic disorder alone. In addition, preliminary work suggests that some of these patients may not respond satisfactorily to antidepressants. In this report, we describe the clinical courses of eight consecutive patients with simultaneous major depression and panic disorder who were referred for ECT at our institution., Method: Eight consecutive patients who met DSM-III-R criteria for simultaneous major depression and panic disorder received ECT. All eight patients were evaluated by a structured clinical interview and the patients' major depression and panic disorder were evaluated with a 7-point Clinical Global Impressions severity rating scale., Results: Before ECT was begun, each subject's panic disorder and depression were rated as at least markedly ill. After receiving ECT, all eight showed improvement in their depression. In addition, none of the eight patients reported having a panic attack from the time of their fourth ECT treatment until discharge., Conclusion: In this report, eight consecutive patients with simultaneous major depression and panic disorder improved with ECT. Further work is required which examines the potential utility of ECT in treating these patients.

Purpose: To determine the effects of age on estimated midbrain volume., Patients and Methods: T2-weighted MR imaging and an unbiased stereologic method were used in 75 volunteers; the subjects ranged in age from 21 to 82 years and were without any significant neurologic or psychiatric disorders., Results: Age was negatively correlated with estimated midbrain volume (R = -.39, P less than .0005), with the anteroposterior diameter through the substantia nigra (R = -.33, P less than .004) and with the interpeduncular distance (R = -.24, P less than .04). The linear measurements for the right and left side were almost identical. These findings are consistent with prior reports of nigrostriatal degeneration with increasing age. Furthermore, they suggest a close symmetry of age-related changes between the right and left side in normal subjects., Conclusions: Volumetric and linear measurements of midbrain morphology with MR may prove useful in the investigation of neurologic disorders such as Parkinson disease.

Bipolar disorder has been reported to occur frequently in a number of subcortical diseases. This suggests that subcortical structures may be involved in the etiology of bipolar disorder in some patients. With the advent of brain magnetic resonance imaging (MRI), in vivo visualization of the subcortical white and gray matter is now possible, allowing the examination of these structures. The authors report a higher occurrence of deep white matter lesions in bipolar patients (44%) compared with age-matched controls (6%). The neuroanatomic and clinical correlates of these lesions will be discussed, along with their potential pathophysiologic significance.

To determine prospectively whether electroconvulsive therapy (ECT) produces structural brain changes, 35 inpatients with depression underwent magnetic resonance imaging before and twice after (at 2 to 3 days and at 6 months) completion of a course of brief-pulse, bilateral ECT. The magnetic resonance images were analyzed blindly for evidence of changes in brain structure using two approaches: measurement of regional brain volumes and a pairwise global comparison. Structural brain abnormalities were present in many patients before ECT. The course of ECT produced no acute or delayed (6-month) change in brain structure as measured by alterations of the total volumes of the lateral ventricles, the third ventricle, the frontal lobes, the temporal lobes, or the amygdala-hippocampal complex. In five subjects, the pairwise global comparisons revealed an apparent increase in subcortical hyperintensity, most likely secondary to progression of ongoing cerebrovascular disease during follow-up. Our results confirm and extend previous imaging studies that also found no relationship between ECT and brain damage.

The basal ganglia are recognized as putative mediators of certain cognitive and behavioral symptoms of major depression. Moreover, patients with basal ganglia lesions have repeatedly exhibited significant affective symptomatology, including apathy, depressive mood, and psychosis. Using high resolution, axial T2 intermediate magnetic resonance images, and a systematic sampling stereologic method, we assessed putamen nuclei volumes in 41 patients with major depression (DSM-III) and 44 healthy volunteer controls of similar age. Depressed patients had significantly smaller putamen nuclei compared with controls. Age was negatively correlated with putamen size in both groups. These results are the first demonstration of diminished putamen volumes in depression and further support a role for basal ganglia structures in the etiopathogenesis of depression.

Intermediate T2-weighted MR images and a systematic sampling stereological method were used in 37 normal volunteers, 24 to 79 years old, to assess the effects of age and sex on cerebellar volume. Female subjects (n = 21) had significantly smaller cerebellar volumes compared with males (n = 16) of similar age (t = -3.9, p less than .0008, two-tail t test). Using straight-line, univariate regression, we determined that age was not a significant predictor of cerebellar volume (R2 = 0.07, t = -1.66, p = 0.11), whereas gender did appear to account for a significant amount of variability in cerebellar volume (R2 = 0.33, t = -4.13, p = .0002). The mean absolute cerebellar volume in this study was 112 ml (SD +/- 16) for all subjects, 104 ml (SD +/- 10) for females, and 122 ml (SD +/- 16) for males. This study demonstrates the feasibility of using MR images along with a systematic stereological method to assess in vivo human cerebellar volume, thereby providing a research tool to correlate cerebellar morphology with cognitive and neuromotor function.

A quantitative magnetic resonance imaging study of regional brain T1 spin-lattice relaxation times in 29 normal volunteers and in 20 patients with major depression revealed significantly shortened T1 relaxation times for the hippocampus in depressed patients. These differences were particularly prominent in elderly depressed patients. T1 relaxation times are reflective of the content and macromolecular environment of tissue water protons; shorter hippocampal T1 values may reflect differences in the content or organizational properties of hippocampal water protons. These findings are consistent with several lines of evidence that have implicated a role for the hippocampus in the regulation of mood and in the pathophysiology of the stress response, and they suggest that major depression may be associated with biophysical tissue changes in the aging hippocampus.

A brain magnetic resonance imaging (MRI) study of the corpus callosum in 36 normal volunteers, ages 26-79 years, revealed that age was positively correlated with the T1 spin-lattice relaxation time of the corpus callosum and was negatively correlated with the corpus callosum cross-sectional area. T1 relaxation times are sensitive to the content and macromolecular environment of tissue water, and variations in callosal T1 may reflect differences in the content or relaxation properties of callosal water. Such changes also potentially could occur secondary to alterations in the composition of callosal myelin. This study confirms and extends prior morphological studies that have reported age-related dimensional changes in the corpus callosum and, in addition, provides evidence of age-related biophysical tissue differences in the human corpus callosum.

In this pilot study, a prolonged (interictal) delirium was induced by electroconvulsive therapy (ECT) in seven out of seven depressed patients with Parkinson's disease. This occurrence of delirium appears much higher than what has been reported in other patient populations. These findings are consistent with several lines of data that have implicated the basal ganglia in the development of delirium from other causes, and they suggest that structural changes in these areas may predispose individuals to develop an interictal delirium during a course of ECT.

The repeatability and accuracy of brain surface cortical sulcal length measurements obtained with three-dimensional (3D) reconstructions of volumetric, gradient-echo magnetic resonance (MR) images were tested. The brains of eight healthy adult volunteers and one cadaver were imaged in both the coronal and sagittal planes to yield a set of 128 1.5-2.0-mm-thick contiguous sections. 3D reconstructions of the brain cerebral cortical surfaces were obtained with computer software. Location and distance measurements of surface sulci were repeated on each reconstructed image. The same structures in the cadaver brain were independently measured with a 3D electromagnetic digitizer to validate the results of the 3D MR imaging method. All measurements from reconstructed images had high repeatability, and there were no statistically significant differences between measurement trials. The accuracy of measurements with 3D MR imaging was also good; the mean difference between digitizer and 3D MR measurements for sulcal lengths was 0.81 cm (average, 5.45-12.9 cm).

Midsagittal magnetic resonance (MR) images of 36 normal volunteers, ranging in age from 26 to 79 years, were used to evaluate the effects of age on the size of posterior fossa structures (cerebellar vermis, midbrain, pons, medulla and fourth ventricle). Our results demonstrate a highly statistically significant age-related decline in the cross-sectional area of the midbrain (r = -.44, p less than 0.007), a less prominent decline in the area of the anterior cerebellar vermis (r = -.33, p less than 0.05) and striking intercorrelations between the dimensions of the pons, medulla and cerebellar vermis. To the best of our knowledge, this is the first MRI demonstration of midbrain atrophy during aging in normal adults.

Subcortical structural changes have been reported to occur in some elderly subjects with late age onset depression. Given the association between diseases affecting subcortical structures and affective disorders, this suggests that these structural changes may be involved in the etiology of late age onset depression in some patients. With the advent of Brain Magnetic Resonance Imaging (MRI), "in vivo" analysis of these subcortical structures is now possible. The authors report a higher occurrence of caudate (60% vs. 11%) and large deep white matter hyperintensities (60% vs. 11%) in late age onset elderly depressed subjects compared with early onset elderly depressed subjects. These results suggest that late age onset depression may be mediated by caudate and white matter structural changes in some patients.

The magnetic resonance scans of 22 patients with early-onset Alzheimer's disease (AD) were compared to 16 age-matched neurologically normal controls for the presence of white matter subcortical hyperintensities (SCH) and periventricular hyperintensities (PVH). Patients with AD were significantly more likely to have evidence of PVH (p less than 0.01) than age-matched controls. There was no significant difference between the two groups in either the frequency of SCH or the size of the largest lesion. Within the AD group, there was no difference demonstrated in the location of the SCH, either in the anterior-posterior plane or between the two hemispheres. Patients with AD more frequently demonstrated ventriculomegaly (p less than 0.001) and sulcal widening (p less than 0.05) compared with controls. This study suggests that the SCH seen in early-onset AD patients on MRI are related more to the aging process than to the AD process and that the increased frequency of PVH may have a relationship to the disease process.

We examined the relationship between platelet [3H]-imipramine binding and leukoencephalopathy as assessed by 1.5 Tesla Magnetic Resonance Imaging (MRI) in 21 elderly depressed patients who satisfied DSM-III criteria for major depression. Both drug-free platelet [3H]-imipramine binding and brain MRI studies were obtained during the same episode of depression. Our findings show a significant inverse relationship between frequency of subcortical hyperintensity (SCH) and the number (Bmax) of platelet [3H]-imipramine binding sites. Patients with Bmax less than 850 fmol/mg protein had significantly larger SCH compared with patients with a higher Bmax. These data provide further support to the potential use of platelet [3H]-imipramine binding studies and brain MR imaging as diagnostic adjuncts in geriatric depression and suggest, moreover, that these two biological markers may be linked in geriatric patients with depression.

Elderly patients are particularly sensitive to the neurologic side effects of psychotropic medications. This increased sensitivity may be related to brain structural changes associated with aging. In this pilot study, the authors report on the occurrence of caudate hyperintensities, using brain magnetic resonance imaging, in seven elderly depressed subjects who developed neuroleptic-induced parkinsonism. Caudate hyperintensities were not observed in any of the seven healthy elderly controls examined. These results suggest that caudate hyperintensities may render some elderly depressed patients susceptible to neuroleptic-induced parkinsonism.

Magnetic resonance images centered at the pituitary stalk were used to measure pituitary gland size in 19 patients with major depression compared with that in age- and sex-matched controls. Depressed patients had significantly greater pituitary cross-sectional area (P = 0.0009) and volume (P = 0.007) than the controls. This difference was particularly prominent in elderly depressed patients compared to elderly controls. These results provide the first demonstration of structural alterations in the pituitary gland in major depression.

1. The frequent occurrence of hypothalamo-pituitary dysfunction in patients with eating disorders as well as prior reports that nutritional and endocrine status influence pituitary morphology, led us to hypothesize that pituitary size and shape may be altered in patients with eating disorders. 2. Magnetic resonance imaging (MRI) does not use ionizing radiation and is currently one of the most feasible modalities available to study the pituitary gland in vivo. Using MRI, we have previously reported in a preliminary study that female patients with eating disorders had significantly smaller pituitary glands than controls. In addition MRI excluded any pituitary mass lesions. 3. In this report, we confirm our previous MRI findings and provide further evidence of pituitary abnormalities in an expanded sample of eating disorder patients. Preliminary data on pituitary volume estimates from MRI scans are provided for a subset of patients and controls.

The authors describe the brain magnetic resonance imaging results and the clinical courses of three patients with late-onset psychoses who were treated with electroconvulsive therapy (ECT). Consistent with previous work, preexisting structural brain changes were present in all three patients. The two patients with the more severe structural changes (lateral ventricular enlargement and large deep-white-matter hyperintensities) failed to respond to ECT. In addition, all three patients had caudate hyperintensities and developed a prolonged interictal ECT-induced delibrium. These observations are also consistent with previous studies that have reported that patients with caudate hyperintensities may be at an increased risk for developing an interictal delirum during a course of ECT.

A prolonged (interictal) but reversible delirium was induced by electroconvulsive therapy (ECT) in 10 of 87 (11%) elderly depressed patients. Brain magnetic resonance imaging (MRI) revealed several structural abnormalities, particularly basal ganglia and moderate to severe subcortical white-matter lesions, in the patients who developed delirium. These findings are consistent with several lines of data that have implicated the basal ganglia and subcortical white matter in the development of delirium from other causes and suggest that lesions in these areas may predispose one to developing an interictal delirium during a course of ECT.

We used sagittal and coronal T1 weighted magnetic resonance images, at 1.5 Tesla, to measure the height, width, length, and cross-sectional area and to generate two estimates of pituitary gland volume in 35 normal volunteers aged 26-79 yr (19 females and 16 males). Subjects over 50 yr of age had significantly smaller pituitary gland height (P = 0.03), area (P = 0.04), and volume (P = 0.04) than those under 50 yr (by two-tailed t test). Overall, age was negatively correlated with pituitary volume (V1: r = -0.51; P = 0.003; V2: r = -0.47; P = 0.008), area (r = -0.43; P = 0.009), and height (r = -0.46; P = 0.005), but not with pituitary length or width. There were no statistically significant differences in pituitary size between men and women (by two-tailed t test). These findings suggest that pituitary gland height provides a good single measure for the assessment of pituitary gland size and that age must be controlled for in studies of pituitary gland size.

We examined magnetic resonance (MR) scans of the heads of 8 patients with late onset psychosis and 8 aged controls. Although some patients had mild cognitive impairment, none had depression or a history or examination suggesting focal brain disease. Thus, all patients met DSM-III-R criteria for late-onset schizophrenia. All 8 patients showed significant leukoencephalopathy or vascular pathology on MR imaging, and temporoparietal and occipital lesions were especially prominent. Little such pathology was evident on control scans. We suggest that focal brain disease of vascular origin may be associated with late-onset psychosis, and that MR scanning of such cases may provide important clues to pathogenesis.

Magnetic resonance imaging (MRI) of the brain was used to examine the morphology and dimensions of the pituitary gland in 18 patients with eating disorders (8 anorectics and 10 bulimics), in comparison with 13 healthy volunteers. None of the 18 patients with anorexia or bulimia had any radiological evidence suggestive of pituitary macroadenoma, cyst, or empty sella. Measurements revealed that the anorectics and bulimics had smaller pituitary gland cross-sectional areas (p less than 0.05) and smaller pituitary gland heights, compared with healthy controls. These preliminary findings in anorectics and bulimics are suggestive of pituitary atrophy secondary to nutritional or endocrine alterations, rather than a primary pituitary pathology.