Abrupt disruption of nicotine addiction and aphaty after strategic acute brain ischemia

167. BAGNATI P, FERNANDEZ SUAREZ M, RODRIGUEZ J, CHREM P, CALVAR J, VENTRICE F, MELI F, CAMPOS J, AMENGUAL A, COHEN G, RUSSO A, ALLEGRI R

Congreso; Annual Meeting of the American Academy of Neurology; 2013

American Academy of Neurology

OBJECTIVE: To analyze shared mechanism of nicotine addiction and apathy by clinical assessment, magnetic resonance imaging (MRI) and Difussion Tensor Imaging(DTI). BACKGROUND: Cigarette addiction is related to the reward pathway that includes the tegmental area connected by the medial forebrain bundle (MFB) to the hypotalamus, accumbens nucleus (NAcc) and the fronto orbital cortex (FO). Apathy is related to the damage of the cingulated gyrus and disruption of networks connecting frontal structures with caudate nucleus, pallidum and thalamus. DESIGN/METHODS: RMI 1,5 tesla MRI and DTI, neuropsychiatric and cognitive assessment. RESULTS: A 62 year old patient with a history of active smoker (30 pack/year), Fagerström Nicotine Dependence Scale: 6 developed sudden onset of apathy (Starkstein Apathy Scale:38) with spontaneous cessation of cigarette smoking without withdrawal symptoms. Social withdraw and indifference was reported by relatives. No significant depressive symptoms were detected. Social Perception measured by "Reading the Mind in the Eyes" Test was abnormal. MRI showed an acute right FO stroke (medial and lateral FO cortex, frontal pole and underneath white matter); DTI showed decreased fiber density of cingulated bundle, uncinate faciculus and medial forebrain bundle in the right. NAcc was preserved. Old ischemic strokes located in the left caudate head and pallidum were detected as well. CONCLUSIONS: Immediate smoke cessation without withdrawal symptoms was observed after a FO lesion with disruption of pathways related to reward. Apathy is unusual in a small frontoorbital lesion. The cingulum bundle was affected without any evidence of anterior cingulum injury, suggesting that some circuits from FO cortex that are passing trough were theoretically related to apathy development. Apathy and smoke cessation could have been related to a "functional" bilateral fronto-subcortical circuit damage due to the combination of old left pallidal and caudate stroke with a deaferentation of the right basal ganglia.