Possible causes of cognitive decline

Cerebral autosomal-dominant arteriopathy with subacute infarcts and leukoencephalopathy is a phenotypically heterogenous disease. Although the parents of the patient we described1 were asymptomatic by history, one of them could well have harboured the same R182C mutation in the Notch3 gene as did the proband. We suggested a new mutation as a possibility only.

We did not test the patient for fasting serum homocysteine levels because the result would not have changed management. To date, it has not been shown that a reduction in homocysteine levels reduces clinical events in terms of stroke or any other vascular disease.2 Nevertheless, we routinely counsel all stroke patients to eat sufficient fruits and green leafy vegetables to ensure that they receive enough B vitamins including pyridoxine, folic acid and cobalamin.

The patient was not initially treated with a statin agent. Since diagnosis, we have observed elevation of his total cholesterol and have begun treatment with a statin. In our opinion, it is more likely that this therapy will result in slowing, rather than acceleration, of the dementing process.3

Michael D. Hill Jessica E. Simon Calgary Stroke Program University of Calgary Calgary, Alta.