Amnesia in the ER: That Ghajini Moment!!! A Case series

Vidya Saketharaman*, Aslesha Vijaay Seth

Department of Emergency Medicine, Kauvery Hospital, Chennai, India

Background

“Sometimes you will never know the true value of a moment until it becomes a memory”- Theodore Seuss Giesel [1].

Being a department of variety and unpredictability that baffle and keep the adrenalin pumping, we often see a number of unique presentations. I have herewith compiled a case series on patients who presented to ER with amnesia.

Physiology of memory formation

“A picture is worth thousand words, but memory is priceless” Henrik Ibsen [2].

Immediate	5 mins duration, highly vulnerable to distraction	Perisylvian cortex, frontal lobe
Recent memory
Explicit memory	Facts, events, requires conscious retrieval	Medial temporal lobe, mammillothalamic and dorsomedial thalamic nucleus
Implicit memory	Procedural skills, "automatic"	Cerebellum, sensory association cortex
Remote memory		Appropriate association cortex
Sensory memory		Occipital cortex (visual), temporal cortex(auditory)

Ghajini 1

A 33/M, with h/o transient memory loss without associated neurological findings.
Immediate memory normal, recent memory loss, remote memory intact.
MRI brain normal, EEG was normal.

Provisional Diagnosis: Transient global amnesia

Patient was started on antiplatelets prophylactically

Ghajini 2

A 62 /F with h/o memory loss, without neurological deficits.
Immediate memory intact, recent memory loss, remote memory impaired.
MRI brain showed hippocampal sclerosis. EEG showed epileptic spikes in the temporal lobe.
Provisional Diagnosis: Temporal Lobe epilepsy.
Patient was offered surgical treatment; she declined and was started on antiepileptics.

Ghajini 3

A 45 /M fell down from the bus; came to ER with loss of memory and nasal bleeding.
Only recent memory was lost.
CT brain was normal.
However, in view of persistent cognitive disturbances, MRI brain was done which showed punctate hemorrhages.
Diagnosis: Traumatic Brain Injury sequelae.
Patient was conservatively managed.

Ghajini 4

22/F was brought with gradual onset memory loss for 5 days.
Immediate memory was intact, recent and remote memory was affected.
MRI Brain showed hyperintensities in mesotemporal regions.
Diagnosis: Herpes simplex encephalitis.
Patient improved with antivirals.

Ghajini 5

57/M ethanolic came with h/o memory loss; immediate memory was impaired, recent memory impaired (explicit), remote memory impaired.
Memory falsifications.
MRI Brain showed hyperintensities in bilateral mamillary bodies.
Serum Vitamin B1 levels were low.
Diagnosis: Korsakoff Syndrome.
Korsakoff’s syndrome is a disorder that primarily affects the memory system in the brain. It usually results from a deficiency of thiamine (vitamin B1), which may be caused by alcohol abuse, dietary deficiencies, prolonged vomiting, eating disorders, or the effects of chemotherapy.
Patient was started on Thiamine.

Discussion

The enigma of memory has been the subject of curiosity and research for many decades. T. Ribot’s (1881) law of retrograde amnesia states that brain damage impairs recently formed memories to a greater extent than older memories, which is generally taken to imply that memories need time to consolidate [4]. A. Jost’s (1897) law of forgetting states that if 2 memories are of the same strength but different ages, the older will decay more slowly than the younger [4]. The investigation of choice for the management of amnesia in Emergency was usually the MRI brain. The many faces of amnesia communicate the pathology significantly with this imaging and determine the prognosis of the condition. All of the cases discussed above had tell-tale signs for the respective diagnosis.

Conclusion

“To know and to remember are two different things”

Amnesia is a condition where history is obtained second-hand from the attendee mostly, but still remains the foundation stone to managing the condition in the emergency department.

References

[1] https://www.goodreads.com/quotes/7488453-you-never-know-the-value-of-a-moment-until-it

[2] https://en.wikipedia.org/wiki/A_picture_is_worth_a_thousand_words#:~:text=%22A%20picture%20is%20worth%20a,than%20a%20mere%20verbal%20description.

[3] Reto Bisaz et al The neurobiological bases of memory formation: from physiological conditions to psychopathology, Psychopathology. 2014;47(6):347-56.

Dr. Vidya Saketharaman

Emergency Care

Dr. Aslesha Vijaay Sheth

Consultant & Clinical Lead

Amnesia in the ER: That Ghajini Moment!!! A Case series