association between wakeboarding and ICA dissection, and fosterfurther reporting of similar cases.

References

1. Hostetler SG, Hostetler TL, Smith GA, et al. Characteristics of water skiing-relatedand wakeboarding-related injuries treated in emergency departments in theUnited States, 2001–2003. Am J Sports Med 2005;33:1065–70.

2. Chia JK, Goh KY, Chan C. An unusual case of traumatic intracranial hemorrhagecaused by wakeboarding. Pediatr Neurosurg 2000;32:291–4.

3. Carson Jr WG. Wakeboarding injuries. Am J Sports Med. 2004;32:164–73.4. Touze E, Gauvrit JY, Moulin T, et al. Risk of stroke and recurrent dissection after a

cervical artery dissection: a multicenter study. Neurology 2003;61:1347–51.5. Gonzales-Portillo F, Bruno A, Biller J. Outcome of extracranial cervicocephalic

arterial dissections: a follow-up study. Neurol Res 2002;24:395–8.6. Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis,

and outcome. Lancet Neurol 2009;8:668–78.7. Engelter ST, Brandt T, Debette S, et al. Antiplatelets versus anticoagulation in

cervical artery dissection. Stroke 2007;38:2605–11.8. Lucas C, Moulin T, Deplanque D, et al. Stroke patterns of internal carotid artery

dissection in 40 patients. Stroke 1998;29:2646–8.

doi:10.1016/j.jocn.2011.02.013

1260 Case Reports / Journal of Clinical Neuroscience 18 (2011) 1260–1261

Transient global amnesia during a professional cello concert

Kiran Thakur, Allan Ropper ⇑Brigham and Women’s Hospital, Department of Neurology, 75 Francis Street, Boston, Massachusetts 02115, USA

a r t i c l e i n f o

Article history:Received 29 March 2010Accepted 26 January 2011

Keywords:MemoryMusicTransient global amnesia

a b s t r a c t

Transient global amnesia (TGA) is a great curiosity in medicine, the underlying pathophysiology of whichremains under debate. When an episode occurs during the performance of a task requiring refined tech-nical skills and an intense level of concentration such as a musical performance, it draws attention to therelationship between memory and performance. It also raises questions of access to procedural memoryand other aspects of stored information. We encountered a renowned and highly proficient musician whowas amnestic for a challenging concert.

� 2011 Elsevier Ltd. All rights reserved.

1. Introduction

Transient global amnesia (TGA) is a great curiosity in medicine,the underlying pathophysiology of which remains under debate.When an episode occurs during the performance of a task requiringrefined technical skills and an intense level of concentration, suchas a musical performance, it draws attention to the relationshipbetween memory and performance. It also raises questions ofaccess to procedural memory and other aspects of stored informa-tion. We encountered a renowned and highly proficient musicianwho was amnestic for a challenging concert.

2. Case report

A 74-year-old right-handed world-renowned cellist wasexamined several days after he had transient memory loss thatencompassed an entire musical performance. The patient had anexceptional natural ability in music when he began playing thecello at 15 years of age. He had advanced enough by the time hewas 17 years old to attend Prades France, and studied at theJulliard School of music at 19 years. Following his training, hejoined a nationally prominent orchestra when he was 28 years old.

On the morning of the concert he remembers having breakfastwith his wife and driving to the concert hall. He had his usualdegree of anxiety prior to a performance, but otherwise felt well.Approximately half an hour prior to entering the stage, the patientspoke with the concert coordinator backstage. They discussed thepieces he was going to play and the patient expressed his nervous-

⇑ Corresponding author. Tel.: +1 617 732 8047; fax: +1 617 975 0978.E-mail address: aropper@partners.org (A. Ropper).

ness to her. She did not appreciate any unusual behavior duringtheir conversation. He went on stage at noon and recalls playingthe first several notes of ‘‘Suite no. 3 in C major, BWV 1009, byJohann Sebastian Bach’’ but does not recall anything further ofhis 30 minute concert. The second piece, ‘‘Sonata for Solo Cello,Opus 8 by Zoltán Kodály’’, is considered by cognoscenti to be oneof the hardest cello pieces ever written, requiring 30 minutes ofcontinuous complex musicianship. Between the two pieces, he re-mained on stage and did not interact with anyone in the concerthall. There was a five minute intermission between the two pieces.The patient played both pieces from memory. According to audi-ence members including his wife and a musician we interviewed,he played perfectly.

After the performance he proceeded backstage to meet the con-cert director and repeatedly reintroduced himself to her. The con-cert director called the musician’s wife backstage because of thisstrange behavior. The patient appeared physically well and wasoriented but could not provide any details of the musical pieceshe had just performed. His wife asked their son to bring the patienthome, now approximately three hours after the beginning of theperformance. His son describes his father acting himself, notrepeating questions, and able to direct him home. The only unusualbehavior that the patient’s son noted was that he was unable to de-scribe any details of the performance. The patient was able, dayslater, to report some memory of driving home with his son and re-calls all events in the evening, four hours after the start of theconcert.

The following morning, he found that the two bottom strings ofhis cello were re-tuned to the lower register required for the Sona-ta by Kodály – this struck him as odd and was his only indicationthat he had played this piece the day before.

One day after the event, his vital signs, orientation, fund ofknowledge, naming, repetition, serial subtraction of sevens, praxis,and writing were normal. He knew the president, vice president,and secretary of state. On three-step Luria hand tasks, he reversedthe first and second maneuvers until the fourth try. He was able todescribe the precise route he drove to the concert hall. His memoryfor distant past events was preserved. At that time and again 1week later he was unable to provide any information about theconcert he had played and was aware of these events only by dis-cussions with his wife.

He had had a previous transient episode of memory loss 2.5years previously while playing a Beethoven duet with his daughteron viola in concert. His wife recalls having tea after the concert andher husband asking repetitive questions such as ‘‘where are we?’’and ‘‘what are we doing here?’’ He was unable to provide anyinformation about the concert he had performed a few minutespreviously. His symptoms lasted about 12 hours. He was seen inthe emergency department and found to have a normal neurolog-ical examination athough he was unable to provide any details ofhis performance or events of the day. An brain MRI and magneticresonance angiogram showed non-specific white matter changesand mild right internal carotid stenosis.

3. Discussion

This eminent musician who had transient global amnesia dur-ing a complex musical performance is of interest beyond theexceptional circumstances in which the episode occurred. All thecharacteristics of the original descriptions of TGA offered by Benonin 1909 and by Fisher and Adams in 1958 occurred in the patientincluding anterograde amnesia and repetitive questioning. Thediagnostic criteria for TGA offered by Hodges et al. include anattack witnessed by a observer of loss of recent memory, an ab-sence of clouding of consciousness or other cognitive impairment,the absence of focal neurological signs or deficits during or afterthe attack, no features of epilepsy, and resolution of the attackwithin 24 hours.1,2 Attacks may be precipitated by the Valsalvamaneuver, physical activity, or psychological stress.3 The concertvenue was small, though formal, and not imbued with specialmeaning for the patient, having played there before. In our patient,a degree of anxiety prior to his musical performance and perhapsthe need for phased breathing, including breath holding, couldhave been implicated but all of these circumstances were routinefor the patient except for the difficulty of the pieces. Our patientendorses that while playing challenging pieces, his breathing pat-tern is altered in a manner that mimics the rhythmic patterns ofthe music. This change in breathing pattern may have caused de-creased cerebral venous return. Chung et al. showed that leftbrachiocephalic vein occlusion caused retrograde venous flowand decreased cerebral venous return. In their study, abnormalintracranial retrograde venous flow was found in 50% of patientswith TGA, but not in normal control subjects.4 Left brachiocephalicocclusion between the aortic arch and the sternum occurs duringregular breathing and may be enhanced during breath holding.

The recurrence of TGA is an interesting but not atypical featureof this patient. Interestingly, his first episode of TGA was during amusical performance as well. During both musical pieces, thepatient varied his breathing pattern, perhaps increasing the likeli-hood of TGA by the mechanism described above. The function ofmemory in performing complex tasks is undoubtedly important.The role of memory in music was explored by Critchley andHenson.5 In their book, they describe various experiments that fur-ther our understanding of musicians’ ability to encode and remem-ber music. They describe the necessity of having remote memories

so that one can draw upon past auditory and visual experiences toinvoke certain emotions. Recent memory helps identify referencesto previous material within a musical piece. However, the mecha-nisms by which we retrieve music from our general memory storesremains poorly understood.

Audience members observing our patient’s performance notednot only technical perfection but also his own emotional connec-tion to the music. The most artful musical performances are in-fused with feeling, with attunement to the composer’s style, anda musician’s own interpretation of the piece. Can any artistic orcreative performance of this caliber be adequately explained by‘‘procedural memory’’? Our musician describes practicing chal-lenging pieces such as those played during this concert hundredsof times to engrain the pieces into his memory. He practices indi-vidual portions of these complicated pieces to create what he de-scribes as a hierarchical scheme in his mind. Thus, he buildsupon each preceding portion from the previous notes he hasplayed. His ability to play the pieces from memory is derived fromthis hierarchical scheme. Like many musicians, the manner bywhich our patient practices these musical pieces makes it feasibleto retrieve them from his long-term memory store and play withtechnical perfection.

In contrast to the usual report of TGA, our patient did not pauseto repeatedly inquire as to what portion of the performance he hadcompleted. This may have been the result of the unusual circum-stances of a solo musical performance without assistance. Alterna-tively, it offers an insight into the moment of onset of TGA. If thefundamental disorder begins during a procedure, it may perplexthe patient in a way that obligates repetitive questioning; if itstarts afterwards, retrograde amnesia may simply extend to theepoch of the act. It is indeed plausible that our patient experiencedthe onset of his amnestic episode towards the end of his perfor-mance or alternatively after his performance was completed. If thisis the case, he experienced retrograde amnesia while he was play-ing the concert. His ability to retune his cello for the Kodály and hisability to play the two pieces sequentially suggests that his seman-tic memory function was intact. Previous studies have shown theshort duration and temporal gradient of memory loss during theperiod of retrograde amnesia in TGA.6 Our study suggests thatthe period of retrograde amnesia was at least 50 minutes, a longerduration of retrograde amnesia than previously described. Thiscase exemplifies the need for further exploration of the relation be-tween musical memory and neuronal function. As has been re-marked, ‘‘the great difficulty in the scientific study of the arts isthat human perception of qualities and patterns is far ahead ofanything which science can apprehend at the present time’’.7

Acknowledgement

This report was written with the cooperation and assent of thepatient.

References

1. Hodges JR, Warlow CP. Syndromes of transient amnesia: towards a classification– a study of 153 cases. J Neurol Neurosurg Psychiatry 1990;53:834–43.

2. Hodges JR, Warlow CP. The etiology of transient global amnesia: a case controlstudy of 114 cases with prospective follow-up. Brain 1990;113:639–57.

3. Lewis SL. Etiology of transient global amnesia. Lancet 1998;352:397–9.4. Chung CP, Hsu HY, Chao AC, et al. Detection of intracranial venous reflux in

patients of transient global amnesia. Neurology 2006;66:1873–7.5. Critchley M, Henson RA, editors. Music and the brain: studies in the neurology of

music. London: Heinemann; 1977.6. Kritchevsky M, Squire LR. Transient global amnesia. Evidence for extensive,

temporally graded retrograde amnesia. Neurology 1989;39:213.7. Poser CM. The book forum. Music and the brain: studies in the neurology of

music. JAMA 1977;238:1185.

doi:10.1016/j.jocn.2011.01.009

Case Reports / Journal of Clinical Neuroscience 18 (2011) 1260–1261 1261