Correspondence
A compulsive collecting behavior following an
A-com aneurysmal rupture
To the Editor: I was intrigued by the beautifully described and
investigated case of “compulsive collecting” associated with orbito-
frontal and caudate injury described by Hahm et al.1 It immedi-
ately made me think of a patient I saw some years ago with
orbitofrontal damage from a head injury, who suddenly developed
compulsive toasting. He would rise to his feet when dining in
restaurants, clear his throat loudly to command attention, and
propose a toast to Her Majesty the Queen. The diners around him
would be surprised, but rise to their feet and obediently lift their
glasses. A minute or two later, the performance would be repeat-
ed—this toast, perhaps, to the Lord Mayor of London. Other
toasts, increasingly absurd, would follow at frequent intervals,
until his embarrassed family had to take him from the restaurant.
This patient, like Hahm’s, seemed to enjoy his toasting, but (while
of considerable intelligence) showed no insight into it. He showed
nothing of the disinhibited cursing or joking one often sees in
orbitofrontal syndromes (and, sometimes, with the caudate in-
volvement in Tourette’s syndrome and Huntington’s chorea)—
only this one behavior of pathological toasting.
Oliver Sacks, MD, New York, NY
Reply from the Authors: We are honored to receive comments
from Dr. Oliver Sacks. We have read and enjoyed his books, in-
cluding The Man Who Mistook His Wife for a Hat and Other
Clinical Tales. We agree with Dr. Sacks’ notion that his patient’s
pathological toasting behavior is similar to our patient’s patholog-
ical collecting and, we think, also with pathological car stealing
(or borrowing) described by Cohen et al.2 The three patients de-
nied any obsession. Rather, they seemed to get pleasure from the
behavior and had no insight into it being inappropriate. Also,
their behaviors were restricted to one specific item or acts and
would not occur unless they were exposed to specific situations.
Therefore, in the dimension of compulsivity and impulsivity of
obsessive-compulsive disorder (OCD) spectrum,3 these patients’
behavior may fall on the impulsive end, although among three
patients, only the behavior of the Cohen et al. patient was harm-
ful or risk seeking. One of the anonymous reviewers of our paper
suggested that it would be provocative to propose the addition of
“impulse control disorder (ICD) secondary to a general medical
condition” to “Impulse-Control Disorders not Elsewhere Classi-
fied” in DSM-IV.4 Dr. Sacks’ unique case reinforces the existence
of such a disease entity and the acquired ICD may be associated
with orbitofrontal–subcortical injury.
Dong Seok Hahm, MD, Duk L. Na, MD, Seoul, Korea
Copyright © 2001 by AAN Enterprises, Inc.
References
1. Hahm DS, Kang Y, Cheong SS, Na DL. A compulsive collecting behav-
ior following an A-com aneurysmal rupture. Neurology 2001;56:398 –
400.
2. Cohen L, Angladette L, Benoit N, Pierrot-Deseilligny C. A man who
borrowed cars. Lancet 1999;353(9146):34.
3. Stein DJ. Neurobiology of the obsessive-compulsive spectrum disorders.
Biol Psychiatry 2000;47:296 –304.
4. American Psychiatric Association. Diagnostic and statistical manual of
mental disorders, 4th ed. Washington, DC: American Psychiatric Asso-
ciation, 1994.
Carotid endarterectomy: Another wake-up call
To the Editor: I read with interest the article and editorial on
carotid endarterectomy (CE).1 Two important points were not ad-
dressed:
1) Will carotid stenting nearly entirely replace endarterectomy
as the treatment of choice? In selected centers and in the hands of
1118 NEUROLOGY 56 April (2 of 2) 2001
experienced operators, the mortality and morbidity is under 1%;
e.g., Dr. Gary Roubin, who has performed over 700 procedures
(personal communication, June 5, 2000).2 Unfortunately, there is a
significant learning curve that has limited the widespread appli-
cation of this useful technique.
2) Can the estimated 1% risk of stroke during conventional
angiography quoted in the article (presumably for selective four-
vessel studies) be decreased by the use of a less-eloquent but safer
aortic arch study in patients able to tolerate the additional dye?
Joseph S. Jeret, MD, Rockville Centre, NY
Reply from the Editorial’s Authors: The replacement of CE by
any other vascular interventional procedure cannot be considered
seriously until the new technique has been evaluated by highly
disciplined clinical trials. The trials must enroll similar patients
randomized to receive either endarterectomy or stenting. All char-
acteristics of the patients will have to be as comparable as ran-
domization will allow; the baseline of investigations must be
comparable, and experts in performing CE, accredited experts in
angioplasty/stenting, and stroke neurologists must be on the team
in each center.
A trial designed to compare stenting with CE with immediate
and long-term stroke and death outcomes in symptomatic patients
will require approximately 3000 patients to be credible. Because of
the better outlook for asymptomatic subjects with carotid stenosis,
the required sample size would be approximately 12,000. First a
trial must be completed that evaluates this new technology in
patients at higher risk and who stand to gain most from any
effective therapy. Stenting in asymptomatic subjects, the subject
of the editorial referred to by Dr. Jeret, is not advisable before the
completion of trials in symptomatic patients.
Carotid stenting is still in the experimental stage. Individual
case series such as the one quoted by Dr. Jeret will not accredit
therapy. Such data are no more acceptable in deciding upon the
value of carotid stenting for prevention of stroke than are data
about a new drug proposed without a group of control subjects
taking standard therapy. North American and several European
trials, if well designed, executed, and analyzed, hopefully will
answer Dr. Jeret’s question in a few years.
Expert neuroradiologists commonly regard an aortic flush as
giving inferior information to a selective catheterization. The
feared intraluminal clot may be missed, as will information about
the extent of intracranial disease and the extent of collateral cir-
culation.3,4 Within a few years advances in imaging may render
conventional angiography obsolete. Some are optimistic that this
point has been reached. Others are more cautious.5
H.J.M. Barnett, MD, London, Ontario, Canada;
J.P. Broderick, MD, Cincinnati, OH
Copyright © 2001 by AAN Enterprises, Inc.
References
1. Barnett HJM, Broderick JP. Carotid endarterectomy: another wake-up
call. Neurology 2000;55:746 –747.
2. Jeret JS. Systematic comparison of the early outcome of angioplasty and
endarterectomy for symptomatic carotid artery disease. Stroke 2000;31:
2522–2523. Letter.
3. Kappelle LJ, Eliasziw M, Fox AJ, Barnett HJM, for the North American
Symptomatic Carotid Endarterectomy Trial (NASCET) Group. Long-
term prognosis of patients with unruptured intracranial aneurysms and
symptomatic internal carotid artery stenosis. Neurology 2000;55:307–
309.
4. Henderson RD, Eliasziw M, Fox AJ, Rothwell PM, Barnett HJM, for the
North American Symptomatic Carotid Endarterectomy Trial (NASCET)
Group. Angiographically defined collateral circulation and the risk of
stroke in patients with severe carotid artery stenosis. Stroke 2000;31:
128 –132.
5. Rothwell PM, Pendlebury ST, Wardlaw J, Warlow CP. Critical appraisal
of the design and reporting of studies of imaging and measurement of
carotid stenosis. Stroke 2000;31:1444 –1450.
 A compulsive collecting behavior following an A-com aneurysmal rupture
Oliver Sacks
Neurology 2001;56;1118
DOI 10.1212/WNL.56.8.1118

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