Assessment of Social Cognition and Theory of Mind: Initial Validation of the Geneva Social Cognition Scale.

BACKGROUND: Social cognition is widely studied in neurology. At present, such evaluations are designed for research or for specific diseases and simple general clinical tools are lacking. We propose a clinical evaluation tool for social cognition, the Geneva Social Cognition Scale (GeSoCS). METHODS: The GeSoCS is a 100-point scale composed of 6 subtests (theory of mind stories, recognition of social emotions, false beliefs, inferences, absurdity judgement and planning abilities) chosen from different validated tests of social and cognitive evaluation. Eighty-four patients with neurological disorders and 52 controls participated in the study. Evaluation duration lasted 20-60 min. RESULTS: Mean scores were 92.6 ± 4.5 for controls and 76.5 ± 15.3 for patients and differentiate patients and controls in all subtests. With a cut-off score of 84, the scale had a sensitivity of 62% and a specificity of 94%. In our stroke subgroup, right CVAs failed in cartoons, inferences, 'mind in the eyes', and in the temporal rule task while left CVAs were impaired in verbal/discourse tasks (social cognition, inferences, absurd stories, and cartoons. CONCLUSIONS: The GeSoCS is a medium duration assessment tool that appears to detect and characterize significant social impairment in neurological patients.

Cost of detecting a chronic solvent encephalopathy case by screening.

BACKGROUND: Stepwise screening of chronic solvent encephalopathy (CSE), using a postal survey followed by clinical examinations, has been shown to detect symptomatic exposed workers with an occupational disease even in industrialized countries with long-term, but relatively low dose exposure. Previous studies have suggested under-detection and late recognition of CSE, when work ability is already markedly reduced. AIMS: The aim was to estimate the cost of detecting one new CSE case by screening and diagnostics, to estimate the career extension needed to cover the cost of screening, and to study the work ability of the CSE cases. METHODS: A financial analysis of stepwise postal CSE screening followed by clinical examinations (SPC screening) was carried out, and the results were compared to those of the group of CSE cases referred to the Finnish Institute of Occupational Health (FIOH) by the existing national practice of occupational health services (OHS screening). The work ability of the SPC screened CSE cases was studied in relation to the retirement rate and the Work Ability Index (WAI). RESULTS: An analysis of the costs of detecting a new verified CSE case revealed them to be approximately 16,500 USD. Using the mean monthly wages in the fields concerned, we showed that if a worker is able to continue working for four months longer, the screening covers these costs. The cost for detecting a CSE case was twenty times higher with the existing OHS routine, when actualized according to the national guidelines. A CSE case detected at an early stage enables occupational rehabilitation or measures to decrease solvent exposure. The retirement rate of the SPC screened CSE cases was significantly lower than that of the OHS screened cases (6.7% vs. 74%). The results suggest that SPC screening detects patients at an earlier stage of the disease, when they are still capable of working. Their WAI sores were nevertheless lower than those of the general population, implying a greater risk of becoming excluded from the labor market. CONCLUSION: Stepwise screening of CSE using a postal survey followed by clinical examinations detected new CSE cases at lower costs than existing OHS screening routines. Detecting CSE at an early stage prevents early retirement.

How do you know when your patient is "waking up": coma recovery assessment in a complex continuing care setting.

Coma, vegetative state (VS) and minimally conscious state (MCS) are disastrous outcomes following severe traumatic brain injury. Due to the extent of the resultant neurological deficits including hemisphere damage, loss of cellular integrity, altered and abnormal movements such as flexor and extensor patterns, and alterations in cranial nerve function, it can become difficult for the interprofessional team to identify when a patient is emerging from their coma. The Glasgow Coma Scale (GCS), commonly used to assess patients with traumatic brain injury (TBI) is not comprehensive or sensitive enough to provide concrete evidence that a patient is emerging from VS to an MCS. The purpose of this paper is to present a case study of a patient who has emerged from a persistent VS to promote a deeper understanding of what is involved when working with this clientele. Challenges in assessment of cognitive functioning, the development of successful communication through the use of technology and the goals of therapy amongst the various health team members will be provided. Collaborative support with the family will also be discussed. Members of the interprofessional team explored the literature to determine coma recovery assessment tools and best evidence guidelines to direct their interventions with this patient.

Promoting adaptive behavior in persons with acquired brain injury, extensive motor and communication disabilities, and consciousness disorders.

These two studies extended the evidence on the use of technology-based intervention packages to promote adaptive behavior in persons with acquired brain injury and multiple disabilities. Study I involved five participants in a minimally conscious state who were provided with intervention packages based on specific arrangements of optic, tilt, or pressure microswitches (linked to preferred environmental stimuli) and eyelid, toe and finger responses. Study II involved three participants who were emerging from a minimally conscious state and were provided with intervention packages based on computer presentations of stimulus options (i.e., preferred stimuli, functional caregiver's procedures, and non-preferred stimuli) and pressure microswitches to choose among them. Intervention data of Study I showed that the participants acquired relatively high levels of microswitch responding (thus engaging widely with preferred environmental stimuli) and kept that responding consistent except for one case. Intervention data of Study II showed that the participants were active in choosing among preferred stimuli and positive caregivers' procedures, but generally abstained from non-preferred stimuli. The results were discussed in terms of the successful use of fairly new/infrequent microswitch-response arrangements (Study I) and the profitable inclusion of functional caregiver's procedures among the options available to choice (Study II).

Further evidence of validity of the Modified Melbourne Assessment for neurologically impaired children aged 2 to 4 years.

AIM: This paper reports the second phase of a study to extend the Melbourne Assessment for use with children with neurological impairment aged 2 to 4 years. The aim was to establish if (1) children's scores on the Modified Melbourne Assessment (MMA) and the Quality of Upper Extremity Skills Test (QUEST) showed a moderate to high, positive relation, (2) children had comparable behaviours for task and time demands on both tools, and (3) scores on the MMA could discriminate between children with mild, moderate, and severe levels of upper limb impairment. METHOD: An observational study of 30 children (19 males, 11 females) with neurological impairment aged 2 to 4 years. Twenty-four children had spasticity (20 with a unilateral and four with a bilateral impairment) and two children presented with athetosis, two with ataxia, and two with hypotonia. RESULTS: A high, positive relation was found between children's scores on the MMA and the QUEST (ρ=0.90; p=0.001). The clinical use of the MMA was comparable to the QUEST. MMA scores were able to discriminate between children's levels of upper limb impairment as determined by clinicians' ratings (F(2,27) =67.76, p=0.001). INTERPRETATION: These findings suggest the MMA can be clinically useful for children as young as 2.5 years and has the advantage of being valid for use with older children. Scores from the tool can also provide therapists with a quantitative means of consistently reporting level of upper limb impairment.

Magnetic resonance imaging volumetric assessment of the extent of contrast enhancement and resection in oligodendroglial tumors.

OBJECT: Oligodendrogliomas that enhance on MR images are associated with poor prognosis. However, the importance of the volume of enhancing tumor tissue, and the extent of its resection, is uncertain. The authors examined the prognostic significance of preoperative and residual postoperative enhancing tissue volumes in a large single-center series of patients with oligodendroglioma. They also examined the relationship between enhancement and characteristic genetic signatures in oligodendroglial tumors, specifically deletion of 1p and 19q (del 1p/19q). METHODS: The authors retrospectively analyzed 100 consecutive cases of oligodendroglioma involving patients who had undergone T1-weighted gadolinium-enhanced MRI at diagnosis and immediately after initial surgical intervention. The presence of preoperative enhancement was determined by consensus. Preoperative and residual postoperative volumes were measured using a quantitative, semiautomated method by a single blinded observer. Intrarater reliability for preoperative volumes was confirmed by remeasurement in a subset of patients 3 months later. Intrarater and interrater reliability for residual postoperative volumes was confirmed by remeasurement of these volumes by both the original and a second blinded observer. Multivariate analysis was used to assess the influence of contrast enhancement at diagnosis and the volume of pre- and postoperative contrast-enhancing tumor tissue on time to relapse (TTR) and overall survival (OS), while controlling for confounding clinical, pathological, and genetic factors. RESULTS: Sixty-three of 100 patients had enhancing tumors at initial presentation. Presence of contrast enhancement at diagnosis was related to reduced TTR and OS on univariate analysis but was not significantly related on multivariate analysis. In enhancing tumors, however, greater initial volume of enhancing tissue correlated with shortened TTR (p = 0.00070). Reduced postoperative residual enhancing volume and a relatively greater resection of enhancing tissue correlated with longer OS (p = 0.0012 and 0.0041, respectively). Interestingly, patients in whom 100% of enhancing tumor was resected had significantly longer TTR (174 vs 64 weeks) and OS (392 vs 135 weeks) than those with any residual enhancing tumor postoperatively. This prognostic benefit was not consistently maintained with greater than 90% or even greater than 95% resection of enhancing tissue. There was no relationship between presence or volume of enhancement and del 1p/19q. CONCLUSIONS: In enhancing oligodendrogliomas, completely resecting enhancing tissue independently improves outcome, irrespective of histological grade or genetic status. This finding supports aggressive resection and may impact treatment planning for patients with these tumors.

Neurobehavioral assessment as a predictor of neurodevelopmental outcome in preterm infants.

OBJECTIVE: Preterm infants are at risk for neurodevelopmental impairment. The Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS) is a standardized assessment for the neurobehavioral integrity of the newborn. The use of NNNS as a prognostic tool is still emerging. We hypothesized that the NNNS examination performed at term equivalent can detect neurobehavioral alterations in very low birth weight infants and can help in predicting their neurodevelopmental outcome at 18 months corrected age (CA). STUDY DESIGN: This is a prospective study that included preterm infants with birth weight <1500 g and gestational age ≤ 34 weeks. They were evaluated with NNNS at term-equivalent and 12 summary scores were assigned. Infants who had 2 or more NNNS summary scores that were 2 s.d. beyond the mean of the study group were categorized as having abnormal NNNS. Mental Developmental Index (MDI) and Psychomotor Developmental Index (PDI) of Bayley Scales of Infant Development (BSID-II) were determined at 18 months CA. Multiple linear regression models were used to examine the predictivity of the NNNS summary scores for both MDI and PDI. RESULT: A total of 41 infants were evaluated at term and at 18 months CA. The average MDI was 78±15 and the average PDI was 80 ± 14. Significant neurodevelopmental delay was observed in 50% and 31% of infants with abnormal and normal NNNS, respectively. Using multiple linear regression, NNNS was predictive for both MDI (P=0.011, adjusted R (2)=0.295) and PDI (P=0.002, adjusted R (2)=0.441). Lower MDI was associated with less regulation and more nonoptimal reflexes, whereas lower PDI was associated with less regulation, more nonoptimal reflexes, hypertonicity and handling. CONCLUSION: NNNS at term-equivalent age can detect neurobehavioral alterations in very low birth weight infants. Individual summary scores showed significant correlation with both the MDI and PDI at 18 months CA.

Assessment battery for communication (ABaCo): normative data.

The Assessment Battery for Communication (ABaCo) was introduced to evaluate pragmatic abilities in patients with cerebral lesions. The battery is organized into five evaluation scales focusing on separate components of pragmatic competence. In the present study, we present normative data for individuals 15-75 years of age (N = 300). The sample was stratified by age, sex, and years of education, according to Italian National Institute of Statistics indications in order to be representative of the general national population. Since performance on the ABaCo decreases with age and lower years of education, the norms were stratified for both age and education. The ABaCo is a valuable tool in clinical practice; the normative data provided here will enable clinicians to determine different kinds and specific levels of communicative impairments more precisely.

Assessment of damage to cerebral white matter fiber in the subacute phase after carbon monoxide poisoning using fractional anisotropy in diffusion tensor imaging.

INTRODUCTION: Chronic neuropsychiatric symptoms after carbon monoxide (CO) poisoning are caused by demyelination of cerebral white matter fibers. We examined whether diffusion tensor imaging can sensitively represent damage to fibers of the centrum semiovale in the subacute phase after CO intoxication. METHODS: Subjects comprised 13 adult patients with CO poisoning, classified into three groups according to clinical behaviors: group A, patients with transit acute symptoms only; group P, patients with persistent neurological symptoms; and group D, patients with "delayed neuropsychiatric sequelae" occurring after a lucid interval. Median fractional anisotropy (FA) and apparent diffusion coefficient (ADC) of the centrum semiovale bilaterally at 2 weeks were compared between these groups and a control group of ten healthy volunteers. Myelin basic protein (MBP) concentration in cerebrospinal fluid was examined at 2 weeks to evaluate the degree of demyelination in patients. RESULTS: MBP concentration was abnormal or detectable for all group P and group D patients but was undetectable for all patients assigned to group A. Low FA values in groups P and D displaying chronic neurological symptoms clearly differed from those in controls and group A without chronic neurological symptoms, but ADC showed no significant differences between patient groups. CONCLUSIONS: MBP concentration at 2 weeks after CO inhalation confirmed a certain extent of demyelination in the central nervous system of patients who would develop chronic neurological symptoms. In these patients, FA sensitively represented damage to white matter fibers in the centrum semiovale in the subacute phase after CO intoxication.

The assessment of minor neurological dysfunction in infancy using the Touwen Infant Neurological Examination: strengths and limitations.

AIM: Little is known of minor neurological dysfunction (MND) in infancy. This study aimed to evaluate the inter-assessor reliability of the assessment of MND with the Touwen Infant Neurological Examination (TINE) and the construct and predictive validity of MND in infancy. METHOD: Inter-assessor agreement was determined in a sample of 40 infants (24 males, 16 females) aged 3 to 12 months (25 born at term: gestational age 37-41wks, median 39; and 15 born preterm, gestational age 24-35wks, median 32). Thirty typically developing term infants (18 males, 12 females; gestational age 37-42wks, median 40) and 59 preterm infants (34 males, 25 females) born at <35 weeks' gestation (gestational age 25-34wks, median 29) participated in the validity study. They were neurologically assessed with the TINE at the corrected ages of 4, 6, 10, and 12 months and with the Hempel assessment at 18 months. RESULTS: The findings indicated that MND can be assessed reliably (inter-assessor agreement: kappa=0.83). MND during infancy was related to prenatal, perinatal, and social factors, and in particular to preterm birth. Neurological condition during infancy was prone to change, but was related to neurological condition at 18 months at all ages tested. INTERPRETATION: We conclude that MND can be determined reliably in infancy. Important considerations in the construct of MND in infancy are its relation to prenatal and perinatal factors, its limited stability, and its moderate predictive value.

[Mentoring system--performance optimization of treatment by formative case management]. / Das Mentoring-System--Qualitätssteigerung im Rehabilitationsprozess durch gestaltendes Case-Management.

The efficiency of the German public health system and its principle of adequate treatment are not up to the standards required by accident insurance companies. These have to be interested in realising optimal treatment, because the amount of pecuniary reparation essentially depends on (the quality of) the state of health of the injured person. To accomplish these objectives, their case management departments have to find a way to use the resources of the public health system and to improve considerably the quality of process und structure of the treatment. This is why case management is becoming increasingly important for insurance companies. Against this background, this case report describes the process of rehabilitation of a 72-year-old woman who had an accident and suffered a traumatic brain injury. This process was managed by AMB Generali Schadenmanagement GmbH in cooperation with the consulting firm Haase & Johanns Consulting, to develop approaches to rehabilitation management. It describes the mutual benefit for the injured person and of the insurer, which is defined by the success of treatment and saving of costs (care home, damages for pain and suffering) amounting to about 700,000 Euros.

Assessment of visuospatial neglect in stroke patients using virtual reality: a pilot study.

One of the neuropsychological deficits that can result from a stroke is the neglect phenomenon. Neglect has traditionally been assessed with paper-and-pencil tasks, which are administered within the reaching space of a person. The purpose of this explorative study is to investigate whether it is possible to assess neglect in the extrapersonal space based on the performance of acute stroke patients, chronic stroke patients and healthy elderly in orientation and exploration tasks when immersed in a three-dimensional (3D)-virtual environment. Six able-bodied healthy elderly and 12 stroke patients (six subacute and six chronic) participated in this explorative cross-sectional study. Neglect was assessed by means of the 3D neglect test. Different parameters were measured at two challenge levels with increasing difficulty. In the easiest level significant differences between the groups were found for total time spent in the test, mean response time left field of vision, and mean response time in the left field of vision of the left virtual reality environment. Differences in search patterns showed that subacute stroke patients had a much more fuzzy search pattern in scanning the environment than healthy elderly and chronic stroke patients. With respect to the more difficult level results showed significant differences between healthy elderly and the total group of stroke patients. The results of this study suggest that a 3D neglect test by means of virtual reality has the potential to detect and measure unilateral neglect.

Use of specific malingering measures in a Spanish sample.

There are an increasing number of tests available for detecting malingering. However, these tests have not been validated for using in Spanish speakers. The purpose of this study is to explore the value of three specific malingering tests in the Spanish population. This study used a known-groups design, together with a group of analog students. The results show that both the Victoria Symptom Validity Test and the b Test can be used to detect malingering in Spanish population. However, some restrictions must be applied when the Rey 15-Item Test is administered and interpreted.

Development and clinical trial of virtual reality-based cognitive assessment in people with stroke: preliminary study.

Stroke and traumatic brain injury affect an increasing number of people, many of whom retain permanent damage in cognitive functions. Conventionally, cognitive function has been assessed by a paper-based neuropsychological evaluation. However these test environments differ substantially from everyday life. This problem can be overcome by using virtual reality (VR) to objectively evaluate behaviors and cognitive function in simulated daily activities. With our virtual shopping simulation, we compared people who had undergone a stroke with control participants in an immersive VR program that used a head-mounted display (HMD). We evaluated user satisfaction with the tests, complications, and the user interface. Significant differences were consistently found between the stroke group and the control group for the following tasks: stage 1 performance index, interaction error; stage 2 delayed recognition memory score, attention index; and stage 3 executive index (p < 0.001). Perceptive dysfunction, visuospatial dysfunction, level of computer experience, and level of education affected the performance of the stroke group. The frequency of complications in the stroke group, calculated using the cut-off score for the Simulator Sickness Questionnaire, was 9.6% for nausea, 41.9% for oculomotor complications, and 25.8% for disorientation. The frequency of complications between the stroke and control groups was not significantly different. Thirty-five percent of participants in the stroke group and 13% in the control group reported difficulties with using the joystick. This computer-generated VR-based cognitive test shows promise in assessing cognitive function in patients with stroke. More refinements are needed in the user interface and the projection methods.

Attack frequency and disease duration as indicators for brain damage in migraine.

OBJECTIVE: The aim of this study was to pinpoint predilection sites of brain damage in migraine by quantitatively identifying morphometric and diffusion differences in migraineurs, compared with control subjects, and to assess whether migraine attack frequency and attack history are indicators for brain abnormalities in migraineurs. BACKGROUND: Previous clinical neuroimaging investigations introduced the concept of migraine as a progressive brain disease. They reported an increased risk of white matter hyperintensities (WMH) with increasing attack frequency in migraineurs. METHODS: We investigated 28 patients with migraine, using high-resolution T1- and diffusion-weighted magnetic resonance imaging and optimized voxel-based morphometry to localize gray and WM density, and fractional anisotropy and apparent diffusion coefficient differences. RESULTS: We identified predilection sites of brain abnormalities in migraineurs in the frontal lobes, brainstem, and the cerebellum, and we show that both attack frequency and disease duration are indicators for brain damage in migraine. CONCLUSION: Our findings report an unbiased quantitative whole brain assessment of morphological abnormalities in migraine. This might help to identify indicators for migraine as a possibly progressive brain disease. In order to reveal the causes and consequences of brain damage in migraine, further neuroimaging studies have to investigate quantitative brain changes in a longitudinal design.

The ischemic stroke patient who worsens: new assessment and management approaches.

The stroke patient who deteriorates presents a common and rewarding diagnostic challenge. Up to one third of ischemic stroke patients worsen after admission, though the frequency of deterioration is declining with modern supportive care. The causes of clinical worsening are diverse; common etiologies include collateral failure, brain edema, seizures, reocclusion after successful initial therapeutic recanalization, and systemic medical complications. Clot propagation and recurrent embolization are only infrequent mechanisms of worsening. The advent of multimodal computed tomography and magnetic resonance imaging has transformed the evaluation of the deteriorating stroke patient. History, physical examination, screening blood work, and emergent reassessment of the cervical and cerebral vasculatures, regional hypoperfusion, and infarct core will yield a firm diagnosis of the cause of clinical worsening in the majority of patients. The therapeutic armamentarium for the worsening stroke patient has expanded greatly. Treatment options now include rescue late endovascular recanalization therapy, pressor collateral enhancement therapy, hemicraniectomy, and additional novel interventions in addition to enhanced supportive care. Because most causes of worsening can be treated effectively, the deteriorating stroke patient merits a swift and incisive diagnostic and therapeutic response.

[Carotid surgery in regional anesthesia--anesthesiological, neurological and surgical aspects]. / Die Chirurgie der A. carotis in Regionalanästhesie--anästhesiologische, neurologische, chirurgische und ökonomische Aspekte.

Surgery of the carotid artery is justified only if it is performed with low complication rates. The essential advantages of regional anesthesia in comparison to general anesthesia are a secure neuromonitoring, hemodynamic stability and prolonged analgesia. Regional anesthesia for carotid surgery, which is described methodically in this paper, needs only a minor expenditure. Our own data show that patients with a contralateral occlusion of the internal carotid artery and patients with a high risk for surgery (ASA IV) are at a high risk for neurological events during carotid crossclamping. Consequences of regional anesthesia on the surgical procedure are to ignore. The question, whether economic advantages exist for regional anesthesia, cannot yet be answered.