Neurologic Outcome Predictors in Pediatric Intracerebral Hemorrhage: A Prospective Study.

BACKGROUND AND PURPOSE: Intracerebral hemorrhage is a considerable source of morbidity and mortality. This 3-center study describes outcomes of pediatric intracerebral hemorrhage and identifies 2-year neurological outcome predictors. METHODS: Children 29 days to 18 years of age presenting with intracerebral hemorrhage from March 2007 to May 2015 were enrolled prospectively. Exclusion criteria included trauma; intracranial tumor; hemorrhagic transformation of arterial ischemic stroke or cerebral sinovenous thrombosis; isolated subdural, epidural, or subarachnoid hemorrhage; and abnormal baseline neurological function. Intracerebral hemorrhage and total brain volumes were measured on neuroimaging. The Pediatric Stroke Outcome Measure assessed outcomes. RESULTS: Sixty-nine children were included (median age: 9.7 years; interquartile range: 2.2-14). Six children (9%) died during hospitalization. Outcomes in survivors were assessed at early follow-up in 98% (median 3.1 months; interquartile range: 3.1-3.8) and at later follow-up in 94% (median: 2.1 years; interquartile range: 1.3-2.8). Over a third had a significant disability at 2 years (Pediatric Stroke Outcome Measure >2). Total Pediatric Stroke Outcome Measure score improved over time (P=0.0003), paralleling improvements in the sensorimotor subscore (P=0.0004). Altered mental status (odds ratio, 13; 95% confidence interval, 3.9-46; P<0.001), hemorrhage volume ≥4% of total brain volume (odds ratio, 17; 95% confidence interval, 1.9-156; P=0.01), and intensive care unit length of stay (odds ratio, 1.1; 95% confidence interval, 1.0-1.2; P=0.002) were significantly associated with poor 2-year outcome. CONCLUSIONS: Over one third of children experienced significant disability at 2 years. Improvements in outcomes were driven by recovery of sensorimotor function. Altered mental status, hemorrhage volume ≥4% of total brain volume, and intensive care unit length of stay were independent predictors of significant disability at 2 years.

Pediatric intracerebral hemorrhage score: a simple grading scale for intracerebral hemorrhage in children.

BACKGROUND AND PURPOSE: The intracerebral hemorrhage (ICH) score is the most commonly used clinical grading scale for outcome prediction after adult ICH. We created a similar scale in children to inform clinical care and assist in clinical research. METHODS: Children, full-term newborns to 18 years, with spontaneous ICH were prospectively enrolled from 2007 to 2012 at 3 centers. The pediatric ICH score was created by identifying factors associated with poor outcome. The score's ability to detect moderate disability or worse and severe disability or death was examined with sensitivity, specificity, and area under the receiver operating characteristic curve. RESULTS: The pediatric ICH score components include ICH volume>2% to 3.99% of total brain volume (TBV): 1 point; ICH volume≥4% TBV: 2 points; acute hydrocephalus: 1 point; herniation: 1 point; and infratentorial location: 1 point. The score ranges from 0 to 5. At 3-month follow-up of 60 children, 10 were severely disabled or dead, 30 had moderate disability, and 20 had good recovery. A pediatric ICH score≥1 predicted moderate disability or worse with a sensitivity of 75% (95% confidence interval [CI], 59% to 87%) and a specificity of 70% (95% CI, 46% to 88%). A pediatric ICH score≥2 predicted severe disability or death with a sensitivity and specificity of 90% (95% CI, 55% to 99%) and 68% (95% CI, 53% to 80%), respectively. The area under the receiver operating characteristic curve for classifying outcome as severe disability or death was 0.88 (95% CI, 0.78-0.97). CONCLUSIONS: The pediatric ICH score is a simple clinical grading scale that may ultimately be used for risk stratification, clinical care, and research.

Automated perfusion imaging for the evaluation of transient ischemic attack.

BACKGROUND AND PURPOSE: Diffusion-weighted imaging (DWI) is recommended for the evaluation of transient ischemic attack. Perfusion imaging can increase the yield of MRI in transient ischemic attack. We evaluated automated bolus perfusion (the time when the residue function reaches its maximum [TMax] and mean transit time [MTT]) and arterial spin labeling (ASL) sequences for the detection of ischemic lesions in patients with transient ischemic attack. METHODS: We enrolled consecutive patients evaluated for suspicion of acute transient ischemic attack by multimodal MRI within 36 hours of symptom onset. Two independent raters assessed the presence and location of ischemic lesions blinded to the clinical presentation. The prevalence of ischemic lesions and the interrater agreement were 1,410 assessed. RESULTS: From January 2010 to 2011, 93 patients were enrolled and 90 underwent perfusion imaging (69 bolus perfusion and 76 ASL). Overall, 25 of 93 patients (27%) were DWI-positive and 14 (15%) were perfusion-positive but DWI-negative (ASL n=9; TMax n=9; MTT n=2). MTT revealed an ischemic lesion in fewer patients than TMax (7 versus 20, P=0.004). Raters agreed on 89% of diffusion-weighted imaging cases, 89% of TMax, 87% o10f010 MTT, and 90% of ASL cases. The interrater agreement was good for DWI, TMax, and ASL (κ=0.73, 0.72, and 0.74, respectively) and fair for MTT (κ=0.43). Diffusion and/or perfusion were positive in 39 of 69 (57%) patients with a discharge diagnosis of possible ischemic event. CONCLUSIONS: Our results suggest that in patients referred for suspicion of transient ischemic attack, automated TMax is more sensitive than MTT, and both ASL and TMax increase the yield of MRI for the detection of ischemic lesions.

Arterial spin labeling imaging findings in transient ischemic attack patients: comparison with diffusion- and bolus perfusion-weighted imaging.

BACKGROUND: Since transient ischemic attacks (TIAs) can predict future stroke, it is important to distinguish true vascular events from non-vascular etiologies. Arterial spin labeling (ASL) is a non-contrast magnetic resonance (MR) method that is sensitive to cerebral perfusion and arterial arrival delays. Due to its high sensitivity to minor perfusion alterations, we hypothesized that ASL abnormalities would be identified frequently in TIA patients, and could therefore help increase clinicians' confidence in the diagnosis. METHODS: We acquired diffusion-weighted imaging (DWI), intracranial MR angiography (MRA), and ASL in a prospective cohort of TIA patients. A subset of these patients also received bolus contrast perfusion-weighted imaging (PWI). Two neuroradiologists evaluated the images in a blinded fashion to determine the frequency of abnormalities on each imaging sequence. Kappa (ĸ) statistics were used to assess agreement, and the χ(2) test was used to detect differences in the proportions of abnormal studies. RESULTS: 76 patients met the inclusion criteria, 48 (63%) of whom received PWI. ASL was abnormal in 62%, a much higher frequency compared with DWI (24%) and intracranial MRA (13%). ASL significantly increased the MR imaging yield above the combined DWI and MRA yield (62 vs. 32%, p < 0.05). Arterial transit artifact in vascular borderzones was the most common ASL abnormality (present in 51%); other abnormalities included focal high or low ASL signal (11%). PWI was abnormal in 31% of patients, and in these, ASL was abnormal in 14 out of 15 cases (93%). In hemispheric TIA patients, both PWI and ASL findings were more common in the symptomatic hemisphere. Agreement between neuroradiologists regarding abnormal studies was good for ASL and PWI [ĸ = 0.69 (95% CI 0.53-0.86) and ĸ = 0.66 (95% CI 0.43-0.89), respectively]. CONCLUSION: In TIA patients, perfusion-related alterations on ASL were more frequently detected compared with PWI or intracranial MRA and were most frequently associated with the symptomatic hemisphere. Almost all cases with a PWI lesion also had an ASL lesion. These results suggest that ASL may aid in the workup and triage of TIA patients, particularly those who cannot undergo a contrast study.

ABC/2: estimating intracerebral haemorrhage volume and total brain volume, and predicting outcome in children.

AIM: Few data exist to aid the clinician in prognosis after paediatric intracerebral haemorrhages (ICHs). Recently, ICH volume as a per cent of total brain volume (TBV) was shown to help predict outcomes in children. Thus, we sought to develop a bedside method of TBV estimation using typical hospital imaging software, and to validate the ABC/2 method for children in order to determine ICH volume and aid prognosis. METHOD: The study group comprised 23 children and adolescents with non-traumatic, acute ICH who had undergone head computed tomography and who were available for analysis. The median age of participants, 14 males (61%) and nine females (39%), was 6 years (range 0-16 y; mean 7.8 y; SD 5.3 y). Preterm infants born at less than 37 weeks' gestation and term infants with pure intraventricular haemorrhages were excluded. Manual segmentation, which is the criterion standard for measurement of ICH volume and TBV, requires specialized software and is time-consuming. We therefore used the well-known 'ABC/2 × slice thickness' method to calculate ICH volume and TBV, thus allowing ICH size to be reported as a percentage of TBV regardless of the absolute size of ICH. RESULTS: The estimated ICH volume was highly accurate compared with the criterion standard (R(2) =0.97 and R(2) =0.93; combined R(2) =0.96), as was the estimated TBV (R(2) =0.89 and R(2) =0.77; combined R(2) =0.89). The interrater reliability was high for both ICH volume and TBV, with an intraclass correlation coefficient of 0.94 and 0.80 respectively. Therefore, using no specialized software, we accurately measured ICH volume as a percentage of TBV. INTERPRETATION: The ABC/2 × slice thickness method is a possible bedside tool for the clinician that can aid prognosis after paediatric ICH.

MRI profile of the perihematomal region in acute intracerebral hemorrhage.

BACKGROUND AND PURPOSE: The pathophysiology of the presumed perihematomal edema immediately surrounding an acute intracerebral hemorrhage is poorly understood, and its composition may influence clinical outcome. Method-Twenty-three patients from the Diagnostic Accuracy of MRI in Spontaneous intracerebral Hemorrhage (DASH) study were prospectively enrolled and studied with MRI. Perfusion-weighted imaging, diffusion-weighted imaging, and fluid-attenuated inversion recovery sequences were coregistered. TMax (the time when the residue function reaches its maximum) and apparent diffusion coefficient values in the presumed perihematomal edema regions of interest were compared with contralateral mirror and remote ipsilateral hemispheric regions of interest. RESULTS: Compared with mirror and ipsilateral hemispheric regions of interest, TMax (the time when the residue function reaches its maximum) and apparent diffusion coefficient were consistently increased in the presumed perihematomal edema. Two thirds of the patients also exhibited patchy regions of restricted diffusion in the presumed perihematomal edema. CONCLUSIONS: The MRI profile of the presumed perihematomal edema in acute intracerebral hemorrhage exhibits delayed perfusion and increased diffusivity mixed with areas of reduced diffusion.

Intracerebral hemorrhage volume predicts poor neurologic outcome in children.

BACKGROUND AND PURPOSE: Although intracerebral hemorrhage (ICH) volume and location are important predictors of outcome in adults, few data exist in children. METHODS: A consecutive cohort of children, including full-term newborns to those younger than 18 years of age with nontraumatic, acute ICH and head CT available for analysis were studied. Clinical information was abstracted via chart review. Hemorrhage volume was expressed as percentage of total brain volume (TBV) with large hemorrhage defined as >or=4% of TBV. Hemorrhages were manually traced on each head CT slice and volumes were calculated by multiplying by slice thickness. Location was classified as supratentorial or infratentorial. Logistic regression was used to identify predictors of poor neurological outcome, defined as a Glasgow outcome scale or=4% of TBV (P=0.03). In multivariate analysis, hemorrhage >or=4% of TBV (OR, 22.5; 95% CI, 1.4-354; P=0.03) independently predicted poor outcome 30 days after ICH. In this small sample, infratentorial hemorrhage location and the presence of intraventricular hemorrhage did not predict poor outcome. CONCLUSIONS: ICH volume predicts neurological outcome at 30 days in children, with worst outcome when hemorrhage is >or=4% of TBV. Location and ICH etiology may also be important. These findings identify children with ICH who are candidates for aggressive management and may influence counseling regarding prognosis.

Hemispherectomy sustained before adulthood does not cause persistent hemispatial neglect.

INTRODUCTION: Hemispatial neglect has been well established in adults following acute ischemic stroke, but has rarely been investigated in children and young adults following brain injury. It is known that young brains have a tremendous potential for reorganization; however, there is controversy as to whether functions are assumed by the opposite hemisphere, or perilesional areas in the same hemisphere. Patients with intractable epilepsy who undergo hemispherectomy for treatment are missing the entire cortex on one side following surgery. In these patients, only the opposite hemisphere is available to assume function. Therefore, they provide the unique opportunity to determine in what cases the left or right hemisphere can take over the spatial attention functions of the opposite hemisphere following damage. The objective of this study was to determine the incidence and types of hemispatial neglect in children and young adults following both right- and left-sided hemispherectomy; which types of spatial attention functions can be assumed by the opposite hemisphere; and whether factors like their age at time of surgery, handedness, or gender influence recovery. METHODS: Thirty-two children and young adults who had previously undergone hemispherectomy were administered two tests to evaluate for two types of hemispatial neglect: a gap detection test and a line cancellation test. Egocentric neglect was defined as significantly more omissions of targets on the contralesional versus ipsilesional side of the page (by chi square analysis; p<.05). Allocentric neglect was defined as significantly more errors in detecting contralesional versus ipsilesional gaps in circles. RESULTS: Only one of the patients displayed statistically significant hemispatial egocentric neglect on the line cancellation test, and none of the patients displayed statistically significant egocentric or allocentric neglect on the gap detection test. CONCLUSIONS: These results imply that reorganization to the contralateral hemisphere occurs peri-hemispherectomy, as there are no perilesional areas to assume function.

Where (in the brain) do semantic errors come from?

BACKGROUND: Semantic errors result from the disruption of access either to semantics or to lexical representations. One way to determine the origins of these errors is to evaluate comprehension of words that elicit semantic errors in naming. We hypothesized that in acute stroke there are different brain regions where dysfunction results in semantic errors in both naming and comprehension versus those with semantic errors in oral naming alone. METHODS: A consecutive series of 196 patients with acute left hemispheric stroke who met inclusion criteria were evaluated with oral naming and spoken word/picture verification tasks and magnetic resonance imaging within 48 h of stroke onset. We evaluated the relationship between tissue dysfunction in 10 pre-specified Brodmann's areas (BA) and the production of coordinate semantic errors resulting from (1) semantic deficits or (2) lexical access deficits. RESULTS: Semantic errors arising from semantic deficits were most associated with tissue dysfunction/infarct of left BA 22. Semantic errors resulting from lexical access deficits were associated with hypoperfusion/infarct of left BA 37. CONCLUSION: Our study shows that semantic errors arising from damage to distinct cognitive processes reflect dysfunction of different brain regions.

Supratentorial regions of acute ischemia associated with clinically important swallowing disorders: a pilot study.

BACKGROUND AND PURPOSE: Dysphagia is a common problem after stroke associated with significant morbidity and mortality. Except for patients with brain stem strokes, particularly lateral medullary strokes, it is difficult to predict which cases are likely to develop swallowing dysfunction based on their neuroimaging. Clear models of swallowing control and integration of cortico-bulbar input have not been defined and the role of subcortical structures is unclear. The purpose of this study was to identify supratentorial regions of interest (ROIs) that might be related to clinically important dysphagia in acute stroke patients, focusing on subcortical structures. METHODS: We studied 29 acute supratentorial ischemic stroke cases admitted to our institution between 2001 and 2005 diagnoses with first ischemic stroke and without history of swallowing dysfunction. Subjects had MRI within 24 hours. Cases were defined as those subjects who were diagnosed as dysphagic after clinical evaluation by a speech language pathologist (SLP) and whose dysphagia was considered clinically significant, ie, requiring treatment by diet modification. Controls were defined as those patients who: (1) passed the stroke unit's dysphagia screening, (2) had a clinical evaluation by SLP that did not result in a diagnosis of dysphagia or diet modifications, or (3) had no documented evidence of dysphagia evaluation or treatment during hospitalization and were discharged on a regular diet. A trained technician, blinded to case-control status, examined 12 ROIs for dysfunctional tissue in diffusion and perfusion-weighted images. The odds ratio (OR) of dysphagia was calculated for each ROI. Logistic regression models were used to adjust for stroke severity (NIHSS) and volume. RESULTS: Analysis of data on 14 cases and 15 controls demonstrated significant differences in the unadjusted odds of dysphagia for the following ROIs: (1) primary somatosensory, motor, and motor supplementary areas (PSSM; OR=10, P=0.009); (2) orbitofrontal cortex (OFC; OR=6.5, P=0.04); (3) putamen, caudate, basal ganglia (PCBG; OR=5.33, P=0.047); and (4) internal capsule (IC; OR=26; P=0.005). Nonsignificant differences were found in the insula and temporopolar cortex. Adjusted OR of dysphagia for subjects with strokes affecting the IC was 17.8 (P=0.03). Adjusted odds ratios for the PSSM, OFC, and PCBG were not statistically significant. CONCLUSIONS: Significantly increased odds of dysphagia were found in subjects with IC involvement. Other supratentorial areas that may be associated with dysphagia include the PSSM, OFC, and PCBG. Analysis of additional areas was limited by the number of subjects in our sample. Future studies with larger sample size are feasible and will contribute to the development of a full swallowing control model.

Neural regions essential for reading and spelling of words and pseudowords.

OBJECTIVE: To identify dysfunctional brain regions critical for impaired reading/spelling of words/pseudowords by evaluating acute stroke patients on lexical tests and magnetic resonance imaging, before recovery or reorganization of structure-function relationships. METHODS: A series of 106 consenting patients were administered oral reading and spelling tests within 24 hours of left supratentorial stroke onset. Patients underwent diffusion- and perfusion-weighted magnetic resonance examination the same day to identify regions of hypoperfusion/infarct of 16 Brodmann areas. RESULTS: Simultaneous logistic regression analysis demonstrated that dysfunction of left Brodmann areas 40 (supramarginal gyrus) and 37 (posterior-inferior temporal/fusiform gyrus) best predicted impairment in reading words (odds ratio [OR], 6.20 [95% confidence interval (CI), 1.54-24.96] and 2.71 [95% CI, 0.87-8.45], respectively), reading pseudowords (OR, 39.65 [95% CI 3.9-400.78] and 4.41 [95% CI, 1.1-17.51], respectively), spelling words (OR, 14.11 [95% CI 1.37-144.93] and 7.41 [95% CI, 1.48-37.24], respectively), and spelling pseudowords (OR, 4.84 [95% CI, 0.73-32.13] and 7.74 [95% CI, 1.56-38.51], respectively). Whole-brain voxel-wise analyses demonstrated voxel clusters within these regions that were most strongly associated with task deficits. INTERPRETATION: Results indicate that a shared network of regions including parts of left Brodmann areas 37 and 40 is necessary for reading and spelling of words and pseudowords. Further studies may define the precise roles of these brain regions in language. Identification of any neural regions specific to one of these tasks or one type of stimuli will require study of more patients with selective deficits.

Neural regions essential for distinct cognitive processes underlying picture naming.

We hypothesized that distinct cognitive processes underlying oral and written picture naming depend on intact function of different, but overlapping, regions of the left hemisphere cortex, such that the distribution of tissue dysfunction in various areas can predict the component of the naming process that is disrupted. To test this hypothesis, we evaluated 116 individuals within 24 h of acute ischaemic stroke using a battery of oral and written naming and other lexical tests, and with magnetic resonance diffusion and perfusion imaging to identify the areas of tissue dysfunction. Discriminant function analysis, using the degree of hypoperfusion in various Brodmann's areas--BA 22 (including Wernicke's area), BA 44 (part of Broca's area), BA 45 (part of Broca's area), BA 21 (inferior temporal cortex), BA 37 (posterior, inferior temporal/fusiform gyrus), BA 38 (anterior temporal cortex) and BA 39 (angular gyrus)--as discriminant variables, classified patients on the basis of the primary component of the naming process that was impaired (defined as visual, semantics, modality-independent lexical access, phonological word form, orthographic word form and motor speech by the pattern of performance and types of errors across lexical tasks). Additionally, linear regression analysis demonstrated that the areas contributing the most information to the identification of patients with particular levels of impairment in the naming process were largely consistent with evidence for the roles of these regions from functional imaging. This study provides evidence that the level of impairment in the naming process reflects the distribution of tissue dysfunction in particular regions of the left anterior, inferior and posterior middle/superior temporal cortex, posterior inferior frontal and inferior parietal cortex. While occipital cortex is also critical for picture naming, it is likely that bilateral occipital damage is necessary to disrupt visual recognition. These findings provide new evidence that a network of brain regions supports naming, but separate components of this network are differentially required for distinct cognitive processes or representations underlying the complex task of naming pictures.

Gender differences in unilateral spatial neglect within 24 hours of ischemic stroke.

Hemispatial neglect is a common and disabling consequence of stroke. Previous reports examining the relationship between gender and the incidence of unilateral spatial neglect (USN) have included either a large numbers of patients with few neglect tests or small numbers of patients with multiple tests. To determine if USN was more common and/or severe in men or women, we examined a large group of patients (312 right-handed) within 24 hours of acute right hemisphere ischemic stroke. Multiple spatial neglect tasks were used to increase the sensitivity of neglect detection. No differences based upon gender were observed for the prevalence, severity, or a combined task measure of USN.

Speech and language functions that require a functioning Broca's area.

A number of previous studies have indicated that Broca's area has an important role in understanding and producing syntactically complex sentences and other language functions. If Broca's area is critical for these functions, then either infarction of Broca's area or temporary hypoperfusion within this region should cause impairment of these functions, at least while the neural tissue is dysfunctional. The opportunity to identify the language functions that depend on Broca's area in a particular individual was provided by a patient with hyperacute stroke who showed selective hypoperfusion, with minimal infarct, in Broca's area, and acutely impaired production of grammatical sentences, comprehension of semantically reversible (but not non-reversible) sentences, spelling, and motor planning of speech articulation. When blood flow was restored to Broca's area, as demonstrated by repeat perfusion weighted imaging, he showed immediate recovery of these language functions. The identification of language functions that were impaired when Broca's area was dysfunctional (due to low blood flow) and recovered when Broca's area was functional again, provides evidence for the critical role of Broca's area in these language functions, at least in this individual.

The right hand draws the trees, but the left draws the forest?

Spatial processing is lateralized: the right hemisphere is optimized for perceiving global aspects of space ("seeing the forest"), while the left hemisphere specializes in perceiving local aspects of space ("seeing the trees"). However, less is known about how the information is shared across the hemispheres and which areas within the corpus callosum are required for transferring and integrating visuospatial information. Here, we report a 60 year old woman with a mass lesion in the splenium of the corpus callosum who demonstrated visuospatial processing deficits that were out-of-proportion to the rest of her neurological examination. Remarkably, in the Rey-Osterrieth Complex figure task, she copied with her left hand the outlines of the figure (global aspects), whereas with her right hand she drew the details of that figure (local aspects). While hemispheric lesions have demonstrated single dissociations of spatial processing, these results indicate that a lesion in the corpus callosum can produce a double dissociation for high-level spatial tasks, as local and global spatial perception are further dissociated with handedness. Interestingly, as little as the posterior third of the corpus callosum is required for proper visuospatial information transfer and integration, which provides important insight into the interhemispheric functional anatomy that underlies visuospatial perception.

Capgras syndrome and unilateral spatial neglect in nonconvulsive status epilepticus.

Nonconvulsive status epilepticus can manifest as personality changes and psychosis. We report an 87-year-old right-handed male presenting with both Capgras syndrome and severe unilateral spatial neglect during nonconvulsive status epilepticus. After treatment of his seizures, his Capgras syndrome and hemispatial neglect resolved. This case illustrates a report of the confluence of Capgras syndrome and documented hemispatial neglect in nonconvulsive status epilepticus only reported once previously [1].

Restoring cerebral blood flow reveals neural regions critical for naming.

We identified areas of the brain that are critical for naming pictures of objects, using a new methodology for testing which components of a network of brain regions are essential for that task. We identified areas of hypoperfusion and structural damage with magnetic resonance perfusion- and diffusion-weighted imaging immediately after stroke in 87 individuals with impaired picture naming. These individuals were reimaged after 3-5 d, after a subset of patients underwent intervention to restore normal blood flow, to determine areas of the brain that had reperfused. We identified brain regions in which reperfusion was associated with improvement in picture naming. Restored blood flow to left posterior middle temporal/fusiform gyrus, Broca's area, and/or Wernicke's area accounted for most acute improvement after stroke. Results show that identifying areas of reperfusion that are associated with acute improvement of a function can reveal the brain regions essential for that function.

Characteristics and reversibility of dementia in Normal Pressure Hydrocephalus.

Studies of the cognitive outcome after shunt insertion for treatment of Normal Pressure Hydrocephalus have reported widely mixed results. We prospectively studied performance of 60 patients with Normal Pressure Hydrocephalus on a comprehensive battery of neuropsychological tests before and after shunt surgery to determine which cognitive functions improve with shunt insertion. We also administered a subset of cognitive tests before and after temporary controlled drainage of cerebrospinal fluid to determine if change on this brief subset of tests after drainage could predict which patients would show cognitive improvement three to six months after shunt insertion. There was a significant improvement in learning, retention, and delayed recall of verbal memory three to six months after surgery (using paired t-tests). The majority (74%) of patients showed significant improvement (by at least one standard deviation) on at least one of the memory tests. Absence of improvement on verbal memory after temporary drainage of cerebrospinal fluid had a high negative predictive value for improvement on memory tests at 3-6 months after surgery (96%; p=0.0005). Also, the magnitude of improvement from Baseline to Post-Drainage on few specific tests of learning and recall significantly predicted the magnitude of improvement after shunt surgery on the same tests (r2=0.32-0.58; p=0.04-0.001). Results indicate that testing before and after temporary drainage may be useful in predicting which patients are less likely to improve in memory with shunting.