Cognitive and psychosocial outcomes following stereotactic radiosurgery for acoustic neuroma.

BACKGROUND: Acoustic Neuroma (AN) is a benign tumour of the eighth cranial nerve. Stereotactic Radiosurgery (SRS) is a common treatment approach. Studies have explored the primary effects of SRS and documented equivalent efficacy for tumour control compared to neurosurgery. OBJECTIVE: Examine the longer term cognitive and psychosocial outcomes of SRS in non-Neurofibromatosis Type II patients utilising both objective and subjective cognitive outcomes associated with quality of life and health related distress. METHODS: Nineteen individuals treated via SRS were assessed using a battery of standardised psychometric tests as well as measures of quality of life and psychological distress. RESULTS: Participants had largely preserved cognitive function except for processing speed, aspects of attention and visual memory relative to age norms. Self-reported quality of life was better than in other AN population studies. Level of psychological distress was equivalent to general population norms. More than half of participants reported subjective cognitive decline though this was not fully supported by objective testing. Subjective cognitive complaints may be associated with lower reported quality of life. CONCLUSIONS: Results are largely consistent with previous findings on the effects of SRS in other clinical groups, which supports SRS as a targeted radiation treatment for AN.

Impact of paroxysmal sympathetic hyperactivity on nutrition management after brain injury: a case series.

OBJECTIVE: To review the nutritional requirements of all new inpatient brain injury admissions presenting with Paroxysmal Sympathetic Hyperactivity (PSH) in the rehabilitation setting. METHODS: RABIU is a 25-bed Regional facility in Northern Ireland which opened in 2006. All records of patients with a single episode non-progressive acquired brain injury admitted to RABIU from 2006 until the present were reviewed for evidence of PSH. Dietetic assessment and management was examined and recorded. RESULTS: Four patients with persisting paroxysmal sympathetic hyperactivity were identified. All patients displayed dystonia and posturing and had clinically important percentage weight loss. All had nutrition and/or hydration requirements markedly above their estimated requirement for slow weight gain, despite adjustment for brain injury. All four had posture-related complications of their dystonia and nutrition. CONCLUSION: Careful monitoring of nutrition, hydration and mineral supplementation is paramount in patients presenting with paroxysmal sympathetic hyperactivity after brain injury. It is argued that morbidity may be reduced by aggressive and expert nutrition management.

Bladder continence management in adult acquired brain injury.

PURPOSE: Persistence of urinary incontinence post acquired brain injury (ABI) carries important prognostic significance. We undertook to document the incidence of urinary incontinence, its management and complications in rehabilitation inpatients following ABI and to assess adherence to post ABI bladder management guidelines. METHOD: A retrospective chart survey of a convenience sample of consecutive admissions to two adult neurorehabilitation units Forster Green Hospital, Belfast, and the Scottish Brain Injury Rehabilitation Service, Edinburgh (SBIRSE). Bladder continence and management on transfer to and discharge from rehabilitation, trial removal of catheter, use of bladder drill, ultrasound investigation, anticholinergic medication and complications were recorded. RESULTS: One hundred and forty six patients were identified. Seventy-seven (52.7%) were independent and continent of urine at rehabilitation admission and 109 (74.7%) on discharge. In all, 13 patients had urinary tract infection, 7 had urethral stricture and 1 developed haematuria whilst catheterised. Ultrasound of renal tracts was underused. Trial removal of catheter after transfer to rehabilitation occurred at a median of 10 days. CONCLUSIONS: Urinary continence was achieved in almost half of incontinent ABI patients during rehabilitation. There is potential for increased use of investigation of the renal tracts. Rehabilitation physicians should consider urethral stricture in the management of continence post ABI.

Botulinum toxin in gait dysfunction due to ankle clonus: a case series.

OBJECTIVES: Our purpose is to assess the effectiveness of Botulinum toxin (Btx) on gait dysfunction due to ankle clonus in neurological patients. METHODS: We use a retrospective case note review of 11 patients attending the Regional Acquired Brain Injury Unit (RABIU), Musgrave Park Hospital, Belfast, Northern Ireland. All patients had received Btx for the treatment of ankle clonus. Demographic data including diagnosis and time since neurological insult was collected. Information regarding walking speed and assistance required to walk before and after Btx treatment was analysed. RESULTS: In 10 of 11 patients, walking speed was significantly improved at 4-6 weeks post Btx injections (P = 0.006) and at 14-16 weeks post Btx injections (P = 0.005). Eight patients reduced their level of dependency on assistance. Subjective improvements in levels of pain, gait pattern and 'toe clawing' were also reported. CONCLUSIONS: Our findings suggest that Botulinum toxin has a role in treating ankle clonus in neurological patients, where it interferes in gait. Walking speed and level of dependence on others improved in this group.

Maintaining community living with post brain injury agitation: a role for sodium valproate.

BACKGROUND: There is limited evidence to support pharmacological interventions for post-brain injury agitation and aggression. CASE REPORT: The case of Patient A, a man with severe agitation and aggression post-brain injury, highlights the successful use of sodium valproate, in the maintenance of community living, which had been threatened by the breakdown of the care package for this lone-dwelling individual. CONCLUSIONS: The case uniquely illustrates the effect of the drug due to a washout period, albeit due to patient non-compliance, allowing comparative observations both on and off and again on medication. In addition, Patient A's aphasia brings to the fore the difficulty with managing such symptoms and the ability of aphasic persons to avail of services and neurobehavioural therapies.

Subarachnoid haemorrhage (SAH): long-term cognitive outcome in patients treated with surgical clipping or endovascular coiling.

PURPOSE: To compare long-term cognitive outcomes of patients treated with surgical clipping or endovascular coiling after subarachnoid haemorrhage (SAH). METHOD: Retrospective matched cohort study assessed neuropsychological functioning at least 12 months after aneurysmal SAH treatment. Fourteen patients treated by endovascular coiling and nine patients treated by surgical clipping participated. After gaining written consent, a comprehensive neuropsychological battery was completed. Standardised tests were employed to assess pre-morbid and current intellectual functioning (IQ), attention, speed of information processing, memory and executive function as well as psychosocial functioning and affect. RESULTS: Treatment groups were not significantly different in terms of age, pre-morbid IQ, time from injury to treatment or time since injury. A significant effect of treatment on full-scale IQ score (p = 0.025), performance IQ (p = 0.045) and verbal IQ score (p = 0.029), all favouring the coiled group was observed. A medium effect size between groups difference in immediate memory (p = 0.19, partial η(2) = 0.08) was also observed. No significant between group differences on attention, executive functioning and speed of information processing measures or mood and psychosocial functioning were noted. Both groups reported increased anxiety and memory, attention and speed of information processing deficits relative to normative data. CONCLUSIONS: Study findings indicate fewer cognitive deficits following endovascular coiling. Cognitive deficits in the clipped group may be due in part to the invasive nature of neurosurgical clipping. Further prospective research with regard to long-term cognitive and emotional outcomes is warranted. IMPLICATIONS OF REHABILITATION: • Treatment of ruptured intracranial aneurysms by either endovascualar coiling or neurosurgical clipping can result in significant long-term physical disability as well as cognitive impairment. • Observed cognitive impairment(s) tend to be less in patients following endovascular coiling. • Following ruptured aneurysm, patients with cognitive impairment report reduced health related quality of life and increased anxiety. • Those with identified cognitive impairment(s) may benefit from cognitive remediation.

Functional outcomes of decompressive hemicraniectomy following malignant middle cerebral artery infarctions: a systematic review.

Decompressive hemicraniectomy has been used increasingly in recent years to treat malignant middle cerebral artery territory infarction. This review examines functional outcome data, with the novel analysis of outcomes according to temporal periods post-surgery. Case series data were pooled to determine significant correlates of outcome. Severe disability was frequently the outcome among survivors within one month post-surgery. Time and rehabilitation were later reflected, with fewer deaths and the emergence of mild to moderate disability increasing in prevalence. Mortality and severe disability were consistently more probable with increasing age. Presurgical clinical status in the form of additional cerebral artery involvement and midline shift also correlated with mortality within the 30-day period post-stroke.