[Disability after stroke: a longitudinal study in moderate and severe stroke patients included in a multidisciplinary rehabilitation program]. / Ictus y discapacidad: estudio longitudinal en pacientes con discapacidad moderada-grave tras un ictus incluidos en un programa de rehabilitacion multidisciplinar.

INTRODUCTION: Stroke is a recognized cause of disability among adults. However the impact that the deficits that occur after a moderate/severe stroke have on long-term disability, as well as the response of the resultant deficits to rehabilitation, are not completely understood. PATIENTS AND METHODS: A total of 396 patients with a modified Rankin score >= 3 after an ischemic (n = 221) or hemorrhagic (n = 175) stroke were included in this study. All patients were assessed with cognitive, behavior, emotional, motor and functional domains. All patients were assessed at baseline and six months after inclusion in a multidisciplinary rehabilitation program. RESULTS: Risk of falling (Berg Balance Scale < 45 in 83.1% of the sample at baseline and 49.5% at follow-up) and functional problems (82.8% with a Barthel Index < 75 at baseline and 53% at follow-up) were the most prevalent deficits. Emotional disturbances were those that most improved while behavioral problems were those that did less. Although global disability improved during treatment among most patients, only 11% of our patients, especially those with preserved cognitive function at baseline, could be classified as patients with mild disability at follow-up. CONCLUSIONS: Stroke consequences are multidimensional. The symptoms that the stroke can cause in multiple domains, as well as the pattern of recovery are widely diverse, with prevalence of behavioral long-term disturbances.

TITLE: Ictus y discapacidad: estudio longitudinal en pacientes con discapacidad moderada-grave tras un ictus incluidos en un programa de rehabilitacion multidisciplinar.Introduccion. Los ictus son causa frecuente de discapacidad en el adulto; sin embargo, la repercusion que los deficits que acontecen tras un ictus moderado-grave tiene sobre el grado de discapacidad final, asi como la respuesta de estos a programas de rehabilitacion, no se ha estudiado por completo. Pacientes y metodos. Se incluyeron 396 pacientes con Rankin modificado >= 3 despues de un ictus isquemico (n = 221) o hemorragico (n = 175). En todos los pacientes se evaluo su situacion cognitiva, conductual, emocional, motora y funcional. Todos los pacientes fueron incluidos en un programa de rehabilitacion multidisciplinar y reevaluados tras seis meses de tratamiento. Resultados. El riesgo de caida (escala de equilibrio de Berg < 45 en el 83,1% de la muestra) y los deficits funcionales (indice de Barthel < 75 en el 82,8% de la muestra) fueron los problemas mas prevalentes en el momento del ingreso, mientras que los conductuales lo fueron en el del alta (55,1% de la muestra). Los problemas emocionales fueron los que mas mejoraron, mientras que los conductuales fueron los que menos lo hicieron. El nivel de discapacidad global mejoro tras el tratamiento, aunque solo un 11% de los pacientes, especialmente los que tenian buena situacion cognitiva en el ingreso, lograron alcanzar una discapacidad leve. Conclusiones. Las consecuencias del ictus son multidimensionales. La afectacion de las distintas esferas y el patron de recuperacion son diferenciales, con predominio a largo plazo de los problemas conductuales.

BioTrak virtual reality system: effectiveness and satisfaction analysis for balance rehabilitation in patients with brain injury.

OBJECTIVE: To study effectiveness of and satisfaction with a virtual reality-based balance rehabilitation system (BioTrak) for patients with acquired brain injury (ABI). MATERIAL AND METHODS: Ten patients with chronic hemiparesis (chronicity>6 months) following an ABI completed a 20-session programme using the balance reaching-task module of the BioTrak system. All patients were assessed at baseline, at the end of treatment, and one month later with the Berg Balance Scale (BBS), the Tinetti Performance-Oriented Mobility Assessment (POMA), and the computerised posturography tool NedSVE/IBV. The posturography study included analysis of sensory indexes, limits of stability, and rhythmic weight shift. The usability study was conducted using an ad hoc questionnaire. RESULTS: Repeated measures ANOVA showed a significant improvement in BBS (P<.01), TBS (P<.01), vestibular index (P<.05), and anterior-posterior weight shift (P<.05); a trend in the same direction was also found for medial lateral weight shift (P=.059). The post-hoc analysis revealed significant improvement between the initial and final assessments for BBS, POMA and anterior-posterior weight shift control; gains remained a month after completing the programme. The system showed a high degree of usability in terms of presence, immersion and user-friendliness, and there was a significant absence of adverse effects. CONCLUSION: Our results confirm the utility of virtual reality systems for balance rehabilitation in this population. Usability data suggest that BioTrak could be adapted for use in multiple rehabilitation settings by a high number of patients.

Evolución y pronóstico en un caso de negligencia unilateral: Estudio longitudinal con el Behavioural Inattention Test / Evaluation and prognosis of a case of unilateral neglect: Longitudinal study with the Behavioural Inattention Test

El síndrome de negligencia unilateral se define como la incapacidad o dificultad del paciente para detectar, referir, orientarse o responder a estímulos presentados contralateralmente a una lesión cerebral en ausencia de trastornos elementales sensitivos o motores. Se asocia fundamentalmente a lesiones parietales derechas y entre sus manifestaciones destacan las alteraciones atencionales, perceptivas y somatosensoriales. Presentamos el caso de un varón de 64 años que sufre una lesión isquémica aguda en territorio completo de la arteria cerebral media derecha. Como consecuencias, se evidencia un severo déficit motor y funcional, así como atencional enmarcado en el contexto de una negligencia unilateral izquierda. Se realizó un seguimiento longitudinal del paciente durante 1 año, empleando para su diagnóstico y posterior evolución el Behavioral Inattentional Test. Nuestro objetivo es mostrar la secuencia de cambios clínicos, cognitivos y funcionales, así como la respuesta de casos de severidad similar al aquí presentado, a programas de rehabilitación específicos (AU)

The unilateral neglect syndrome is defined as the inability or difficulty to identify, refer, orient or respond to stimuli presented contralaterally to a brain injury in the absence of elementary sensory or motor disorders. This syndrome is often associated with right parietal lesions, and the most frequent manifestations are attentional disturbances, perceptual deficits and somatosensorial disabilities. We present the case of a 64-year old male suffering from an acute ischemic stroke affecting the complete territory of the right middle cerebral artery. After the stroke, the patient had severe motor and functional deficits, associated with an intense attentional deficit in the context of a left unilateral neglect. We carried out a longitudinal study using the Behavioral Inattentional Test to measure the clinical course during a one-year follow-up. Our goal has been to show the sequence of clinical, cognitive and functional changes as well as the response of cases having similar severity to our case presented herein to specific rehabilitation programs (AU)

[The clinical relevance of FDG-PET imaging in severe traumatic brain injuries]. / Relevancia clínica de la FDG-PET en los traumatismos craneoencefálicos graves.

AIM: To evaluate the usefulness of positron emission tomography (PET) as a predictor of long-term disability after a severe traumatic brain injury (TBI). PATIENTS AND METHODS: Fifty-six patients who had sustained a severe TBI were assessed with a broad battery of cognitive and functional scales at baseline and 6-months after inclusion in a multidisciplinary rehabilitation program. All patients underwent a FDG-PET at baseline. A physician blind to clinical data performed a semiquantitative analysis (normal vs altered) of functional neuroimaging (PET), including four cortical and three subcortical areas. The total number of lesions (cortical, subcortical and total) was correlated to the intensity of the TBI and to clinical data at admission and at follow-up. RESULTS: All patients showed changes in cerebral metabolism, being the thalamus the area most frequently affected. The degree of cerebral hypometabolism showed a significant correlation with TBI severity, functional disability, global outcome and cognitive impairment not only at baseline but also at follow-up. CONCLUSIONS: According to our results, FDG-PET may be a useful tool when studying brain dysfunction after severe TBI. FDG-PET findings correlate with the TBI severity, and with the level of patients' disability, as well as with the degree of memory and intelligence impairment. However, clinical variables related to the severity of the TBI, still are the best predictors of functional outcome after TBI.

Relevancia clínica de la FDG-PET en los traumatismos craneoencefálicos graves / The clinical relevance of FDG-PET imaging in severe traumatic brain injuries

Resumen. Objetivo. Demostrar la utilidad de la tomografía por emisión de positrones (PET) como predictor de la discapacidad a largo plazo tras un traumatismo craneoencefálico (TCE). Pacientes y métodos. Se evaluó neuropsicológica y funcionalmente a 56 pacientes que habían sufrido un TCE grave al inicio y aproximadamente seis meses después de su inclusión en un programa de rehabilitación multidisciplinar. A todos los pacientes se les realizó una tomografía por emisión de positrones con fluordeoxiglucosa al inicio del tratamiento. De forma ciega, se determinó la presencia o ausencia de alteraciones en cuatro áreas corticales y tres subcorticales, y se determinaron tres índices cualitativos de metabolismo cerebral (cortical, subcortical y total). Los índices de metabolismo se correlacionaron con las variables relacionadas con la gravedad del traumatismo, y con la situación cognitiva y funcional de los pacientes en el momento de realizar la PET y al finalizar el programa de rehabilitación. Resultados. Todos los pacientes mostraron alteraciones en el metabolismo cerebral, y el tálamo fue el área más frecuentemente afectada. La intensidad del hipometabolismo cerebral se correlacionó significativamente con la gravedad del TCE y con la alteración cognitiva y funcional tanto al inicio como al final del tratamiento. Conclusiones. Las técnicas de neuroimagen funcional presentan una excelente sensibilidad para detectar alteraciones tras un TCE, además de ofrecer una buena correlación anatomoclínica. No obstante, las variables relacionadas con la gravedad del TCE, siguen siendo las mejores predictoras de la discapacidad resultante tras un TCE (AU)

Summary. Aim. To evaluate the usefulness of positron emission tomography (PET) as a predictor of long-term disability after a severe traumatic brain injury (TBI). Patients and methods. Fifty-six patients who had sustained a severe TBI were assessed with a broad battery of cognitive and functional scales at baseline and 6-months after inclusion in a multidisciplinary rehabilitation program. All patients underwent a FDG-PET at baseline. A physician blind to clinical data performed a semiquantitative analysis (normal vs altered) of functional neuroimaging (PET), including four cortical and three subcortical areas. The total number of lesions (cortical, subcortical and total) was correlated to the intensity of the TBI and to clinical data at admission and at follow-up. Results. All patients showed changes in cerebral metabolism, being the thalamus the area most frequently affected. The degree of cerebral hypometabolism showed a significant correlation with TBI severity, functional disability, global outcome and cognitive impairment not only at baseline but also at follow-up. Conclusions. According to our results, FDG-PET may be a useful tool when studying brain dysfunction after severe TBI. FDG-PET findings correlate with the TBI severity, and with the level of patients’ disability, as well as with the degree of memory and intelligence impairment. However, clinical variables related to the severity of the TBI, still are the best predictors of functional outcome after TBI (AU)

Pronóstico y neuroimagen funcional en un caso de intoxicación por metanol / Prognosis and functional neuroimaging in a case of methanol intoxication

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[When do patients with traumatic brain injury lose verbal information? Implications for cognitive rehabilitation]. / Cuándo pierden la información verbal los pacientes con daño cerebral postraumático? Implicaciones para la rehabilitación cognitiva.

AIM: Longitudinal study of verbal learning and memory processes after traumatic brain injury (TBI). PATIENTS AND METHODS: Twenty-six patients who had sustained a moderate-severe TBI were assessed with a Spanish version of the California Verbal Learning Test at the time of admission and 6-months after inclusion in a multidisciplinary rehabilitation program that comprised rehabilitation strategies for memory impairments. Global memory indexes were determined, including retroactive interference, proactive interference and recall indexes controlled for level of verbal acquisition. Memory change over time was correlated to demographic and clinical relevant variables, including the level of patients' self-awareness. RESULTS: More than 75% of our patients presented learning, immediate memory and delayed memory deficits at baseline, with an important effect of retroactive interference (69%). At 6-month follow-up, 34.6% showed learning difficulties, 46.2% immediate memory deficits, and 53% delayed memory problems, with 34.6% of the patients showing retroactive interference. Chronicity, level of self-awareness and premorbid intelligence correlated to the degree of memory change over time. CONCLUSIONS: Prominent verbal memory problems developed, not only during the first months after TBI but also over time are mostly due to impaired consolidation related to an intense retroactive interference. These data should be considered when developing memory rehabilitation strategies.

[Clinical utility of the 64-card version of the Wisconsin Card Sorting Test in patients with traumatic brain injury]. / Utilidad clinica de la versión de 64 cartas del test de clasificación de cartas de Wisconsin en pacientes que han sufrido un traumatismo craneoencefálico.

AIMS: To analyze the validity of the single deck 64-card Wisconsin Card Sorting Test (WCST-64) compared to the standard version (WCST-128), and to study the sensibility of both versions to identify changes over time in patients with traumatic brain injury (TBI). PATIENTS AND METHODS: The WCST was administered twice across a 6-month period to a sample of 50 patients with TBI. Pearson correlation coefficients were calculated to examine bivariate associations between WCST-128 scores and the corresponding WCST-64 scores at inclusion and at follow-up. Agreement in classification of impairment (z = -1) or normal performance was calculated for the two tests (kappa). Significant change over time was also analyzed for both versions of the test (paired-samples t test). RESULTS: The results revealed positive and significant correlations between both measures as well as a significant agreement in the classification of patients as having deficits or not. Moreover, the WCST-128 and the WCST-64 showed similar ability to identify changes over time. CONCLUSIONS: Our findings showed strong associations between scores derived from the two test and support the comparability of both versions when analyzing cross-sectional or longitudinal data. The findings support the use of the WCST-64 in evaluations of executive deficits of patients with moderate and severe TBI.

Utilidad clínica de la versión de 64 cartas del test de clasificación de cartas de Wisconsin en pacientes que han sufrido un traumatismo craneoencefálico / Clinical utility of the 64-card version of the Wisconsin card sorting test in patients with traumatic brain injury

Estudiar la relación entre las versiones estandarizada (WCST-128) y abreviada (WCST-64) del test declasificación de cartas de Wisconsin, con el fin de valorar su utilidad comparable y establecer la sensibilidad de ambas versiones para detectar cambios a lo largo del tiempo en una muestra clínica de pacientes con el diagnóstico de traumatismo craneoencefálico (TCE). Pacientes y métodos. La muestra estuvo compuesta por 50 pacientes con TCE, que fueron evaluadosen dos ocasiones, con un intervalo de aproximadamente seis meses. Se correlacionaron las puntuaciones entre ambas versiones tanto al inicio como al final (Pearson), así como su capacidad para detectar alteraciones (kappa) y cambios a lo largo del tiempo (t de Student para muestras pareadas). Resultados. Los resultados mostraron correlaciones positivas estadísticamentesignificativas entre las puntuaciones directas de la mayoría de los índices de ambas versiones, así como un significativo acuerdo en la clasificación de los pacientes en función de la presencia (z = –1) o no de déficit, tanto en la primera como en lasegunda valoración. Además, ambas versiones mostraron capacidad similar para detectar cambios a lo largo del tiempo. Conclusiones. Nuestros resultados demuestran la utilidad comparable entre el WCST-128 y el WCST-64, tanto transversal como longitudinalmente, de forma que ambas versiones se pueden considerar igualmente idóneas para la detección de déficit en funciones ejecutivas en pacientes que han sufrido un TCE. La versión abreviada, sin embargo, sería más apropiada cuando sequiera reducir el efecto fatiga teniendo la garantía de una detección del déficit adecuada

To analyze the validity of the single deck 64-card Wisconsin Card Sorting Test (WCST-64) compared to thestandard version (WCST-128), and to study the sensibility of both versions to identify changes over time in patients with traumatic brain injury (TBI). Patients and methods. The WCST was administered twice across a 6-month period to a sample of 50 patients with TBI. Pearson correlation coefficients were calculated to examine bivariate associations between WCST-128scores and the corresponding WCST-64 scores at inclusion and at follow-up. Agreement in classification of impairment (z = –1) or normal performance was calculated for the two tests (kappa). Significant change over time was also analyzed for both versions of the test (paired-samples t test). Results. The results revealed positive and significant correlations betweenboth measures as well as a significant agreement in the classification of patients as having deficits or not. Moreover, the WCST-128 and the WCST-64 showed similar ability to identify changes over time. Conclusions. Our findings showed strong associations between scores derived from the two test and support the comparability of both versions when analyzing crosssectionalor longitudinal data. The findings support the use of the WCST-64 in evaluations of executive deficits of patients with moderate and severe TBI

¿Cuándo pierden la información verbal los pacientes con daño cerebral postraumático? Implicaciones para la rehabilitación cognitiva / When do patients with traumatic brain injury lose verbal information? Implications for cognitive rehabilitation

Estudio longitudinal sobre los procesos de aprendizaje y memoria verbal tras un traumatismo craneoencefálico(TCE). Pacientes y métodos. Se evaluaron 26 pacientes que habían sufrido un TCE con el test de aprendizaje verbal complutense de forma subaguda (1-5 meses después del TCE) y tras seis meses de rehabilitación multidisciplinar. Se determinaronlos coeficientes globales de la escala, incluyendo interferencia retro y proactiva y los índices de evocación controlados según el grado de aprendizaje previo. Se determinaron los índices de cambio a lo largo del proceso de seguimiento (puntuaciónglobal final de cada variable menos puntuación inicial) y se correlacionaron (Spearman) con las variables demográficas y clínicas con reconocido valor pronóstico, incluyendo el grado de conciencia de enfermedad. Resultados. Más de las tres cuartas partes de nuestros pacientes presentaban alteraciones de aprendizaje, de memoria inmediata y de memoria tardía,con un importante efecto de interferencia retroactiva en 18 (69%) pacientes. A los seis meses, un 34,6% presentaba alteraciones de aprendizaje, un 46,2% de memoria inmediata, un 53% de memoria tardía, y el efecto interferencial se mantenía en un 34,6%. La cronicidad, el grado de conciencia de los déficit y la capacidad intelectual premórbida correlacionaron con los índices de cambio. Conclusiones. La mayoría de los problemas de evocación que aparecen tanto de forma subaguda como crónica tras un TCE se debe a problemas de consolidación en relación con un potente efecto de interferencia retroactiva. Estos datos deben considerarse a la hora de diseñar estrategias de intervención terapéutica, dado su beneficio

Longitudinal study of verbal learning and memory processes after traumatic brain injury (TBI). Patients and methods. Twenty-six patients who had sustained a moderate-severe TBI were assessed with a Spanish version of the California Verbal Learning Test at the time of admission and 6-months after inclusion in a multidisciplinary rehabilitation program thatcomprised rehabilitation strategies for memory impairments. Global memory indexes were determined, including retroactive interference, proactive interference and recall indexes controlled for level of verbal acquisition. Memory change over timewas correlated to demographic and clinical relevant variables, including the level of patients’ self-awareness. Results. More than 75% of our patients presented learning, immediate memory and delayed memory deficits at baseline, with an importanteffect of retroactive interference (69%). At 6-month follow-up, 34.6% showed learning difficulties, 46.2% immediate memory deficits, and 53% delayed memory problems, with 34.6% of the patients showing retroactive interference. Chronicity, level ofself-awareness and premorbid intelligence correlated to the degree of memory change over time. Conclusions. Prominent verbal memory problems developed, not only during the first months after TBI but also over time are mostly due to impaired consolidation related to an intense retroactive interference. These data should be considered when developing memory rehabilitation strategies

[The 'awareness climbing': an educational board game for improving self-awareness following acquired brain injury]. / 'Escalada de la conciencia': un instrumento para mejorar la conciencia de enfermedad en pacientes con dano cerebral adquirido.

AIM: To establish the effectiveness of an educational board game for improving self-awareness following acquired brain injury. PATIENTS AND METHODS: The 'awareness climbing' is a board game format intervention for improving awareness of patients with acquired brain injury (ABI) and for facilitating the use of anticipatory and compensatory strategies. 17 patients with ABI (traumatic brain injury, 10; stroke, 5; others, 2) were included in a self-awareness rehabilitation program using the 'awareness climbing'. Self-awareness was assessed with the Self-Awareness of Deficit Interview (SADI) before and after game intervention. According to the SADI self-awareness consists of three-interdependent levels: intellectual awareness (impairments), emergent awareness (disability) and anticipatory awareness, which involve the client predicting when impairments will affect his or her performance. RESULTS: Initially five patients showed impaired intellectual awareness, four patients had difficulties on emergent awareness and nine patients showed deficits on anticipatory awareness. Intellectual awareness improved in 10 patients, while six patients experienced improvements in emergent awareness over the intervention period. The most striking change was an improvement in 70% of the sample (n = 11) in anticipatory awareness after game sessions. CONCLUSION: According to SADI scores we suggest that the 'awareness climbing' may be a useful tool for improving self-awareness after acquired brain injury.

‘Escalada de la conciencia’: un instrumento para mejorar la conciencia de enfermedad en pacientes con daño cerebral adquirido / The "awareness climbing". an educational board game for improving self-awareness following acquired brain injury

Objetivo. Determinar la eficacia de una herramienta lúdico-terapéutica (‘escalada de la conciencia’) como método para rehabilitar la conciencia de enfermedad en sujetos con daño cerebral adquirido (DCA). Pacientes y métodos. La ‘escalada de la conciencia’ es una herramienta lúdica que facilita la adquisición de conocimientos necesarios para la adecuada percepción de las deficiencias y pone en práctica estrategias de afrontamiento y compensación de las diferentes limitaciones funcionales generadas tras un DCA. Se incluyó a 17 pacientes con DCA (traumatismo craneoencefálico, 10; ictus, 5; otros, 2). El grado de conciencia de los déficit y de sus implicaciones funcionales se valoró mediante la Self-Awareness of Deficit Interview (SADI) antes y después de un programa de intervención que incluía esta herramienta. La entrevista SADI mide tres aspectos de la conciencia: autoconciencia de los déficit, conciencia de las consecuencias funcionales y capacidad de establecer metas realistas. Resultados. Inicialmente, cinco pacientes presentaban problemas de autopercepción de sus déficit; cuatro, problemas de autopercepción de su discapacidad, y nueve tenían dificultades para establecer metas realistas de futuro. A lo largo del proceso de seguimiento, la percepción de los déficit mejoró en diez pacientes, y la percepción de las dificultades generadas por tales déficit, en seis. El cambio más significativo fue que, tras las sesiones de entrenamiento, el 70% de los sujetos (n = 11) aprendió a establecer metas realistas en función de los problemas generados por su patología. Conclusión. Los resultados obtenidos en la entrevista SADI convierten la ‘escalada de la conciencia’ en un instrumento válido y útil en el proceso rehabilitador de la conciencia de enfermedad en pacientes con DCA

Aim. To establish the effectiveness of an educational board game for improving self-awareness following acquired brain injury. Patients and methods. The ‘awareness climbing’ is a board game format intervention for improving awareness of patients with acquired brain injury (ABI) and for facilitating the use of anticipatory and compensatory strategies. 17 patients with ABI (traumatic brain injury, 10; stroke, 5; others, 2) were included in a self-awareness rehabilitation program using the ‘awareness climbing’. Self-awareness was assessed with the Self-Awareness of Deficit Interview (SADI) before and after game intervention. According to the SADI self-awareness consists of three-interdependent levels: intellectual awareness (impairments), emergent awareness (disability) and anticipatory awareness, which involve the client predicting when impairments will affect his or her performance. Results. Initially five patients showed impaired intellectual awareness, four patients had difficulties on emergent awareness and nine patients showed deficits on anticipatory awareness. Intellectual awareness improved in 10 patients, while six patients experienced improvements in emergent awareness over the intervention period. The most striking change was an improvement in 70% of the sample (n = 11) in anticipatory awareness after game sessions. Conclusion. According to SADI scores we suggest that the ‘awareness climbing’ may be a useful tool for improving self-awareness after acquired brain injury

Encefalopatía hipoxico-isquémica tras session de rayos ultraviolet: evolución y seguimiento / Anoxic encephalopathy after ultraviolet radiation session: follow-up and results

La encefalopatía anóxica se produce tras una deprivación cerebral aguda de oxígeno generada comúnmente por una insuficiencia cardiocirculatoria y/o respiratoria. Recientemente se ha publicado un interesante caso de una mujer que sufrió una posible encefalopatía anóxica tras una sesión de rayos ultravioleta. En este trabajo presentamos la evolución clínica de la paciente tras su inclusión en un programa de rehabilitación multidisciplinar abordando el tratamiento del amplio espectro de alteraciones cognitivas, psicopatológicas y funcionales que esta patología puede generar. Durante mucho tiempo el síndrome anoxoisquémico ha sido el paradigma clínico con el que muchos tratados de neurología han estudiado el síndrome amnésico hipocámpico. En nuestro caso la paciente presentaba al ingreso intensas dificultades en todos los procesos mnésicos tanto verbales como visuales asociados a una moderada desorientación temporal y a ligeras deficiencias en atención sostenida, selectiva y alternante. La estrategia de rehabilitación fundamental y decisiva en la evolución de la paciente fue la compensación del déficit facilitada por su adecuada conciencia de enfermedad y por la especificidad de la afectación cognitiva sobre tareas mnésicas con relativa preservación del resto de funciones. La presentación de este peculiar caso nos da la ocasión de mostrar el enfoque global de la rehabilitación y la recuperación de la normalidad de la vida diaria, aun cuando los déficit persistan (AU)

Anoxic encephalopathy is the consequence of acute cerebral oxygen deprivation usually generated by cardiac arrest and/or respiratory failure. Recently an interesting case of one patient with cerebral anoxia after ultraviolet radiation session has been published. This paper shows the clinical evolution of this patient after inclusion in a multidisciplinary rehabilitation program, which included treatment of the psychopathological, neuropsychological and functional impairments that this pathology often generates. Over successive decades cerebral anoxia has come to be identified principally as one of the most significant causes of an isolated amnesia syndrome. Our patient presented at baseline intense difficulties in every verbal and visual memory processes associated with moderate impairments in sustained, selective and shifting attention as well as temporal disorientation. Compensation of memory deficit was the main rehabilitation strategy used in this case. This rehabilitation approach was possible thanks to the high degree of self-awareness of memory deficits shown by the patient and the selective impairment of memory with partial preservation of the rest of cognitive functions. This particular case gives us the opportunity to show the multidisciplinary approach of cognitive rehabilitation and the process of reintegration to social activities and to productive work even when deficits persist (AU)

[Anoxic encephalopathy after ultraviolet radiation session: follow-up and results]. / Encefalopatía hipoxico-isquémica tras sesión de rayos ultravioleta: evolución y seguimiento.

Anoxic encephalopathy is the consequence of acute cerebral oxygen deprivation usually generated by cardiac arrest and/or respiratory failure. Recently an interesting case of one patient with cerebral anoxia after ultraviolet radiation session has been published. This paper shows the clinical evolution of this patient after inclusion in a multidisciplinary rehabilitation program, which included treatment of the psychopathological, neuropsychological and functional impairments that this pathology often generates. Over successive decades cerebral anoxia has come to be identified principally as one of the most significant causes of an isolated amnesia syndrome. Our patient presented at baseline intense difficulties in every verbal and visual memory processes associated with moderate impairments in sustained, selective and shifting attention as well as temporal disorientation. Compensation of memory deficit was the main rehabilitation strategy used in this case. This rehabilitation approach was possible thanks to the high degree of self-awareness of memory deficits shown by the patient and the selective impairment of memory with partial preservation of the rest of cognitive functions. This particular case gives us the opportunity to show the multidisciplinary approach of cognitive rehabilitation and the process of reintegration to social activities and to productive work even when deficits persist.

[Intelligence, memory and malingering: correlation between scales]. / Inteligencia, memoria y simulación: correlaciones entre instrumentos de medida.

OBJECTIVES: To validate the test of memory malingering (TOMM), and to study the influence of intelligence and memory on its performance in brain injury patients. PATIENTS AND METHODS: A total of 30 patients with traumatic head injury were included in the study. All patients were assessed with the Complutense verbal learning test, the Visual Reproduction subtest of the Wechsler memory scale-revised, the Boston naming test, two fluency tests (FAS, and animals), the Wechsler adult intelligence test-III, and with the TOMM. Cognitive results below 1 standard deviation (SD) from normative data were considered 'abnormal'. A parametric correlation between TOMM scores and cognitive tests was used to detect whether memory and intelligence were affecting TOMM performance. Statistical significance was set up at p<0.05. RESULTS: Between 46.1% (Boston) and 81.4% (WAIS-III performance IQ) of the sample presented cognitive deficits. Up to 83.3% of the patients scored above the cutoff point suggestive of malingering in the TOMM (45/50). Significance correlations were found between TOMM scores and memory or intelligence indexes. DISCUSSION: The TOMM is a useful tool to detect malingering in head injured patients. Effects of low intelligence coefficients, as well as memory deficits should be considered in clinical practice when evaluating patients with TOMM scores suggestive of malingering.

[Anoxic encephalopathy. Clinical description, prognosis and neuroimaging]. / Encefalopatía anóxica. Descripción clínica, pronóstico y neuroimagen.

OBJECTIVES: To describe the clinical profile (neuropsychological, psychopathological, functional and neuroimaging), as well as the evolution of patients with anoxic encephalopathy. PATIENTS AND METHODS: Nine patients with anoxic encephalopathy attending our Service were included in the study. All patients were assessed with a broad range of neuropsychological tests, checklists of psychopathological symptoms, and several functional scales. A CT/MRI or a positron emission tomography (PET) were performed in five patients. Five patients were admitted to a multidisciplinary rehabilitation program. RESULTS: All patients showed problems in orientation, executive functions, verbal learning an immediate and long-term verbal memory, in association with diffuse cognitive changes in other functions. Psychopathologically, all patients showed apathy-indifference, and eight subjects showed anosognosia. All subjects have an important dependence in daily activities. CT/MRI were normal or showed subcortical changes whereas the PET showed a predominantly cortical hypometabolism with specific patterns. There were no significant improvements after rehabilitation in treated patients. CONCLUSION: In the absence of a unique clinical profile, our patients with anoxic encephalopathy showed similarities in their symptoms (diffuse cognitive deficits with predominance of amnesic and executive impairments; presence of apathy and anosognosia; complete functional dependence; and poor response to the rehabilitation). Functional neuroimaging could be a useful tool for a better understanding of these encephalopathies.

Inteligencia, memoria y simulación: correlaciones entre instrumentos de medida / Intelligence, memory and malingering: correlation between scales

Objetivos. Analizar el patrón de respuestas al test de simulación de problemas de memoria (TOMM) y la relación existente entre la ejecución de este test y el nivel intelectual y memorístico tras un traumatismo craneoencefálico (TCE). Pacientes y métodos. Se estudiaron 30 pacientes que habían sufrido un TCE. A todos ellos se les administró el test de aprendizaje verbal complutense (TAVEC), el subtest de reproducción visual de la escala de memoria de Wechslerrevisada, el test de denominación de Boston, dos test de fluencia verbal, el test de inteligencia para adultos (WAIS-III) y el TOMM. Los índices situados por debajo de una desviación estándar de la media normativa de cada test se consideraron 'alterados'. Como método estadístico se empleó una correlación de Pearson entre el TOMM y el resto de los test, con un nivel de significación p < 0,05. Resultados. Entre el 46,1 por ciento (Boston) y el 81,4 por ciento (WAIS-III CI manipulativo) de la muestra, presentaba alteraciones cognitivas. El 83,3 por ciento (n = 25) de los pacientes evaluados obtuvo una puntuación superior al punto de corte sugestivo de simulación (45/50 en el TOMM-II). Se hallaron correlaciones significativas entre la puntuación del TOMM-II y las pruebas de memoria, así como con el WAIS-III. Conclusiones. El TOMM es un test útil para detectar problemas de simulación de memoria tras un TCE. Nuestros resultados constatan la existencia de relaciones entre el nivel intelectual y de memoria y la ejecución en el TOMM. En la práctica clínica conviene considerar este efecto en pacientes con puntuaciones en el TOMM sugestivas de simulación (AU)

Objectives. To validate the test of memory malingering (TOMM), and to study the influence of intelligence and memory on its performance in brain injury patients. Patients and methods. A total of 30 patients with traumatic head injury were included in the study. All patients were assessed with the Complutense verbal learning test, the Visual Reproduction subtest of the Wechsler memory scale-revised, the Boston naming test, two fluency tests (FAS, and animals), the Wechsler adult intelligence test-III, and with the TOMM. Cognitive results below 1 standard deviation (SD) from normative data were considered ‘abnormal’. A parametric correlation between TOMM scores and cognitive tests was used to detect whether memory and intelligence were affecting TOMM performance. Statistical significance was set up at p < 0.05. Results. Between 46,1% (Boston) and 81.4% (WAIS-III performance IQ) of the sample presented cognitive deficits. Up to 83.3% of the patients scored above the cutoff point suggestive of malingering in the TOMM (45/50). Significance correlations were found between TOMM scores and memory or intelligence indexes. Discussion. The TOMM is a useful tool to detect malingering in head injured patients. Effects of low intelligence coefficients, as well as memory deficits should be considered in clinical practice when evaluating patients with TOMM scores suggestive of malingering (AU)

Encefalopatía anóxica. Descripción clínica, pronóstico y neuroimagen / Anoxic encephalopathy. Clinical description, prognosis and neuroimaging

Objetivos. Describir las características clínicas (neuropsicológicas, psicopatológicas, funcionales y de neuroimagen), así como la evolución clínica de pacientes que han sufrido una encefalopatía anóxica. Pacientes y métodos. Se incluyeron nueve pacientes con encefalopatía anóxica que fueron atendidos en nuestro servicio.La evaluación se compuso de: 1) valoración neuropsicológica (orientación, atención, aprendizaje, memoria, praxis, gnosias, funciones ejecutivas, lenguaje e inteligencia general); 2) valoración psicopatológica (síntomas neuropsiquiátricos, conciencia de enfermedad); 3) valoración funcional (Barthel, FIM-FAM). A todos se les realizó RM, TCoPET. Cinco pacientes fueron admitidos en un programa de rehabilitación multidisciplinar. Resultados. Todos los pacientes presentaban una importante alteración en la capacidad de orientación, funciones ejecutivas, aprendizaje, memoria inmediata y, especialmente, memoria a largo plazo. En el resto de las funciones cognitivas, la heterogeneidad era mayor. Psicopatológicamente, todos mostraban apatía, y ocho de los nueve mostraban anosognosia. Funcionalmente, todos los sujetos tenían una importante dependencia en las actividades de la vida diaria. Las pruebas de neuroimagen (TC/RM) fueron normales o mostraron lesiones subcorticales, mientras que el PET mostró una afectación predominantemente cortical con patrones específicos. Apenas se apreciaron mejorías significativas tras el proceso rehabilitador en los pacientes tratados. Conclusiones. Si bien parece no existir un patrón clínico único típico de la encefalopatía anóxica, sí parecen existir características comunes (afectación cognitiva difusa con predominio de alteración de la memoria y de las funciones ejecutivas, presencia de apatía y anosognosia, dependencia funcional completa y escasa respuesta a la rehabilitación). Las pruebas de neuroimagen funcional son una herramienta útil para una mejor comprensión, y valoración pronóstica y terapéutica de esta patología (AU)

Objectives. To describe the clinical profile (neuropsychological, psychopatological, functional and neuroimaging), as well as the evolution of patients with anoxic encephalopathy. Patients and methods. Nine patients with anoxic encephalopathy attending our Service were included in the study. All patients were assessed with a broad range of neuropsychological tests, checklists of psychopathological symptoms, and several functional scales. A CT/MRI or a positron emission tomography (PET) were performed in five patients. Five patients were admitted to a multidisciplinary rehabilitation program. Results. All patients showed problems in orientation, executive functions, verbal learning an immediate and long-term verbal memory, in association with diffuse cognitive changes in other functions. Psychopathologically, all patients showed apathy-indifference, and eight subjects showed anosognosia. All subjects have an important dependence in daily activities. CT/MRI were normal or showed subcortical changes whereas the PET showed a predominantly cortical hypometabolism with specifical patterns. There were no significance improvements after rehabilitation in treated patients. Conclusion. In the absence of a unique clinical profile, our patients with anoxic encephalopathy showed similarities in their symptoms (diffuse cognitive deficits with predominance of mnesic and executive impairments; presence of apathy and anosognosia; complete functional dependence; and poor response to the rehabilitation). Functional neuroimaging could be a useful tool for a better understanding of these encephalopaties (AU)

[Neuropsychiatric disorders in Parkinson's disease]. / Trastornos neuropsiquiátricos en la enfermedad de Parkinson.

OBJECTIVE: This paper reviews the main neuropsychiatric disorders associated with Parkinson's disease (PD) and describes the neuropathological hypothesis proposed to explain these symptoms. DEVELOPMENT: This disease is usually associated with neuropsychiatric complications such as depression, anxiety and apathy. Besides, psychiatric symptoms are one of the most common side effects of antiparkinsonian drug-therapy. CONCLUSIONS: Depression is the most frequent emotional disorder reported in patients with PD. Up to 20% of parkinsonian patients meet DSM-IV criteria for major depressive episode and another 20% for dysthymia, while the prevalence of depression in normal aged population is about 2-8%. The relationship between PD and depression has not been fully established. Some investigators have suggested that depressive symptoms in PD are causally related to the underlying neuropathological process, affecting predominantly serotoninergic and dopaminergic pathways. Alternatively, depression in PD may represent a normal reaction to the progressive physical impairment induced by the disease. Otherwise, up to 20% of parkinsonian patients present levodopa-induced psychiatric complications. Visual hallucinations are the commonest, but delusions, confusional states, sexual disorders and sleep disorders have also been described. Serotonin and dopamine have been implicated in the neuropathological basis of these disorders.