Course of recovery and prediction of outcome in young patients in a prolonged vegetative or minimally conscious state after severe brain injury: An exploratory study.

AIMS: To explore the course of recovery of consciousness and factors predicting the outcome of severe brain injury with a prolonged period of unconsciousness in children and young adults receiving a specialized rehabilitation treatment, the Early Intensive Neurorehabilitation Programme (EINP). METHODS: A cohort of forty-four patients aged 1.6-25.5 years (M=16.0) with traumatic acquired brain injury (TBI) or non-traumatic acquired brain injury (nTBI) were examined using the Western Neuro Sensory Stimulation Profile every two weeks, from the application for EINP until discharge. The level of consciousness was assessed with the Post-Acute Level of Consciousness Scale, and the level of disability was determined by the Disability Rating Scale. Long-term level of disability of all TBI patients (N=32) was assessed between 2.0 and 4.4 years after discharge from EINP. RESULTS: Two-thirds of all patients recovered to consciousness. Three recovery patterns were identified: remaining in a vegetative state (VS), slow recovery of consciousness, and fast recovery of consciousness. In the long-term, 11 of the TBI patients were severely disabled, 13 were moderately disabled, and 4 were mildly disabled. All TBI patients who were in VS at discharge either had deceased, or recovered to a very severely disabled state. CONCLUSIONS: Three recovery patterns identified in an early stage after starting EINP made it possible to predict long-term level of disability.

Is cognitive functioning associated with subjective quality of life in young adults with spina bifida and hydrocephalus?

OBJECTIVE: To test the hypothesis that cognitive functioning is associated with subjective quality of life of young adults with spina bifida and hydrocephalus (SBHC). DESIGN: Cross-sectional multi-centre study in The Netherlands. SUBJECTS: A total of 110 young adults with SBHC (16-25 years old, 63% female). METHODS: Cognitive domains measured were intelligence (Raven Standard Progressive Matrices), memory (Wechsler Memory Scale) and executive functioning (Wisconsin modified Card Sorting Test (WmCST), Trail Making Test A and B (TMT) and UNKA word production test). Subjective quality of life was measured with a visual analogue scale. Correlations and hierarchical regression analysis controlling for age, gender and functional independence were applied. RESULTS: The TMT score was significantly associated (-0.25) with subjective quality of life. In the hierarchical regression analysis both the WmCST and TMT scores were significant determinants of subjective quality of life (Beta values 0.24 and -0.31 respectively). Intelligence, memory and word production were not related to subjective quality of life. All 5 cognitive variables together explained a significant additional 14.6% of the variance of subjective quality of life (total explained variance 19.9%). CONCLUSION: Executive functioning was associated with subjective quality of life in young adults with spina bifida and hydrocephalus. This finding underlines the importance of examining cognitive functioning of persons with SBHC in addition to medical and functional status in medical care and outcome research.

Impact of internal capsule lesions on outcome of motor hand function at one year post-stroke.

OBJECTIVE: To investigate the association between damage to different levels of the corticofugal tract and long-term hand motor recovery. DESIGN: Prospective cohort study. PATIENTS: Seventy-five first-ever middle cerebral artery stroke survivors. METHODS: Hand motor function was assessed with the Fugl-Meyer Motor Assessment Scale at one year post-stroke. Localization of the corticofugal tract was assessed on axial magnetic resonance imaging slices using a corticofugal mask defining involvement of the motor cortex, corona radiata or internal capsule and combinations of these structures, adjusted for lesion volume. RESULTS: Longitudinal involvement of all 3 levels of the corticofugal tract and partial involvement of the internal capsule were associated with a significant probability of poor motor hand function recovery. The probability of regaining hand function ranged from 54% if the corticofugal tract was only partly affected to 13% if both motor cortex and internal capsule were affected. CONCLUSION: At one year post-stroke, lesions of the internal capsule were associated with a significantly lower probability of return of isolated hand motor function than lesions of the cortex, subcortex and corona radiata. Since recovery of isolated hand and finger movements is important for regaining a functional upper limb in everyday living, these patients should be identified early post-stroke in order to evaluate specific hand function training.

Predicting long-term independency in activities of daily living after middle cerebral artery stroke: does information from MRI have added predictive value compared with clinical information?

BACKGROUND AND PURPOSE: To investigate whether neuroimaging information has added predictive value compared with clinical information for independency in activities of daily living (ADL) 1 year after stroke. METHODS: Seventy-five first-ever middle cerebral artery stroke survivors were evaluated in logistic regression analyses. Model 1 was derived on the basis of clinical variables; for model 2, neuroimaging variables were added to model 1. Independent variables were stroke severity (National Institutes of Health Stroke Scale), consciousness (Glasgow Coma Scale), urinary continence, demographic variables (age, gender, relationship, educational level), hospital of admission, and clinical instruments: sitting balance (trunk control test), motor functioning (Motricity Index), and ADL (Barthel Index). Neuroimaging variables, determined on conventional MRI scans, included: number of days to scanning, lesion volume, lesion localization (cortex/subcortex), hemisphere, and the presence of white matter lesions. ADL independency was defined as 19 and 20 points on Barthel Index. Differences in accuracy of prediction of ADL independence between models 1 and 2 were analyzed by comparing areas under the curve (AUC) in a receiver operating characteristic analysis. RESULTS: Model 1 contained as significant predictors: age and ADL (AUC 0.84), correctly predicting 77%. In model 2, number of days to scanning, hemisphere, and lesion volume were added to model 1, increasing the AUC from 0.84 to 0.87, accurately predicting 83% of the surviving patients. CONCLUSIONS: Clinical variables in the second week after stroke are good predictors for independency in ADL 1 year after stroke. Neuroimaging variables on conventional MRI scans do not have added value in long-term prediction of ADL.

Functional independence among young adults with spina bifida, in relation to hydrocephalus and level of lesion.

Knowledge about the level of functional independence that can be expected in adulthood might support decisions on the treatment of newborn infants with spina bifida. This study determined functional independence among young adults with spina bifida and its relationships with pathological characteristics known from birth (hydrocephalus and level of lesion). Data were collected from medical records and by physical examination. Functional independence was assessed on six domains (self-care, sphincter control, transfers, locomotion, communication, and social cognition) using the Functional Independence Measure (FIM). Participants were 165 patients with spina bifida (69 males, 96 females; age range 16 to 25y, mean 20y 9mo [SD 2.9]; 117 with hydrocephalus). Patients without hydrocephalus were independent for all FIM domains except sphincter control, as were patients with hydrocephalus with a lesion level below L2. Most patients with hydrocephalus and a lesion at L2 or above were dependent as regards sphincter control (98%), locomotion (79%), and self-care (54%), and quite a few needed support in transfers (38%), social cognition (29%), and communication (15%).

Probability of regaining dexterity in the flaccid upper limb: impact of severity of paresis and time since onset in acute stroke.

BACKGROUND AND PURPOSE: To improve the accuracy of early postonset prediction of motor recovery in the flaccid hemiplegic arm, the effects of change in motor function over time on the accuracy of prediction were evaluated, and a prediction model for the probability of regaining dexterity at 6 months was developed. METHODS: In 102 stroke patients, dexterity and paresis were measured with the Action Research Arm Test, Motricity Index, and Fugl-Meyer motor evaluation. For model development, 23 candidate determinants were selected. Logistic regression analysis was used for prognostic factors and model development. RESULTS: At 6 months, some dexterity in the paretic arm was found in 38%, and complete functional recovery was seen in 11.6% of the patients. Total anterior circulation infarcts, right hemisphere strokes, homonymous hemianopia, visual gaze deficit, visual inattention, and paresis were statistically significant related to a poor arm function. Motricity Index leg scores of at least 25 points in the first week and Fugl-Meyer arm scores of 11 points in the second week increasing to 19 points in the fourth week raised the probability of developing some dexterity (Action Research Arm Test >or=10 points) from 74% (positive predictive value [PPV], 0.74; 95% confidence interval [CI], 0.63 to 0.86) to 94% (PPV, 0.83; 95% CI, 0.76 to 0.91) at 6 months. No change in probabilities of prediction dexterity was found after 4 weeks. CONCLUSIONS: Based on the Fugl-Meyer scores of the flaccid arm, optimal prediction of arm function outcome at 6 months can be made within 4 weeks after onset. Lack of voluntary motor control of the leg in the first week with no emergence of arm synergies at 4 weeks is associated with poor outcome at 6 months.