Jamuna Rajeswaran

Recovery of resting brain connectivity ensuing mild traumatic brain injury

Brains reveal amplified plasticity as they recover from an injury. We aimed to define time dependent plasticity changes in patients recovering from mild traumatic brain injury (mTBI). Twenty-five subjects with mild head injury were longitudinally evaluated within 36 h, 3 and 6 months using resting state functional connectivity (RSFC). Region of interest (ROI) based connectivity differences over time within the patient group and in comparison with a healthy control group were analyzed at p < 0.005. We found 33 distinct ROI pairs that revealed significant changes in their connectivity strength with time. Within 3 months, the majority of the ROI pairs had decreased connectivity in mTBI population, which increased and became comparable to healthy controls at 6 months. Within this diffuse decreased connectivity in the first 3 months, there were also few regions with increased connections. This hyper connectivity involved the salience network and default mode network within 36 h, and lingual, inferior frontal and fronto-parietal networks at 3 months. Our findings in a fairly homogenous group of patients with mTBI evaluated during the 6 month window of recovery defines time varying brain connectivity changes as the brain recovers from an injury. A majority of these changes were seen in the frontal and parietal lobes between 3 and 6 months after injury. Hyper connectivity of several networks supported normal recovery in the first 6 months and it remains to be seen in future studies whether this can predict an early and efficient recovery of brain function.

EEG Neurofeedback therapy: Can it attenuate brain changes in TBI?

BACKGROUND Electroencephalogram Neurofeedback therapy (EEG-NFT) has several potential beneficial effects in terms of improving cognition and electrophysiological regulation among patients with brain injury. However, in vivo structural and functional changes remain less explored. OBJECTIVE The aim of the present study is to explore EEG-NFT induced in vivo changes in traumatic brain injury (TBI) patients. METHOD Two patients with mean age of 15 years with moderate head injury who had more than seven post concussion symptoms and poor cognitive performances (<5 percentile) were subjected to 20 sessions of EEG-NFT. The neuropsychological test scores, post concussion symptoms and MRI scan of the brain were recorded pre-post to EEG-NFT. RESULTS During EEG-NFT the cognitive scores and concussion symptoms improved significantly (p < 0.05). The EEG-NFT has shown significant increase in cortical grey matter (GM) volumes (p < 0.0001) and fractional anisotropy (FA) of cortical white matter (WM) tracts (p < 0.0001, voxel max 60 and above). There was a significant decrease in global, local efficiency, cost and clustering coefficient of functional connectivity (Wilcoxon Sign Rank Test p < 0.05). Interestingly there was a significant increase in thalamo-cortical connection (increase FA value) after EEG-NFT. CONCLUSION The EEG-NFT therapy has shown significant changes in structural and functional connectivity among young moderately injured TBI patients.

Neuropsychological Profile of Duchenne Muscular Dystrophy

Duchenne muscular dystrophy (DMD) is an inherited myogenic disorder characterized by progressive muscle wasting. DMD is a fatal X-linked recessive disorder with an estimated prevalence of 1 in 3,500 male live births. This disease has long been associated with intellectual impairment. Research has shown that boys with DMD have variable intellectual performance, indicating the presence of specific cognitive deficits. The aim of the study was to use a battery of intelligence, learning, and memory tests to identify a neuropsychological profile in boys with DMD. A total of 22 boys diagnosed with DMD in the age range of 6 to 10 years old were evaluated using the Wechsler Intelligence Scale for Children-Third Edition, Reys Auditory Verbal Learning Test, and the Memory for Designs Test. The data were interpreted using means, standard deviations, percentages, and percentiles. Normative data were also used for further interpretation. The results showed that boys with DMD had a significantly lower IQ (88.5). Verbal IQ (86.59) was found to be lower than Performance IQ (92.64). There was evidence of impaired performance on the Processing Speed, Freedom From Distractibility, and Verbal Comprehension Indexes. Specific deficits in information processing, complex attention, immediate verbal memory span, verbal working memory, verbal comprehension, vocabulary, visuoconstruction ability, and verbal learning and encoding were observed. However, perceptional organization, general fund of information, abstract reasoning, visual discrimination and acuity, visual learning and memory, and verbal memory were adequate. The neuropsychological findings support the hypothesis that these children have specific cognitive deficits as opposed to a global intellectual deficit.

Perception of illness in patients with traumatic brain injury.

Background: Perception of illness plays an important role in recovery process. It affects our coping behaviors, adherence to treatment and preventive measures taken for healthy recovery. Aims: The aim of the study is to examine perception of illness in patients with traumatic brain injury (TBI). Materials and Methods: This was a cross sectional study design done on sample of 31 patients with mild to moderate TBI. Depression anxiety stress scales-21 (DASS-21), Brief illness perception questionnaire (IPQ) and Rivermead Post Concussion Symptoms Questionnaire (RPQ) was used. Statistical Analysis: Descriptive and correlational statistics was used. Results: The results indicated that overall higher percentage falls within low and medium range of IPQ. However higher percentage falls within higher range, on coherence and emotional response subscales of IPQ. Consequence, timeline, personal control, treatment control, concern, emotional control, and total of the subscales of IPQ were positively correlated with RPQ3 and RPQ13 at 0.01 and 0.05 level of significance. A significant correlation was found between demographic variables and subscales of IPQ at 0.01 and 0.05 level of significance. Conclusion: The study shows one to one relationship between symptoms experienced by patients, how they perceive their illness and socio demographic variables.

Role of the thalamus in natural recovery of cognitive impairment in patients with mild traumatic brain injury

Abstract Introduction: Patients with mild traumatic brain injury (mTBI) may have normal neuroimaging but manifest with a broad-spectrum of cognitive-deficits, which may resolve eventually. The function of the thalamus in the process of natural-recovery remains elusive. The current study investigates the role of the thalamus in natural-recovery of cognitive-deficits in patients with mTBI. Methods: Twenty-one patients with mTBI were evaluated with an initial MRI scan, within 36 hours of injury and assessed with neuropsychological tests(NPT) at 3–4 weeks after injury. First and second follow-up MRI and NPT were performed at 3–4 months and 6–7 months, respectively. The volume and tensor measures of the thalamus and cognitive-scores were analysed at each assessment using repeated-measures of variance. The association of cognitive-scores with corresponding period imaging measures was analysed using bivariate-correlation. Results: Serial evaluation showed that all the cognitive-domains improved significantly. During this period there was a significant increase in mean thalamic volume (p = 0.049, effect-size = 0.18). After 3–4 months there was emergence of anisotropic thalamo-cortical connections. At 2–3 weeks and 6–7 months after injury, the alterations in diffusivity values were positively associated with improvement in memory-scores. Improvement in attention-scores correlated significantly with changes in tensor values at the 6–7 months after-injury. Conclusion: The correlation between improvement in cognitive-scores and changes in thalamic tensor and volume measures reflect the role of the thalamus in natural-recovery after mTBI.

Silent epidemic: The effects of neurofeedback on quality-of-life

Background: The complex interaction of human, vehicle and environmental factors along with a lack of sustainable preventive programs has contributed to the “silent epidemic” of traumatic brain injuries (TBI). TBI poses a grave threat to the quality-of-life (QOL). Aim: The aim of the present study was to examine the effects of neurofeedback in QOL in patients with TBI. Materials and Methods: Pre- and post-interventional study design was adopted. Sixty patients, 30 in the intervention group (IG) and 30 in waitlist group with the diagnosis of TBI in the age range of 18-49 years were assessed on QOL scale, after obtaining the informed consent. Patients in the IG were given 20 sessions of alpha-theta neurofeedback training (NFT), 5 sessions / week. Statistics Analysis: Descriptive statistics, Spearmans correlation, Mann-Whitney and Chi-squared test was used. Results and Conclusion: Patients in the IG showed statistical improvements in QOL post post-neurofeedback. Results are encouraging for the incorporation of NFT into treatment programs for patients with TBI in improving QOL.

Preservation of cognitive and musical abilities of a musician following surgery for chronic drug-resistant temporal lobe epilepsy: a case report.

ABSTRACT Mesial temporal lobe epilepsy (TLE) affects a range of cognitive functions and musical abilities. We report a 16-year-old boy diagnosed with drug-resistant right-medial TLE. He is a professional musician, trained in Carnatic classical music. Clinical, electrophysiological, magnetic resonance imaging (MRI) and positron emission tomography evaluation localized the seizure focus to the right medial temporal lobe. Patient underwent detailed neuropsychological evaluation and functional MRI (fMRI) for musical abilities prior to surgery. He underwent an awake craniotomy and tailored resection of lateral neocortex as well as amygdalohippocampectomy under guidance of cortical stimulation and clinical monitoring. The superior temporal gyrus where activation was revealed on task-based fMRI was preserved. At 16-month follow-up, there was no seizure recurrence and his cognitive functions including musical abilities did not deteriorate with surgery. The task-based fMRI while listening to music revealed bilateral frontotemporal activation. There was evidence of increased left frontotemporal connectivity during the postsurgical period in the resting state fMRI. It is hypothesized that the intact neuropsychological and musical abilities might be as a result of intense musical training from an early age despite the illness leading to functional and neural adaptation of the brain might have contributed to his preserved cognitive functions and musical skills. Intense musical training at a young age perhaps not only honed a range of cognitive functions but also resulted in functionally more efficient cognitive networks despite the surgical resection.

Factors determining cognitive dysfunction in cerebral small vessel disease

Introduction: Vascular dementia consists of cognitive and functional impairment due to cerebrovascular brain injury. With reference to small vessel disease (SVD), even though the radiological evidence of SVD is present in a large number of persons above the age of 80 years, less than one-third of the people progress to dementia. Hence, if those factors are identified, we may be able to formulate strategies to protect that percentage of patients who progress to dementia. In this study, we have analyzed some genetic and nongenetic factors in patients with and without a cognitive impairment in the presence of radiological SVD. Patients and Methods: Two hundred and ten patients who satisfied the criteria for the study were included. All medical comorbidities, demographic factors, substance abuse, etc., were documented and neuropsychological evaluation done. In addition, the genetic testing was done for the polymorphisms of TT, TC, and CC alleles of CYP11B2 based on the literature evidence of the association of CYP11B2 polymorphism and hypertension. Results: This prospective hospital-based study revealed a significant relationship among hypertension, hyperhomocysteinemia, and severity of white matter changes but other comorbidities did not correlate. No significant correlation was seen between cognitive dysfunction and severity of white matter changes or genotypes TT, TC, and CC. However, TC genotype was more common in male hypertensives. Even though hypertension and hyperhomocysteinemia were associated with leukoaraiosis, none of the factors studied trigger conversion of these radiological changes to clinical cognitive impairment. Discussion and Conclusion: Severity of cerebral white matter changes seems to correlate with hypertension and hyperhomocysteinemia, however, none of the co-morbidities studied including the three polymorphisms of CYP11B2, that is, TT, TC, and CC seem to determine the conversion of leukoaraiosis to dementia.

Impairments in quality of life and cognitive functions in long-term survivors of glioblastoma

Background: The incidence of long-term survival in glioblastoma (GBM), i.e., >3 years, ranges from 3% to 5%. Although extensive research is performed in novel therapies for prolonging survival, there is a scarcity of research focusing on the impact of tumor and treatment on cognitive, psychological, and social status of survivors. This study is an attempt to look into this poorly addressed important issue. Materials and Methods: Nine patients (six adults and three children) with GBM who had survived >3 years were included in the study. The quality of life (QOL) functions were assessed with the World Health Organization QOL Questionnaire BREF questionnaire. The neuropsychological assessment was done using the National Institute of Mental Health and Neurosciences neuropsychology battery for adults and children. The scores were compared with normative data. Results: The physical and psychological health-related QOL of long-term GBM survivors were affected considerably due to fatigue, poor quality of sleep, inability to concentrate, presence of depression, financial burden with impaired personal and social relationships (P < 0.05). Different domains of cognitions such as motor speed (P = 0.0173), mental speed (P = 0.0022), sustained attention (P = 0.0001), long-term memory (P = 0.0431), mental flexibility (P < 0.05), and planning and executive functions (P < 0.05) were significantly impaired affecting personal, social, and professional lives. Conclusion: The health-related QOL and cognition are significantly impaired in GBM long-term survivors. As the incidence of long-term survival is very less, there is a need for larger multicenter studies to come up with definitive results, which in turn can help in formatting the rehabilitative and support programs for these patients.

Demographic features and neuropsychological correlates in a cohort of 200 patients with vascular cognitive decline due to cerebral small vessel disease

Introduction: Vascular dementia is the second most common form of dementia and is potentially reversible. Small vessel disease (SVD) closely mimics degenerative dementia in view of its sub-acute onset and progressive course. Therefore, unlike large vessel disease, Hachinski Ischemic scale score may not always reflect vascular cognitive decline resulting in diagnostic and therapeutic confusions. Therefore, there is a need for detailed neuropsychological assessment for various cognitive domains for early identification of vascular cognitive decline as it carries a very good long term prognosis for cognitive morbidity, unlike degenerative dementias. Patients and Methods: This prospective study involves thorough domain based neuropsychological assessment of patients with a radiological diagnosis of SVD involving the following parameters-digit forward and backward, category fluency, color trails, stick test, logical memory test, and bender gestalt test. Magnetic resonance imaging scans done using 3-tesla machines and SVD graded using Fazekas visual scale. Results: The mean Hachinskis score was less sensitive for differentiating vascular dementia from degenerative dementia. However, the domain based neuropsychological scores were highly sensitive showing statistically significant impairment in all 6 domains tested and compared with Fazekas 1-3 grades in imaging. Discussion and Conclusion: This study aimed at establishing an early diagnosis of vascular mild cognitive impairment using domain wise neuropsychological testing and correlating it with radiological scores. Hachinskis score is more sensitive for large vessel disease in view of acute onset and step-like progression as against steady progression in SVD. However, domain-wise testing was highly sensitive in identifying early cognitive impairment in patients with SVD, and early therapeutic interventions are highly rewarding.