Kjell Flekkøy

Early Post-Stroke Cognition in Stroke Rehabilitation Patients Predicts Functional Outcome at 13 Months

Objective: To identify prognostic factors associated with functional outcome at 13 months in a sample of stroke rehabilitation patients. Specifically, we hypothesized that cognitive functioning early after stroke would predict long-term functional outcome independently of other factors. Methods: 163 stroke rehabilitation patients underwent a structured neuropsychological examination 2–3 weeks after hospital admittance, and their functional status was subsequently evaluated 13 months later with the modified Rankin Scale (mRS) as outcome measure. Three predictive models were built using linear regression analyses: a biological model (sociodemographics, apolipoprotein E genotype, prestroke vascular factors, lesion characteristics and neurological stroke-related impairment); a functional model (pre- and early post-stroke cognitive functioning, personal and instrumental activities of daily living, ADL, and depressive symptoms), and a combined model (including significant variables, with p value <0.05, from the biological and functional models). Results: A combined model of 4 variables best predicted long-term functional outcome with explained variance of 49%: neurological impairment (National Institute of Health Stroke Scale; β = 0.402, p < 0.001), age (β = 0.233, p = 0.001), post-stroke cognitive functioning (Repeatable Battery of Neuropsychological Status, RBANS; β = –0.248, p = 0.001) and prestroke personal ADL (Barthel Index; β = –0.217, p = 0.002). Further linear regression analyses of which RBANS indexes and subtests best predicted long-term functional outcome showed that Coding (β = –0.484, p < 0.001) and Figure Copy (β = –0.233, p = 0.002) raw scores at baseline explained 42% of the variance in mRS scores at follow-up. Conclusions: Early post-stroke cognitive functioning as measured by the RBANS is a significant and independent predictor of long-term functional post-stroke outcome.

Regional cerebral blood flow in schizophrenia: repeated studies during a psychotic episode

Regional cerebral blood flow (rCBF) measurements and clinical ratings were performed on 17 schizophrenic patients and a subgroup of 10 medication-free patients before and after treatment. While clinically exacerbated patients had normal blood flow, patients in remission showed a redistribution of flow with lower values in frontal areas. Anteroposterior ratios correlated with the degree of behavioral disturbances, suggesting that the level of frontal lobe activity in schizophrenia may be a function of the patients clinical state at the time of study.

Association between ApoE ε4 and Cognitive Impairment after Stroke

Background and Purpose: The understanding of the contribution of genetic factors to cognitive impairment after stroke is incomplete. The aim of the study was to examine whether the apolipoprotein E ε4 allele (ApoE ε4) is a risk factor for cognitive impairment in the early phase after stroke. Methods: The sample comprised 152 Norwegian stroke rehabilitation inpatients (mean age 76.8 years, SD 10.5) examined at a mean of 18.3 days (SD 13.4) after hospital admission. Post-stroke cognitive impairment was assessed with the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). The following proposed risk factors were analysed: ApoE genotype, demographics (age, sex, education), pre-stroke cognitive reduction [Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE)], pre-stroke vascular factors (including previous stroke), stroke characteristics (type, location), and neurological stroke-related impairment [National Institutes of Health Stroke Scale (NIHSS)]. Cognitive impairment was defined as an RBANS total index score ≤1.5 SD below the mean. Multiple logistic regression analyses were performed to find risk factors for post-stroke cognitive impairment. Results: Four variables were found to be independent risk factors for cognitive impairment after stroke: ApoE ε4 (OR = 3.7; 95% CI = 1.2–11.6), IQCODE score ≥3.44 (OR = 9.2; 95% = CI 2.3–37.2), total or partial anterior stroke syndromes (OR = 3.2; 95% CI = 1.3–8.0), and NIHSS total score >5 (OR = 7.3; 95% CI = 2.7–19.7). No association between ApoE ε4 and pre-stroke cognitive reduction (IQCODE) was found. Conclusions: The presence of one or two ApoE ε4 alleles may be a significant independent risk factor for cognitive impairment in the early phase after stroke.

The scope of early traumatic brain injury as a long-term health concern in two nationwide samples: prevalence and prognostic factors.

Primary objectives: To examine the scope of paediatric traumatic brain injury (TBI) as a health concern and to identify prognostic factors for TBI-related sequelae. Methods and procedures: The study was prospective and nationwide. A questionnaire was sent to a study group (SG) of all 0–19 years old in Iceland, diagnosed ∼16 years earlier with TBI during a 1-year period, 1992–1993 (n = 550) and to a control group (CG) (n = 1232), selected from the National Register. Main outcomes and results: In the CG 49.5% reported having sustained TBI and 7.0% reported long-term disability. In the group with TBI, force of impact to the head, more than one incident of TBI and the injury severity by gender interaction predicted late symptoms. TBI severity had substantially less effect than force of impact and was close to non-existent for females. Conclusions: Based on two independent nationwide samples, the scope of TBI as a health concern in adolescence and young adulthood is greater than previously documented. The findings suggest that TBI event-related factors, especially force of impact, have greater predictive value than clinical symptoms of severity at the acute stage, females being more sensitive to the effects of mild TBI than males.

Cognitive impairment and the role of the ApoE ε4-allele after stroke—a 13 months follow-up study

To examine the relationship between the ApoE ε4 allele and cognitive impairment 13 months after stroke.

Urban-rural differences in pediatric traumatic head injuries: A prospective nationwide study

Aims To estimate differences in the incidence of recorded traumatic head injuries by gender, age, severity, and geographical area. Methods The study was prospective and nationwide. Data were collected from all hospitals, emergency units and healthcare centers in Iceland regarding all Icelandic children and adolescents 0–19 years old consecutively diagnosed with traumatic head injuries (N = 550) during a one-year period. Results Annual incidence of minimal, mild, moderate/severe, and fatal head injuries (ICD-9 850–854) was 6.41 per 1000, with 95% confidence interval (CI) 5.9, 7.0. Annual incidence of minimal head injuries (ICD-9 850) treated at emergency units was 4.65 (CI 4.2, 5.1) per 1000, mild head injuries admitted to hospital (ICD-9 850) was 1.50 (CI 1.3, 1.8) per 1000, and moderate/severe nonfatal injuries (ICD-9 851–854) was 0.21 (CI 0.1, 0.3) per 1000. Death rate was 0.05 (CI 0.0, 0.1) per 1000. Young children were at greater risk of sustaining minimal head injuries than older ones. Boys were at greater risk than girls were. In rural areas, incidence of recorded minimal head injuries was low. Conclusions Use of nationwide estimate of the incidence of pediatric head injury shows important differences between urban and rural areas as well as between different age groups.

Reduced insight in bipolar I disorder: Neurofunctional and neurostructural correlates A preliminary study

BACKGROUND To correlate measures of insight for own psychopathology to structural and functional brain imaging findings in 21 patients with DSM-IV bipolar I disorder. METHODS Insight was assessed using the Scale to Assess Unawareness of Mental Disorder (SUMD). Resting single photon emission computed tomography (SPECT) and computed tomography (CT) was conducted in patients and 21 normal comparison subjects matched for age, gender and handedness. RESULTS Reduced general insight and symptom awareness, but not symptom attribution, were significantly related to cortical and subcortical atrophy, respectively. No correlations between SPECT and insight measures were identified. LIMITATIONS Limited sample size and the use of resting state SPECT. CONCLUSIONS General and symptom awareness were related to measures of brain atrophy but not to neurofunctioning as measured by SPECT. Future research should consider the structure and function of specific cortical regions, including the frontal and parietal cortices.

Factor analysis of the Montgomery Aasberg depression rating scale in an elderly stroke population

Depression is frequent in elderly stroke patients, and the pathophysiology may involve psychological as well as organic mechanisms.

The prognostic value of injury severity, location of event, and age at injury in pediatric traumatic head injuries

Aims To estimate the prognostic value of injury severity, location of event, and demographic parameters, for symptoms of pediatric traumatic head injury (THI) 4 years later. Methods Data were collected prospectively from Reykjavik City Hospital on all patients age 0–19 years, diagnosed with THI (n = 408) during one year. Information was collected on patient demographics, location of traumatic event, cause of injury, injury severity, and ICD-9 diagnosis. Injury severity was estimated according to the Head Injury Severity Scale (HISS). Four years post-injury, a questionnaire on late symptoms attributed to the THI was sent. Results Symptoms reported were more common among patients with moderate/severe THI than among others (p < 0.001). The event location had prognostic value (p < 0.05). Overall, 72% of patients with moderate/severe motor vehicle-related THI reported symptoms. There was a curvilinear age effect (p < 0.05). Symptoms were least frequent in the youngest age group, 0–4 years, and most frequent in the age group 5–14 years. Gender and urban/rural residence were not significantly related to symptoms. Conclusions Motor vehicle related moderate/severe THI resulted in a high rate of late symptoms. Location had a prognostic value. Patients with motor vehicle-related THI need special consideration regardless of injury severity.

Long-term outcome of medically confirmed and self-reported early traumatic brain injury in two nationwide samples

Abstract Primary objectives: To assess long-term effects of early traumatic brain injury (TBI) on mental health, cognition, behaviour and adjustment and to identify prognostic factors. Methods and procedures: A 1-year nationwide cohort of all 0–19 year old Icelandic children and adolescents diagnosed with TBI in 1992–1993 (n = 550) received a questionnaire with clinical outcome scales and questions on TBI and socio-economic status (SES) by mail ∼16 years post-injury. A control group (n = 1232), newly selected from the National Registry, received the same questionnaire. Non-respondents answered a shorter version by telephone. Overall participation was 67%. Main outcomes and results: Medically confirmed and self-reported TBI was reflected in worse outcome. Force of impact, number and severity of TBIs predicted poorer results. Parental SES and demographic factors had limited effects. Not reporting early, medically confirmed TBI did not exclude cognitive sequelae. In self-reported disability, absence of evaluation for compensation was not linked to outcome. Conclusions: Clinical outcome was consistent with late complaints attributed to early TBI. TBI-related variables had greater prognostic value than other factors. Self-reporting of TBI sustained very early in life needs supplementary information from parents and medical records. More consistency in compensation evaluations following paediatric TBI is indicated.