Stein Andersson

Coping strategies in patients with acquired brain injury: relationships between coping, apathy, depression and lesion location

Coping strategies in individuals suffering severe traumatic brain injury (TBI), cerebrovascular accidents (CVA), or hypoxic brain injury (HBI) were investigated in relation to apathy, depression, and lesion location. Seventy patients (27 with TBI, 30 with CVA, and 13 with HBI) filled in a coping questionnaire (COPE) and were evaluated with respect to apathy and depression. A comparison sample of 71 students also filled in COPE. Patients coping strategies were similar to the comparison group, but patients tended to display less differentiated coping styles. A factor analysis indicated two dimensions of coping in the patient sample; approach oriented and avoidance oriented coping. Approach and avoidance coping sum scores, based on subscales from the two factors, were positively correlated in the patient sample, but not in the comparison group. Lack of active approach oriented coping was associated with apathy, whereas avoidant coping was associated with depression. Coping styles were not related to lesion location. Apathy was related to subcortical and right hemisphere lesions. In bivariate analyses, depression was unrelated to lesion location, but, in a MANCOVA, avoidant coping, apathy and lesion location (left hemisphere lesions) contributed to the variance in positive depressive symptoms. The consistent relationships between coping strategies and neuropsychiatric symptoms were interpreted as two dimensions of adaptational behaviour: an active vs. passive dimension and a depression?distress-avoidance dimension.

Apathy and depressed mood in acquired brain damage: relationship to lesion localization and psychophysiological reactivity

BACKGROUND Apathy is a frequent neurobehavioural sequel in patients with acquired brain damage and it may seriously affect outcome of rehabilitation. METHODS Patients with traumatic brain injury, cerebrovascular insults and hypoxic brain injury, categorized into four lesion localization groups: left hemisphere damage (LHD); right hemisphere damage (RHD); bilateral hemispheric damage (BHD); and subcortical damage (SCD) were assessed with the Apathy Evaluation Scale (AES) and Montgomery and Asberg Depression Rating Scale (MADRS). Heart rate and electrodermal activity were recorded in an experimental situation that exposed the patients to mental stressors in order to measure psychophysiological reactivity. RESULTS Significant differences in level of apathy were found between diagnostic groups as well as between localization subgroups. SCD and RHD patients displayed most apathy. Factor analysis of MADRS revealed a three-factor solution; depressed mood, somatic symptoms and negative symptoms. Apathy was significantly correlated with negative symptoms in all localization subgroups, except among the BHD patients. Apathy was not correlated with depressed mood or somatic symptoms. Moreover, apathy was significantly correlated with heart rate reactivity, but not with electrodermal reactivity. CONCLUSION Apathy is common, its severity depending on diagnosis and localization of lesion. Apathy and depression in brain damaged patients share common features, but may be differentiated. The significant relationship between apathy and heart rate may provide a psychophysiological correlation of the disengagement, lack of interest and absence of emotional responsivity typically seen in apathy. The results have implications for the theoretical understanding of apathy and related negative symptoms, and for rehabilitation practice.

Emotional activation during therapeutic interaction in traumatic brain injury: effect of apathy, self-awareness and implications for rehabilitation

Apathy and reduced self-awareness are frequent occurring neurobehavioural sequelae following traumatic brain injury (TBI). Apathy, in terms of reduced goal directed activity and lowered motivation, and reduced self-awareness have a negative impact on the rehabilitation process. In this study, 30 patients suffering severe TBI were clinically rated for apathy and monitored for cardiovascular and electrodermal reactivity during baseline, neutral speech and therapeutic interaction. Applying a cut-off score criterion, two thirds of the TBI sample were classified as apathetic. The apathetic patients showed less psychophysiological reactivity from neutral speech to therapeutic interaction, compared to non-apathetic patients. They also reported less perceived emotional discomfort in the therapeutic situation measured with a visual analogue scale. Moreover, reduced self-awareness was associated with low autonomic reactivity. The results suggest that the reduced psychophysiological reactivity in apathetic patients may be a correlate to the lack of emotional responsivity, disengagement, lack of insight and concern about their own situation. Clinically, these results may have implications for psychotherapeutic intervention aimed at improving self-awareness. Recording psychophysiological responses during therapeutic interaction may serve as a method for monitoring emotional involvement during psychotherapy with TBI patients.

Cognitive Impairment 3 Months After Moderate and Severe Traumatic Brain Injury: A Prospective Follow-Up Study

OBJECTIVE To explore the magnitude and frequency of cognitive impairment 3 months after moderate to severe traumatic brain injury (TBI), and to evaluate its relationship to disability at 1-year follow-up. DESIGN Prospective follow-up study. SETTING Regional level I trauma center. PARTICIPANTS Patients aged 15 to 65 years with definite TBI, defined as Glasgow Coma Scale score of 3 to 13 and injury documented by magnetic resonance imaging (n=59) or computed tomography (n=2); healthy volunteers (n=47) served as controls. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Neuropsychological assessment 3 months postinjury and Glasgow Outcome Scale Extended (GOSE) at 3 and 12 months postinjury. RESULTS Patients with TBI performed worse than controls, most consistently in terms of information processing speed and verbal memory. However, a maximum of only 43% of patients with TBI had impaired test scores (defined as <1.5 SD below mean of normative data) on any one measure. Based on a selection of 9 tests, a 0 or 1 impaired score was seen in 46 (98%) of 47 controls, in 20 (57%) of 35 patients with moderate TBI, and in 9 (35%) of 26 patients with severe TBI. At 1 year postinjury, disability (defined as GOSE score ≤6) was present in 57% of those with 2 or more impaired test scores and in 21% of those with 0 or 1 impaired score (P=.005). CONCLUSIONS In this sample of patients with recent, definite TBI and healthy volunteers, we found that TBI affected cognition in moderate as well as severe cases. The presence of cognitive impairment was associated with future disability. However, half of the patients with moderate TBI and even one third of those with severe TBI had a normal cognitive assessment 3 months postinjury.

Generalized Role for the Cerebellum in Encoding Internal Models: Evidence from Semantic Processing

The striking homogeneity of cerebellar microanatomy is strongly suggestive of a corresponding uniformity of function. Consequently, theoretical models of the cerebellums role in motor control should offer important clues regarding cerebellar contributions to cognition. One such influential theory holds that the cerebellum encodes internal models, neural representations of the context-specific dynamic properties of an object, to facilitate predictive control when manipulating the object. The present study examined whether this theoretical construct can shed light on the contribution of the cerebellum to language processing. We reasoned that the cerebellum might perform a similar coordinative function when the context provided by the initial part of a sentence can be highly predictive of the end of the sentence. Using functional MRI in humans we tested two predictions derived from this hypothesis, building on previous neuroimaging studies of internal models in motor control. First, focal cerebellar activation–reflecting the operation of acquired internal models–should be enhanced when the linguistic context leads terminal words to be predictable. Second, more widespread activation should be observed when such predictions are violated, reflecting the processing of error signals that can be used to update internal models. Both predictions were confirmed, with predictability and prediction violations associated with increased blood oxygenation level-dependent signal in the posterior cerebellum (Crus I/II). Our results provide further evidence for cerebellar involvement in predictive language processing and suggest that the notion of cerebellar internal models may be extended to the language domain.

Reduced Neuroanatomic Volumes in Long-Term Survivors of Childhood Acute Lymphoblastic Leukemia

PURPOSE To compare regional brain volumes in adult long-term survivors of childhood acute lymphoblastic leukemia (ALL) and healthy controls. PATIENTS AND METHODS We investigated 130 survivors of childhood ALL diagnosed between 1970 and 2002 with magnetic resonance imaging (MRI) and neuropsychological testing at a median of 22.5 years after diagnosis. Morphometric analyses including whole-brain segmentation were performed using a validated automated procedure; 130 healthy adults served as controls. RESULTS Compared with healthy controls, ALL survivors showed significantly smaller volumes of cortical gray matter, cerebral white matter, amygdala, caudate, hippocampus, thalamus, and estimated intracranial volume. Effect sizes ranged from small to medium. The strongest effect was found for the caudate, which on average was 5.2% smaller in ALL survivors. Caudate volumes were also smaller when controlling for intracranial volume, suggesting a specific effect. Neither age at diagnosis nor treatment variables such as radiation therapy or drug dose had a major impact on neuroanatomic volumes. Neuropsychological assessment revealed reduced processing speed, executive function, and verbal learning/memory in survivors compared with controls but no difference in estimated general intellectual ability. In ALL survivors, but not in controls, neuropsychological test results correlated with volumes of cortical gray matter, caudate, and thalamus as well as intracranial volume. CONCLUSION Structural MRI of long-term survivors of childhood ALL demonstrated smaller volumes of multiple brain structures compared with healthy controls. Because of possible selection biases, these results must be interpreted with caution. Future studies are required to clarify the significance of these findings and the neurobiologic mechanisms involved.

Leucoencephalopathy after inhalation of heroin: a case report.

in all patients. The average disability score for blepharospasm after pretarsal treatment was 0-6 (0-5) (P < 0-001). The mean duration of the clinical effect was 67-2 (17-2) days. All the patients complained of a slight, but definite, increase in pain during pretarsal injections (compared with orbital injections); most patients had ecchymoses at the injection sites. Ptosis or diplopia were not seen after pretarsal injections. This study shows that pretarsal BTX injections resulted in a pronounced symptomatic improvement of blepharospasm in patients who failed to benefit after standard orbital injections. Lack of efficacy of orbital BTX treatment is not usually related to antibody production.2 Our study shows that all the patients responded favourably to BTX when it was injected either at orbital or at pretarsal sites. All these patients had a typical blepharospasm and did not meet the clinical criteria for a diagnosis of apraxia of eyelid opening or of levator palpebrae inhibition; these have been reported to respond to pretarsal but not to orbital treatment.6 As pretarsal injections may be effectively used to treat patients affected by blepharospasm who do not improve after orbital injections, this raises the question as to whether all patients with blepharospasm should be regularly treated at pretarsal sites. We think that this technique should be employed in all cases of blepharospasm, either alone or in combination with orbital infiltration. A slight increase in pain during treatment and in the incidence of ecchymoses are counterbalanced by higher clinical efficacy, immediacy of benefit, and reduction of dose and cost. This study was supported by Comitato Promotore Telethon grant E113 to AA. A ALBANESE A R BENTIVOGLIO C COLOSIMO Istituto di Neurologia, Universit* Cattolica del Sacro Cuore, Roma, Italy G GALARDI L MADERNA Clinica Neurologica, Istituto Scientifico San Raffaele, Milano, Italy P TONALI Ospedale CSS IRCCS, San Giovanni Rotondo, Italy

Self-reported cognitive problems in testicular cancer patients: Relation to neuropsychological performance, fatigue, and psychological distress ☆

OBJECTIVE There is a concern about negative cognitive effects of systemic chemotherapy. We prospectively explored self-reported cognitive problems in testicular cancer patients (TCPs) treated with and without chemotherapy. METHODS One hundred and twenty-two TCPs were interviewed about concentration and memory problems shortly after orchidectomy but before any additional treatment (baseline), and then at a median of 1 year after end of treatment (follow-up). Symptoms of psychological distress, fatigue, and peripheral neurotoxicity were assessed by questionnaires, and patients also underwent neuropsychological testing. Self-reported cognitive problems were compared between three treatments groups: no chemotherapy, one cycle of chemotherapy, and multiple cycles of chemotherapy. Variables associated with an increase of self-reported cognitive problems from baseline to follow-up were explored. RESULTS Significantly larger proportions of TCPs in the two chemotherapy groups had an increase of self-reported cognitive problems from baseline to follow-up compared to the no-chemotherapy group. Increase of self-reported cognitive problems was significantly associated with psychological distress, fatigue, lower level of education, and Raynaud-like symptoms, but not with a decline in neuropsychological test performance. CONCLUSION In this explorative study of TCPs, an increase of self-reported cognitive problems from baseline to 1-year follow-up was associated with chemotherapy and with symptoms of fatigue and psychological distress at follow-up, while no significant association was found with a decline in neuropsychological test performance.

Differentiated patterns of cognitive impairment 12 months after severe and moderate traumatic brain injury

Abstract Objective: To assess cognitive function at 12 months after moderate and severe traumatic brain injury (TBI) separately, as well as improvement from 3 to 12 months and relationship to global outcome. Methods: Cognitive function among patients with moderate (n = 30, Glasgow Coma Scale score (GCS) 9–3) and severe traumatic brain injury (n = 20, GCS score ≤ 8), recruited from an unselected neurosurgical cohort, all with MRI performed in the early phase were assessed with a neuropsychological test battery and Glasgow Outcome Scale Extended. Healthy volunteers (n = 47) matched for age, gender and years of education served as controls. Results: Executive function was reduced at 12-months post-injury in patients with both moderate and severe TBI. However, motor function, processing speed and memory were reduced only among patients with severe TBI. Both patients with moderate and severe TBI improved their processing speed and visual memory. Patients with moderate TBI also improved motor function, while patients with severe TBI also improved executive function. Conclusion: Differentiating between patients with moderate and severe TBI yields a more accurate description of cognitive deficits and their improvement over time. Further, executive dysfunction and attention problems affected the ability to resume independent living and employment regardless of injury severity and age.

Assessment of P3a and P3b after moderate to severe brain injury.

The purpose of the study was to examine the P3a and P3b components of the event-related brain potential (ERP) in patients sustaining moderate to severe brain injury. Electrophysiological and behavioral responses were recorded in brain injured (N = 18) and healthy control (N = 21) participants during performance of an auditory 3-stimulus distractor paradigm. Auditory stimuli consisted of a series of repetitive standard tones (75 ms), occasionally interrupted by equiprobable target (25 ms) and distractor sounds (white noise). Tone duration discrimination accuracy was similar in patients and controls, but patients had prolonged reaction times to targets. The reaction time delay was paralleled by a prolongation of P3b latency to targets in the patient group relative to controls. The stimulus and task dependent modulation of ERP responses in the brain injury group was similar to that of controls in terms of the spatial distribution of ERPs over the scalp. However, the brain injury group had attenuated P3a and P3b amplitudes to distractor and target stimuli, respectively. The electrophysiological data suggest a deficit in the allocation of attentional resources to the processing of deviant stimuli in the brain injury group.