Stephen N. Macciocchi

Postconcussive symptoms after uncomplicated mild head injury

Postconcussive symptomatology was studied in 587 patients with uncomplicated mild head injury. There was a linear decrease in symptomatology over the 1-year follow-up period. Headache was the most frequently reported postconcussive symptom. Symptom constellations consistent with postconcussive syndr

Neuropsychological sequelae of minor head injury.

Seventy-one patients with minor head injury were given extensive neuropsychological evaluations 3 months after injury. A significant percentage of the patients demonstrated cognitive impairment, which seemed essentially unrelated to the length of unconsciousness or of posttraumatic amnesia. Impaired patients evidenced memory and visuospatial deficits. Cognitively impaired patients also had difficulty returning to work after injury. The psychological and cognitive impairment that follows minor head injury is discussed in relation to diagnostic and intervention issues.

Ischemic Stroke: Relation of Age, Lesion Location, and Initial Neurologic Deficit to Functional Outcome

OBJECTIVEnEstablish the relation between age, gender, initial neurologic deficit, stroke location, prior stroke, hemisphere of stroke, and functional outcome in ischemic stroke.nnnDESIGNnSingle group, multivariate, repeated measures design with 327 persons having ischemic stroke recruited from 20 participating centers.nnnSETTINGnTwenty European stroke centers.nnnPATIENTSnConsecutive admissions of men and women between the ages of 40 and 85 yrs with a hemispheric stroke caused by middle cerebral artery ischemia and a Unified Neurological Stroke Scale score of 5 to 24.nnnINTERVENTIONSnInpatients enrolled in the trial received traditional rehabilitation therapies including physical therapy, occupational therapy, and speech therapy when appropriate.nnnMAIN OUTCOME MEASURESnBarthel Index computed at 7 to 10 days and 3 months poststroke.nnnRESULTSnPositive functional outcomes were significantly related to the absence of prior strokes, a younger age, a less severe initial neurologic deficit, stroke involving cortical structures, and dominant (left hemisphere) lesions.nnnCONCLUSIONSnDespite some inconsistencies in existing literature, standardized prospective examination of outcome after stroke clearly demonstrated the effect of age, initial severity of stroke, and lesion location as predictors of functional outcome.

Outcome after mild head injury

Although concern about mild sports head injury has significantly increased in the past decade, few well-controlled studies exist. As such, we are not able to definitively specify the effect of injury biomechanics, severity, frequency, and complications on outcome. Until more definitive research is completed, management of mild head injury will have to be based on clinical judgment rather than empiric fact. Despite present empiric limitations, several tentative conclusions appear appropriate. First, head injury is a relatively frequent occurrence in sports. Second, the overwhelming majority of single, grade 1 injuries have few persisting symptoms, and morbidity in the short-term appears low. Third, multiple injuries (> 3), especially grade 2 or grade 3, may have long-term irreversible consequences. Fourth, as best as we can tell, athletes with apparently equivalent injuries by clinical standards may have different outcomes. Finally, outcome in mild sports head injury must receive increased research attention, and some symmetry and coordination of efforts should be encouraged.

Disability following head injury.

Disability following head injury varies depending on injury mechanism, neuropathology, and other factors, including medical complications. Mild head injury (Glasgow Coma Scale score 13-15) has been shown to have considerable variability in outcome. Some persons experience rapid symptom resolution whereas others continue to evidence symptoms for an extended duration. A small, but clinically significant number of patients may be neuropsychologically and occupationally disabled at least up to 1 year postinjury. Methodological problems continue to plague mild head injury outcome studies. In contrast, moderate (Glasgow Coma Scale score 9-12) and severe head injury (Glasgow Coma Scale score 3-8) result in more consistent patterns of disability following injury. In general, patients who sustain moderate to severe head injury tend to experience persistent and extensive neuropsychological, psychiatric, and occupational impairment. The impact of rehabilitative interventions is variable and dependent on injury severity, intervention type, and outcome criteria.

“Practice makes perfect:” Retest effects in college athletes

Retest effects on a diverse set of neuropsychological measures were established using a normal sample comprised of college athletes (N = 110). Results suggest that retest effects vary depending on the type of test used, but the magnitude of effect on individual tests can be quite large. Implications of using tests with large retest effects or tests without established retest effect sizes are discussed.

The relationship between neuropsychological impairment in alcoholics and treatment outcome at one year

One hundred and thirty-two (132) patients with a diagnosis of alcohol dependence who participated in an inpatient treatment program were assessed on select neuropsychological measures and followed for a one year period. Neuropsychological, personality, and demographic variables did not predict outcome defined as abstinence at one year follow-up. Relapsed patients displayed slightly better initial neuropsychological functioning compared to abstainers, although this effect was not significant when these measures were controlled for age and education. These findings and the clinical implications of neuropsychological assessment in alcoholic populations is discussed.

Ethical considerations in clinical neuroscience : Current concepts in neuroclinical trials

BACKGROUNDnEthical decision making in clinical trials has become increasingly emphasized at many levels of the review process.nnnSUMMARY OF REVIEWnEthical concepts applicable to neuroclinical trials are reviewed. The discussion is directed toward ethical concerns that investigators must consider and justify prior to institutional review board submission. Risk-benefit analysis, methodology (randomization, placebo, design), and consent (informed, deferred, waived) are reviewed and guidelines of the Office for Protection From Research Risk are described.nnnCONCLUSIONSnInvestigators proposing neuroclinical trials face increasing ethical scrutiny by institutional review boards. Attention to ethical issues early in the trial planning process is recommended.

Decision and attribution bias in neurorehabilitation

OBJECTIVEnExamine neurorehabilitation therapists clinical predictions and attributions for outcomes.nnnDESIGNnSingle sample, repeated measures.nnnPARTICIPANTSnA sample of 51 neurorehabilitation therapists selected from representative disciplines including occupational therapy, physical therapy, speech therapy, and recreation therapy.nnnMAIN OUTCOME MEASURESnSelf-report questionnaire on factors related to positive and negative outcomes in neurorehabilitation. Rank order listing of factors influencing outcome in neurorehabilitation.nnnRESULTSnWithout cuing, therapists did not identify injury severity as factor in outcome (p < .0001). Therapists also made internal attributions for positive outcomes and external attributions for negative outcomes (p < .0001).nnnCONCLUSIONSnNeurorehabilitation therapists tend to ignore injury severity as factor in outcome unless encouraged to do so. Therapists accept personal responsibility for positive outcomes, but not for negative outcomes. Neurorehabilitation teams may benefit from education on factors affecting prognosis and attribution bias found in clinical practice.

Neurorehabilitation outcome in moyamoya disease

Moyamoya is a disease characterized by occlusion of the internal carotid, anterior, and middle cerebral arteries with associated rich collateral flow that presents a cloudy appearance on angiogram resembling a puff of smoke. The disease is most often progressive with associated hemiparesis and cognitive impairment. The functional outcome of patients with moyamoya is not well described in the literature. We describe four women (ages 25-36) who were transferred to a rehabilitation service after an average 17 days (12-26 days) in an acute care setting. Initial functional impairment was estimated using the Functional Independence Measure (FIM) score after discharge from inpatient rehabilitation (23-53 days) and was compared to the Uniform Data System for Medical Rehabilitation (UDSMR) for first stroke patients. Average admission FIM scores were similar in the two groups. The patients with moyamoya had a higher discharge FIM, longer length of stay, and slower rate of progress. Data on long-term survival and functional level would be useful, but it appears patients with moyamoya disease may benefit from rehabilitation oriented toward neurological deficits.