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Variability in mild head injury outcome as a function of admission Glasgow coma scale score
Abstracts of 14th Annual Meeting
315
Systemic lupus erythematosus (SLE) is a muitisystem autoimmune disease that is often associated with central nervous system abnormalities. Neuropsychiatric manifestations, or CNS-SLE, occur in 25-75% of patients. Mechanisms of CNS-SLE will be presented. Early undetected cognitive impairment may unnecessarily diminish quality of life and complicate medical management. Through case study presentation, this paper demonstrates the value of early, ongoing neuropsychoiogical assessment and treatment in patients with CNSSLE. D.J. is a 39-year-old WF evaluated i 8 months after diagnosis. EEG. and MRI scans were normal. Behaviorally, D.J. complained of diminished work performance, spelling difficulty, forgetfulness, and difficulty following conversations. Her forgetfulness resulted in a kitchen fire and several thousand dollars in damages. Initial neuropsychological evaluation included the following: WAIS-R, WRAT-R, TPT, WSCT, PASAT, Selective Reminding Test, RCF Drawing, WMS-Russel version, Trails A & B, AST, BNT, GPB, and MMPI-2. Results indicated a pattern of mild to moderate diffuse neurocognitive impairment. Functions most significantly affected included attention and concentration, visual and verbal m e m o r y and learning, and fine motor speed. Subsequent to the evaluation, D.J. was provided with education behavioral recommendations, compensatory strategies for memory and organization, and counseling to promote psychological adjustment. Upon notification of test results, her rheumatologist and neurologist were able to more effectively monitor her clinical condition and adjust steroid dosages. D.J. was able to maintain her employment through job modification and reduced work hours. She employed compensatory strategies to facilitate home management. Six and twelve month evaluations demonstrated continued persistence of deficits without further deterioration. This paper demonstrates the value of early detection and treatment of neurocognitive impairment in SLE patients. Close communication between physicians, neuropsychologists, and rehabilitative therapists can significantly enhance the quality of life in SLE patients with neurocognitive impairment.
Culotta, V. P., Sementilli, M. E., Gerold, K., & Pafford, J. Variability in Mild Head Injury Outcome as a Function of Admission Glasgow Coma Scale Score. Research examining the neurobehavioral recovery and outcome of mild head injury (MHI) has yielded conflicting results. Variability in the outcome literature has been attributed to the selection of appropriate controls and the influence of moderator variables such as preinjury neurological and psychological status, substance use, malingering, and concurrent injuries. However, a major source of outcome variability may be inherent in the parameters defining MHI. Specifically, the inclusion of GCS 13-15 assumes an unreasonable degree of homogeneity in injury severity. The purpose of this study was to determine whether significant differences in injury severity exist between patients with an admission GCS of 13, 14, and 15.3,370 consecutive nonmissle head injury
316
Abstracts of 14th Annual Meeting
patients with an admission GCS score of 13--15 and a positive loss of consciousness were reviewed. 2,398 patients were admitted with a GCS = 15,796 patients had a GCS = 14, and 176 patients had GCS = 13. All patients were admitted to a Level I trauma center between 1990 and 1992. Patients were compared across the following variables indicative of injury severity: frequency of intracranial pathology visualized on CT scan and need for neurosurgical (NS) intervention within the first 24 hours. Positive CT findings were as follows: GCS 15 = 4%, GCS 14 = 16%, and GCS 13 = 28%. Patients requiring NS intervention: GCS 15 = 0.4%, GCS 14 = 1.6%, and GCS 13 = 4.5%. Chisquare analysis yielded statistically significant findings (p < .05) across all variables. These findings illustrate the range of injury severity across GCS 13-15 and may account for a large measure of the variability in studies examining neurobehavioral outcome. This data supports the need for refinement in the current classification of MHI and argues for the use of admission GCS score as a moderator in outcome analysis.
Cyrus, P. A., Krengel, M. H., Fama, R., Knoefel, J., & White, R. F. Evaluation of Cognitive Function in a Patient with Cerebral Amyloid Angiopathy. Cerebral amyloid angiopathy (CAA) is a disease most common in elerly patients which leads to recurrent cerebral hemorrhages. Pathologically, cerebral arterioles demonstrates deposition of amyloid. This finding also is seen in Alzheimer's Disease (AD). Few studies exist which address the cognitive changes in CAA. We questioned if the neropsychologicai profile of CAA would be consistent with AD, vascular dementia, or a combination of findings. A patient with probable CAA (with hemorrhagic infarcts in the left cerebellum, right occipital, and left occipital lobes) was evaluated on two occasions with a battery of nuropsychological tests. On the first assessment, 2 years after the last hemorrhage, the patient's deficits included difficulty in tracking, encoding, and retrieval. Severe visuospatial impairment and perseverations were noted. Reasoning and naming were relatively intact. These findings were consistent with a diffuse multifocal vascular dementia. Sixteen months later, follow-up testing revealed deficits in attention and auditory tracking, verbal fluency, markedly decreased verbal and visual memory, and an inability to learn new material. Visuospatial tasks remained severely affected. Follow-up test results were consistent with a progressive decline in functioning such as is seen in patients with AD. The patient had no new lesions to account for these changes in cognition and the pattern of deficits were not consistent with a diffuse vascular dementia. In conclusion, this case study suggests that the neuropsychologicai profile for CAA represents features consistent with a diffuse multifocal vascular dementia and a progressive dementia such as AD.
D'Agaro, W. R., Macciocchi, S. N., Reid, D. B., & Ryan, T. V. Preservation of Awareness Following Severe Head Injury: Evidence for a Disturbance in Self-Evaluation.
315
Systemic lupus erythematosus (SLE) is a muitisystem autoimmune disease that is often associated with central nervous system abnormalities. Neuropsychiatric manifestations, or CNS-SLE, occur in 25-75% of patients. Mechanisms of CNS-SLE will be presented. Early undetected cognitive impairment may unnecessarily diminish quality of life and complicate medical management. Through case study presentation, this paper demonstrates the value of early, ongoing neuropsychoiogical assessment and treatment in patients with CNSSLE. D.J. is a 39-year-old WF evaluated i 8 months after diagnosis. EEG. and MRI scans were normal. Behaviorally, D.J. complained of diminished work performance, spelling difficulty, forgetfulness, and difficulty following conversations. Her forgetfulness resulted in a kitchen fire and several thousand dollars in damages. Initial neuropsychological evaluation included the following: WAIS-R, WRAT-R, TPT, WSCT, PASAT, Selective Reminding Test, RCF Drawing, WMS-Russel version, Trails A & B, AST, BNT, GPB, and MMPI-2. Results indicated a pattern of mild to moderate diffuse neurocognitive impairment. Functions most significantly affected included attention and concentration, visual and verbal m e m o r y and learning, and fine motor speed. Subsequent to the evaluation, D.J. was provided with education behavioral recommendations, compensatory strategies for memory and organization, and counseling to promote psychological adjustment. Upon notification of test results, her rheumatologist and neurologist were able to more effectively monitor her clinical condition and adjust steroid dosages. D.J. was able to maintain her employment through job modification and reduced work hours. She employed compensatory strategies to facilitate home management. Six and twelve month evaluations demonstrated continued persistence of deficits without further deterioration. This paper demonstrates the value of early detection and treatment of neurocognitive impairment in SLE patients. Close communication between physicians, neuropsychologists, and rehabilitative therapists can significantly enhance the quality of life in SLE patients with neurocognitive impairment.
Culotta, V. P., Sementilli, M. E., Gerold, K., & Pafford, J. Variability in Mild Head Injury Outcome as a Function of Admission Glasgow Coma Scale Score. Research examining the neurobehavioral recovery and outcome of mild head injury (MHI) has yielded conflicting results. Variability in the outcome literature has been attributed to the selection of appropriate controls and the influence of moderator variables such as preinjury neurological and psychological status, substance use, malingering, and concurrent injuries. However, a major source of outcome variability may be inherent in the parameters defining MHI. Specifically, the inclusion of GCS 13-15 assumes an unreasonable degree of homogeneity in injury severity. The purpose of this study was to determine whether significant differences in injury severity exist between patients with an admission GCS of 13, 14, and 15.3,370 consecutive nonmissle head injury
316
Abstracts of 14th Annual Meeting
patients with an admission GCS score of 13--15 and a positive loss of consciousness were reviewed. 2,398 patients were admitted with a GCS = 15,796 patients had a GCS = 14, and 176 patients had GCS = 13. All patients were admitted to a Level I trauma center between 1990 and 1992. Patients were compared across the following variables indicative of injury severity: frequency of intracranial pathology visualized on CT scan and need for neurosurgical (NS) intervention within the first 24 hours. Positive CT findings were as follows: GCS 15 = 4%, GCS 14 = 16%, and GCS 13 = 28%. Patients requiring NS intervention: GCS 15 = 0.4%, GCS 14 = 1.6%, and GCS 13 = 4.5%. Chisquare analysis yielded statistically significant findings (p < .05) across all variables. These findings illustrate the range of injury severity across GCS 13-15 and may account for a large measure of the variability in studies examining neurobehavioral outcome. This data supports the need for refinement in the current classification of MHI and argues for the use of admission GCS score as a moderator in outcome analysis.
Cyrus, P. A., Krengel, M. H., Fama, R., Knoefel, J., & White, R. F. Evaluation of Cognitive Function in a Patient with Cerebral Amyloid Angiopathy. Cerebral amyloid angiopathy (CAA) is a disease most common in elerly patients which leads to recurrent cerebral hemorrhages. Pathologically, cerebral arterioles demonstrates deposition of amyloid. This finding also is seen in Alzheimer's Disease (AD). Few studies exist which address the cognitive changes in CAA. We questioned if the neropsychologicai profile of CAA would be consistent with AD, vascular dementia, or a combination of findings. A patient with probable CAA (with hemorrhagic infarcts in the left cerebellum, right occipital, and left occipital lobes) was evaluated on two occasions with a battery of nuropsychological tests. On the first assessment, 2 years after the last hemorrhage, the patient's deficits included difficulty in tracking, encoding, and retrieval. Severe visuospatial impairment and perseverations were noted. Reasoning and naming were relatively intact. These findings were consistent with a diffuse multifocal vascular dementia. Sixteen months later, follow-up testing revealed deficits in attention and auditory tracking, verbal fluency, markedly decreased verbal and visual memory, and an inability to learn new material. Visuospatial tasks remained severely affected. Follow-up test results were consistent with a progressive decline in functioning such as is seen in patients with AD. The patient had no new lesions to account for these changes in cognition and the pattern of deficits were not consistent with a diffuse vascular dementia. In conclusion, this case study suggests that the neuropsychologicai profile for CAA represents features consistent with a diffuse multifocal vascular dementia and a progressive dementia such as AD.
D'Agaro, W. R., Macciocchi, S. N., Reid, D. B., & Ryan, T. V. Preservation of Awareness Following Severe Head Injury: Evidence for a Disturbance in Self-Evaluation.