Key neurological impairments influence function-related group outcomes after stroke.
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BACKGROUND AND PURPOSE: The function-related group (FRG) classification is based on functional assessment and has been assumed to encompass the effects of different patterns and severity of neurological impairments. This assumption may not be correct. It has been proposed as a means of comparing rehabilitation outcome across institutions. If neurological impairments significantly affect FRG outcome, then higher FRG outcome scores may reflect selection bias favoring patients with fewer neurological impairments rather than better quality of rehabilitation care. The goal of this study was to assess the influence of motor, somatosensory, and hemianopic visual impairments on FRG outcomes after stroke. METHODS: All 288 consecutive stroke patients discharged in 1999 from an acute rehabilitation hospital were assigned to 1 of 5 FRGs on the basis of their Functional Independence Measure (FIM) mobility subscore and age. Each FRG was also stratified into 1 of 4 cohorts on the basis of the presence or absence of key neurological impairments: motor impairment only (M), motor plus either somatosensory or hemianopic visual impairment (MS/MV), motor plus somatosensory plus hemianopic visual impairment (MSV), and other combinations of impairments. FIM scores were available every 10 days for all patients from admission to discharge. The effect of impairment group on outcome was assessed within each FRG category through repeated-measures analysis of variance to assess differences in serial FIM scores across the 4 impairment groups. The distribution of each of the 4 impairment groups across the 5 FRGs was assessed with chi2 analysis. RESULTS: The numbers of patients in each of the 5 FRGs from the lowest level, FRG-11, to the highest, FRG-15, were as follows: 78 (27%), 47 (16%), 75 (26%), 55 (19%), and 33 (11%). Different neurological impairments were associated with significantly different mean+/-SD discharge FIM scores as follows: for FRG-11, MSV=63+/-16, MS/MV=68+/-19, and M=81+/-13 (P=0.04); for FRG-12, MSV=47+/-14, MS/MV=61+/-12, and M=75+/-11 (P=0.01); and for FRG-13, MSV=79+/-20, MS/MV=85+/-19, and M=96+/-10 (P<0.02). For FRG-14 and FRG-15, those with M impairments had the highest and those with MSV impairments had the lowest discharge FIM scores, but the differences did not reach statistical significance. The chi2 analysis showed a highly significant difference in representation of MSV impairments across FRG-11 through FRG-15 as follows: 35 of 78 (45%), 20 of 47 (43%), 11 of 74 (15%), 4 of 55 (7%), and 2 of 33 (6%). For patients classified as having an M deficit only or other impairment, the results were as follows: 19 of 78 (24%), 15 of 47 (32%), 41 of 75 (55%), 41 of 55 (75%), and 27 of 33 (82%) (chi(2) analysis=78.7, P<0.0001). CONCLUSIONS: The presence of motor, somatosensory, and hemianopic visual impairment significantly affects FRG outcome and should be included in future outcome assessment tools. Comparisons of FIM change and efficiency scores across institutions are potentially biased by referral and selection criteria favoring equally dysfunctional but less neurologically impaired individuals. (+info)
Viewing less to see better.
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OBJECTIVE: To assess the efficacy, as well as the long term duration, of a new procedure for the rehabilitation of visuospatial neglect in patients with right hemisphere stroke. METHODS: Patients with right unilateral hemispheric damage identified with neglect were assigned to a treatment (T+) or a control (T-) group. The treatment consisted in abolishing all visual inputs from the right hemispace for one week by means of specially devised hemiblinding goggles. Patients' visuospatial abilities were tested and compared between groups immediately after the week of treatment. Both groups were further assessed one week after treatment suspension for evaluation of long term beneficial effects. RESULTS: Following the treatment, a substantial amelioration of visuospatial neglect symptoms was selectively observed in the T+ group. In contrast, untreated patients showed only weak signs of recovery. Most important, the amelioration obtained in the T+ group of patients was not ephemeral, being significantly maintained after a further period of one week, even after suspension of the treatment. CONCLUSION: The protracted efficacy of the proposed "hemiblinding technique" may have important implications for the recovery of visuospatial neglect and may be a very promising tool for investigating both the cognitive and the neural basis of neglect rehabilitation. (+info)
Tuberous sclerosis presenting in late adult life.
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A 59 year old woman presented with a three year history of left sided weakness. Magnetic resonance imaging of the brain showed a large high signal lesion occupying most of the right temporal lobe with mass effect. A probable diagnosis of low grade glioma led to temporal lobectomy. Histology revealed dysplastic cortical morphology typical of tuberous sclerosis. There were no clinical signs or family history of the disease. Ultrasound showed multiple bilateral renal angiomyolipomas, confirming the diagnosis of tuberous sclerosis. Molecular genetic analysis of peripheral white blood cells identified a novel mis-sense mutation R1409W in exon 33 of the TSC2 gene. (+info)
Criteria for early detection of temporal hemianopia in asymptomatic pituitary tumor.
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PURPOSE: To determine new criteria for early detection of temporal hemianopia in patients with asymptomatic pituitary tumor. METHODS: Fifteen patients without visual symptoms had pituitary tumor and subtle defects or normal visual fields by Goldmann perimetry. Twelve patients with visual symptoms had pituitary adenoma and visual field defects detected by Goldmann perimetry. All were examined by automated perimetry. The relationship between the tumor and the optic chiasm was graded by magnetic resonance imaging (MRI) on a scale of 0-4. Grade number increased with extent of compression. Temporal hemianopia observed by automated perimetry was estimated from normal data (52 normal fields). Vertical step was determined from the number of adjacent pairs along the midline; sensitivity was lower in the temporal field than in the nasal field. Temporal depression was calculated by the quadrant sum of sensitivity. RESULTS: All patients with symptomatic pituitary adenoma had vertical step and temporal depression in the upper field. Nine of 15 patients without visual symptoms had vertical step or temporal depression. Of nine patients with temporal hemianopia, two of four patients had grade 1 compression, three of five had grade 2, and four of four had grade 3. CONCLUSIONS: New criteria by automated perimetry could detect temporal hemianopia in patients with asymptomatic pituitary tumor. (+info)
Retinotopic modulation of space misrepresentation in unilateral neglect: evidence from quadrantanopia.
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A patient with right sided brain damage suffered contralesional neglect, inferior quadrantanopia (with 0 degrees sparing in the left eye and 13 degrees sparing in the right), and a visual field restriction (to 15 degrees ) in the upper contralesional quadrant of the left eye. In binocular vision, the patient showed underestimation of the horizontal size of contralesional line segments unless cued to localise their end points. When asked to reproduce, in monocular vision, 10 degrees and 20 degrees distances between two attentionally cued end points lying on the frontal vertical plane, the patient showed relative contralesional overextension and ipselesional underextension along the directions falling within the blind sectors of the neglected space. No asymmetry was present along the directions falling within the seeing sectors of the same space. These findings suggest precise retinotopic modulation of space misrepresentation in unilateral neglect. (+info)
Quantitative analysis of axonal loss in band atrophy of the optic nerve using scanning laser polarimetry.
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AIMS: To measure axonal loss in patients with band atrophy from optic chiasm compression using scanning laser polarimetry (GDx, Laser Diagnostic Technologies, Inc, San Diego, CA, USA) and to evaluate the ability of this instrument to identify this pattern of retinal nerve fibre layer (RNFL) loss. METHODS: 19 eyes from 17 consecutive patients with band atrophy of the optic nerve and permanent temporal hemianopia due to chiasmal compression, and 19 eyes from an age and sex matched control group of 17 healthy individuals were prospectively studied. All patients were submitted to an ophthalmic examination including Goldmann perimetry and evaluation of the RNFL using scanning laser polarimetry. Mean RNFL thickness around the optic disc were compared between the two groups. The diagnostic performance of the deviation from normal analysis provided by the GDx software was also assessed. RESULTS: The peripapillary RNFL thickness (mean (SD)) of eyes with band atrophy was 47.9 (7.63) micro m, 37.1 (8.48) micro m, 57.0 (9.31) micro m, and 37.2 (8.86) micro m in the superior, temporal, inferior, and nasal regions, respectively. The total average was 43.7 (12.0) micro m. In the control group, the corresponding values were 71.1 (12.2) micro m, 40.4 (10.9) micro m, 85.4 (14.0) micro m, and 49.8 (10.1) micro m. The total average measured 67.9 (11.2) micro m. The measurements from eyes with optic atrophy were significantly different from those in the control group in all regions but the temporal. The deviation from normal analysis provided by the GDx software failed to identify the majority of abnormalities in the temporal and nasal regions of patients with band atrophy. CONCLUSIONS: Scanning laser polarimetry was able to identify axonal loss in the superior, inferior, and nasal regions, but failed to detect it in the temporal region of the optic disc, despite the fact that this area was clearly altered in eyes with band atrophy. This examination also showed poor sensitivity to detect axonal loss in the nasal region when GDx software analysis was used. The results of this study emphasise that RNFL evaluation using scanning laser polarimetry should be interpreted with caution in the study of eye diseases that lead to axonal loss predominantly in the nasal and temporal areas of the optic disc. (+info)
Nasotemporal overlap of retinal ganglion cells in humans: a functional study.
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PURPOSE: A zone of overlap along the vertical retinal meridian where ipsi- and contralaterally projecting ganglion cells intermingle has been demonstrated histologically in nonhuman primates. The widening of the zone of overlap in the foveal region was thought to produce a foveal sparing extending 1.5 degrees in the blind hemifield in human hemianopia. The functional relevance of the nasotemporal overlap is still unclear and cannot be shown definitely by conventional perimetry, because of insufficient spatial accuracy, light-scattering effects, and insufficient fixation control. Therefore, this study was undertaken to investigate the vertical field border by a perimetric method that does not have these shortcomings. METHODS: A scanning laser ophthalmoscope (SLO) was used to scan vertical triplets of dots along the vertical field border in 20 patients (36 eyes) with homonymous hemianopia without macular sparing. Stimuli and fundus were imaged simultaneously for fixation monitoring. RESULTS: None of the patients showed a field border that coincided exactly with the vertical midline. In 34 eyes, the seeing area extended from the vertical meridian into the blind hemifield and formed a vertical strip of perception. None of the patients showed additional foveal sparing. Twenty-two eyes showed a concave shape of the seeing area within the foveal region of the blind hemifield. CONCLUSIONS: Our results show that the nasotemporal overlap exists in humans. It consists of a strip of intact perception reaching into the blind hemifield. The concave shape can be explained by the size and distribution of the receptive fields of the retinal ganglion cells. (+info)
Aphasia in acute stroke.
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Previous surveys of stroke populations have offered only cursory information on language disturbance, and, conversely, few surveys of aphasic populations have dealth exclusively with stroke or with acute phenomena. This paper describes aphasia in 850 acute stroke patients consecutively registered by the Harlem Regional Stroke Program, of whom 177 (21%) were aphasic; of these, nine were of Broca's type, 24 were of Wernicke's type, 14 were of anomic, ten were conduction, seven were of "isolation" type, and 107 were "mixed." An unexpected finding was a significant over-representation of men among the nonfluent aphasics. During the following four to 12 weeks, 12% of fluent aphasics died, and 12% remained moderately or severely impaired; among survivors, aphasia improved in 74%, and in 44% it cleared completely. During the same period, 32% of nonfluent aphasics died, and 34% remained moderately or severely impaired; among survivors, aphasia improved in 52%, and in only 13% did it clear completely. In both fluent and nonfluent groups, hemiparesis and/or visual field cut were associated with poor prognosis. (+info)