FIND Stroke Recovery Study (FIND): rationale and protocol for a longitudinal observational cohort study of trajectories of recovery and biomarkers poststroke

INTRODUCTION

Comprehensive studies mapping domain-specific trajectories of recovery after stroke and biomarkers reflecting these processes are scarce. We, therefore, initiated an exploratory prospective observational study of stroke cases with repeated evaluation, the FIND Stroke Recovery Study. We aim to capture trajectories of recovery from different impairments, including cognition, in combination with broad profiling of blood and imaging biomarkers of the recovery.

METHODS AND ANALYSIS

We recruit individuals with first-ever stroke at the stroke unit at the Sahlgrenska University Hospital, Sweden, to FIND. The inclusion started early 2018 and we aim to enrol minimum 500 patients. Neurological and cognitive impairments across multiple domains are assessed using validated clinical assessment methods, advanced neuroimaging is performed and blood samples for biomarker measuring (protein, RNA and DNA) at inclusion and follow-up visits at 3 months, 6 months, 1 year, 2 years and 5 years poststroke. At baseline and at each follow-up visit, we also register clinical variables known to influence outcomes such as prestroke functioning, stroke severity, acute interventions, rehabilitation, other treatments, socioeconomic status, infections (including COVID-19) and other comorbidities. Recurrent stroke and other major vascular events are identified continuously in national registers.

ETHICS AND DISSEMINATION

FIND composes a unique stroke cohort with detailed phenotyping, repetitive assessments of outcomes across multiple neurological and cognitive domains and patient-reported outcomes as well as blood and imaging biomarker profiling. Ethical approval for the FIND study has been obtained from the Regional Ethics Review Board in Gothenburg and the Swedish Ethics Review Board. The results of this exploratory study will provide novel data on the time course of recovery and biomarkers after stroke. The description of this protocol will inform the stroke research community of our ongoing study and facilitate comparisons with other data sets.

TRIAL REGISTRATION NUMBER

The protocol is registered at http://www.

CLINICALTRIALS

gov, Study ID: NCT05708807.

Decision-making under ambiguity after frontal lobe resection for epilepsy

PURPOSE

Decision-making is crucial to daily life and can impact our society as well as economic conditions. Although the frontal lobes have been identified as important for decision-making, this capacity has only been studied to a limited extent in frontal lobe epilepsy and not at all after frontal lobe resection (FLR) for epilepsy. This study aimed to explore decision-making under ambiguity after FLR for epilepsy.

METHODS

Fourteen patients having undergone FLR for epilepsy completed the Iowa Gambling Task (IGT) which is a widely used tool to measure decision-making under ambiguity. Iowa Gambling Task scores included in the analysis were: total net score, separate scores from five blocks across the test, and a change score (last block of IGT minus first block). A group of healthy controls (n = 30) was used as a comparison. Associations between IGT and standardized neuropsychological methods for assessment of executive functions, self-rating questionnaires of mental health, fatigue, and behavior linked to frontal lobe dysfunction were also investigated.

RESULTS

The patient group performed inferior to controls at the final block of the IGT (p =.001).A group difference in IGT change scores was found (p =.005), reflectingthe absence of a positive change in performance over time for the FLR group compared to the control group. Correlations with tests of executive functions as well as self-rating scales were mainly statistically nonsignificant.

CONCLUSIONS

This study shows that patients having undergone FLR for epilepsy have difficulties with decision-making under ambiguity. The performance illustrated a failure to learn throughout the task. Executive as well as emotional deficits may impact decision-making processes in this patient group and need to be considered in further studies. Prospective studies with larger cohorts are needed.

Fatigue 7 years post-stroke: Predictors and correlated features

Background

Post‐stroke fatigue (PSF) is common with great impact on quality of life. We explored predictive and cross‐sectionally correlated features in the long term after ischemic stroke.

Methods

This study comprises 430 participants of the prospective Sahlgrenska Academy Study on Ischemic Stroke (SAHLSIS), aged 18–69 years at index stroke. Information on acute stroke severity and cardiovascular risk factors was collected at index stroke. After 7 years, PSF was assessed by the Daily Fatigue Impact Scale (D‐FIS). Cognitive, neurological, and functional outcomes, and symptoms of depression and anxiety, pain, insomnia, and physical activity were also assessed. Associations between baseline variables and PSF were analyzed by ordinal regression. Correlations between PSF and cross‐sectionally assessed variables, and between PSF and baseline variables, were analyzed with Spearman's or point‐biserial correlation for the whole sample and in sex‐stratified analyses.

Results

At 7 years post‐stroke, 80% of the participants reported some impact of fatigue. Female sex and stroke severity were independently associated with PSF, whereas no associations were detected with baseline cardiovascular risk factors. In cross‐sectional analyses at 7 years, we found correlations between PSF and poor functional, neurological, and cognitive outcomes, as well as depressive symptoms, anxiety, insomnia, pain, and low physical activity (p < .001 throughout). The correlation with insomnia was stronger in women than in men (two‐way ANOVA interaction test, p = .03).

Conclusions

Our findings confirm that PSF is common in the long term after ischemic stroke and show a complex interplay with sex and several other outcomes. Future studies should address causal relationships and interventions towards fatigue and coexisting features.

Cognitive screen and employment long-term after infratentorial stroke

OBJECTIVES

Motor problems are well-described neurological deficits that occur commonly after an infratentorial ischemic stroke. However, the brain stem and cerebellum are also part of the neural interconnections responsible for cognition, emotions, and behavioral responses. We lack studies on long-term cognitive outcomes and patient employment after an infratentorial stroke. In the present study, we described and compared long-term poststroke cognitive outcomes and employment between patients that experienced infratentorial and supratentorial ischemic strokes.

MATERIALS AND METHODS

We included consecutive patients that experienced an acute ischemic stroke at ≤58 years of age. Patients were classified according to the stroke location. At seven years poststroke, surviving participants were assessed for neurological deficits (National Institutes of Health Stroke Scale [NIHSS]), functional outcome (modified Rankin Scale [mRS]), cognitive function Barrow Neurological Institute Screen (BNIS), and employment.

RESULTS

Among 141 participants, 25 (18%) had infratentorial and 116 (82%) had supratentorial strokes. At the 7-year poststroke follow-up, there was no significant difference in BNIS total scores; with a median of 43 (IQR 40.5-46) and 41 (IQR 38-46) in the infratentorial and supratentorial groups, respectively. This result indicated that cognitive dysfunction occurred frequently in both groups. Similar employment rates were observed in the infratentorial (48%) and supratentorial (55%) groups. Both groups had a median NIHSS score of 0 and a median mRS score of 2 at the 7-year follow-up.

CONCLUSION

Patients who survived an infratentorial or supratentorial ischemic stroke had similar rates of long-term cognitive dysfunction and difficulties in returning and/or remaining at work.

Cognitive function is an important determinant of employment amongst young ischaemic stroke survivors with good physical recovery

BACKGROUND AND PURPOSE

This cross-sectional cohort study aims at investigating young ischaemic stroke survivors with good physical recovery 7 years post-stroke in order to analyze the relation between late cognitive ability and employment.

METHODS

Consecutive ischaemic stroke survivors participating in the Sahlgrenska Academy Study on Ischemic Stroke, <55 years of age at stroke onset, and with no or minimal persisting neurological deficits corresponding to a score ≤2 on the National Institutes of Health Stroke Scale at long-term follow-up 7 years post-stroke were included. At this follow-up, the participants were assessed with respect to general cognitive function, processing speed, executive functions, cardiovascular risk factors, self-reported employment, cognitive difficulties, fatigue, depressive symptoms, anxiety and physical function.

RESULTS

Seven years post-stroke 112/142 (79%) had part-time or full-time work and 30/142 (21%) had full-time disability pension or sick leave. Compared to those with full-time disability pension or sick leave, participants with current employment demonstrated significantly better performance with respect to general cognitive function and processing speed, and significantly lower self-ratings for cognitive difficulties, physical limitations, fatigue and depressed mood. Multivariable logistic regression selected self-rated memory (odds ratio [OR] 2.61, 95% confidence interval [CI] 1.61-4.21), processing speed (OR 3.50, 95% CI 1.67-7.33) and self-rated communication skills (OR 3.46, 95% CI 1.75-6.85) as most important correlates (area under the curve 0.83-0.87) of having current employment.

CONCLUSION

This study indicates that cognitive dysfunction is an important contributor to long-term work disability amongst young stroke survivors with good physical recovery.

Motor Function in the Late Phase After Stroke: Stroke Survivors' Perspective

Objective

To examine the association between observer-assessed functional status and perceived recovery in the late phase after stroke. The study also aimed to determine whether observer-assessed functional improvements as a result of horse-riding therapy (H-RT) are related to enhanced perception of stroke recovery.

Methods

This is a descriptive correlational study using data derived from a three-armed randomized controlled trial in which 123 individuals were enrolled, among whom 43 received H-RT for 12 weeks. The measures included the Modified Motor Assessment Scale, Berg Balance Scale, Timed Up and Go, timed 10-m walk, and perceived recovery from stroke indicated by item #9 in the Stroke Impact Scale (version 2.0). Spearman rank order correlation (rs) was used in the analyses.

Results

There were moderate to strong positive or negative correlations between all four observer-assessed motor variables and participants’ ratings of perceived late-phase stroke recovery at trial entrance, ranging from r_s=-0.49 to r_s=0.54 (p<0.001). The results of the correlational analyses of variable changes showed that, after the end of the H-RT intervention, both self-selected and fast gait speed improvement were significantly correlated with increments in self-rated stroke recovery (r_s=-0.41, p=0.01 and r_s=-0.38, p=0.02, respectively).

Conclusion

This study provided data supporting the association between individual ratings of self-perceived recovery after stroke and observer-assessed individual motor function. The results further demonstrate that enhancement in perceived stroke recovery after completing the intervention was associated with objectively measured gains in both self-selected and fast gait speed.

The presence and prediction of lateralized inattention 7 years post-stroke

OBJECTIVE

Lateralized inattention is a typical sign of neglect and related to poor functional outcome. Knowledge of the long-term course of this phenomenon is limited. The purpose of this study was to investigate presence and predictors for signs of lateralized inattention 7 years after stroke.

METHODS

From a cohort of acute ischemic stroke patients, aged 18-69 years (n = 297), a consecutive series of 188 survivors without recurrent stroke at follow-up 7 years later were included. Within the first week after stroke onset, stroke severity was assessed according to the Scandinavian Stroke Scale. Target omissions, asymmetry of omissions, and perceptual speed according to Star- and Letter Cancellation Tests were also assessed. Presence of lateralized inattention at the 7-year follow-up was investigated with the Star- and Letter Cancellation Tests and with the neglect item in the National Institutes of Health Stroke Scale.

RESULTS

At the follow-up, 22 (11.7%) participants had lateralized inattention and the multivariable regression showed that independent significant baseline predictors were total omissions in target cancellations (P < .001) and inferior baseline performance on visual processing speed (P = .008).

CONCLUSION

About one of ten individuals exhibited signs of lateralized inattention 7 years after stroke. Baseline performance in perceptual processing speed and target omissions independently predicted presence of late signs of lateralized inattention. This is the first time processing speed is recognized as a significant predictor of lateralized inattention several years after the stroke incidence, indicating that the longitudinal course of processing speed following stroke is a critical subject for future research.

Predicting verbal memory decline following temporal lobe resection for epilepsy

OBJECTIVES

The aim of the study was to develop a prediction model for verbal memory decline after temporal lobe resection (TLR) for epilepsy. The model will be used in the preoperative counselling of patients to give individualized information about risk for verbal memory decline.

MATERIALS AND METHODS

A sample of 110 consecutive patients who underwent TLR for epilepsy at Sahlgrenska University Hospital between 1987 and 2011 constituted the basis for the prediction model. They had all gone through a formal neuropsychological assessment before surgery and 2 years after. Penalized regression and 20 × 10-fold cross-validation were used in order to build a reliable model for predicting individual risks.

RESULTS

The final model included four predictors: side of surgery; inclusion or not of the hippocampus in the resection; preoperative verbal memory function; and presence/absence of focal to bilateral tonic-clonic seizures (TCS) the last year prior to the presurgical investigation. The impact of a history of TCS is a new finding which we interpret as a sign of a more widespread network disease which influences neuropsychological function and the cognitive reserve. The model correctly identified 82% of patients with post-operative decline in verbal memory, and the overall accuracy was 70%-85% depending on choice of risk thresholds.

CONCLUSIONS

The model makes it possible to provide patients with individualized prediction regarding the risk of verbal memory decline following TLR. This will help them make more informed decisions regarding treatment, and it will also enable the epilepsy surgery team to prepare them better for the rehabilitation process.

Long-term performance of instrumental activities of daily living in young and middle-aged stroke survivors-Impact of cognitive dysfunction, emotional problems and fatigue

Background

With an upward trend in the number of people who return home to independent living after stroke, the ability to perform more complex activities is becoming an increasingly important long-term outcome after stroke. Although associations between Instrumental Activities of Daily Living (IADL) and cognitive dysfunction, emotional problems, and fatigue have been reported, less is known about the long-term impact of these stroke consequences on the performance of everyday activities in young and middle-aged stroke survivors.

Objective

To explore the impact of cognitive dysfunction, emotional problems, and fatigue on long-term performance of instrumental activities of daily living in young and middle-aged stroke survivors

Method

Data on stroke survivors, aged 18–69 at index stroke, were collected from the Sahlgrenska Academy Study on Ischaemic Stroke. IADL outcome was assessed using the Frenchay Activities Index (FAI), and the impact of chosen variables was assessed using Spearman´s rank-order correlation and logistic regression.

Results

Seven years after index stroke, 296 stroke survivors (median age of 64) were included in this study. Cognitive dysfunction showed the strongest correlations with FAI outcome and independently explained worse outcome on FAI summary score and the domain of work/leisure activities. Fatigue was independently explanatory of worse outcome on FAI summary score and domestic chores, while depressive symptoms independently explained worse outcome on work/leisure activities. In a subgroup with only those participants who had no or minimal residual neurological deficits at follow-up (NIHSS score 0), cognitive dysfunction independently explained worse outcome on FAI summary score and work/leisure activities. Depressive symptoms independently explained worse outcome on FAI summary score and domestic chores.

Conclusion

Our results show that in young and middle-aged stroke survivors, cognitive dysfunction, depressive symptoms, and fatigue negatively impact performance of IADL even at seven years post stroke onset. Further, we have shown that an impact of both cognitive dysfunction and depressive symptoms can be found also among stroke survivors with mild or no remaining neurological deficits.

Fibrinogen concentrations predict long-term cognitive outcome in young ischemic stroke patients

BACKGROUND

Cognitive impairment is frequent after stroke, and young patients may live with this consequence for a long time. Predictors of cognitive outcomes after stroke represent a current gap of knowledge.

OBJECTIVES

To investigate levels of three hemostatic biomarkers as predictors of long-term cognitive function after stroke.

METHODS

This longitudinal study included consecutively recruited patients with ischemic stroke at 18-69 years (n = 268). Blood was collected 3 months after index stroke and analyzed for plasma concentrations of fibrinogen, von Willebrand factor (VWF) and tissue-type plasminogen activator (t-PA) antigen. Cognitive function 7 years after index stroke was assessed by the Barrow Neurological Institute Screen for Higher Cerebral Functions (BNIS). Participants with stroke <50 years of age were also examined by the Trail Making Test A and B (n = 41). Associations between biomarker concentrations and cognitive scales were assessed in the whole group and in participants with stroke <50 years of age.

RESULTS

The hemostatic biomarkers fibrinogen, VWF and t-PA, were all correlated to total BNIS score, but these associations did not withstand adjustment for confounding factors in the whole group. However, in patients <50 years, we found an independent association between fibrinogen concentrations and total BNIS score (βstd = -.27, 95% confidence interval [CI], -0.47 to -0.07) and to performance on the Trail Making Test A (βstd = .31, 95% CI, 0.03-0.58). No such association was seen for the Trail Making Test B.

CONCLUSION

High convalescent fibrinogen concentrations were associated with worse long-term cognitive outcomes in ischemic stroke <50 years of age. We propose further investigations of fibrinogen in relation to cognitive function in stroke in the young.

Executive function and attention in patients with stress-related exhaustion: perceived fatigue and effect of distraction

Cognitive impairment has frequently been shown in patients who seek medical care for stress-related mental health problems. This study aims to extend the current knowledge of cognitive impairments in these patients by focusing on perceived fatigue and effects of distraction during cognitive testing. Executive function and attention were tested in a group of patients with stress-related exhaustion (n = 25) and compared with healthy controls (n = 25). Perceived fatigue was measured before, during and after the test session, and some of the tests were administered with and without standardized auditory distraction. Executive function and complex attention performance were poorer among the patients compared to controls. Interestingly, their performance was not significantly affected by auditory distraction but, in contrast to the controls, they reported a clear-cut increase in mental tiredness, during and after the test session. Thus, patients with stress-related exhaustion manage to perform during distraction but this was achieved at a great cost. These findings are discussed in terms of a possible tendency to adopt a high-effort approach despite cognitive impairments and the likelihood that such an approach will require increased levels of effort, which can result in increased fatigue. We tentatively conclude that increased fatigue during cognitive tasks is a challenge for patients with stress-related exhaustion and plausibly of major importance when returning to work demanding high cognitive performance.

Long-Term Improvements After Multimodal Rehabilitation in Late Phase After Stroke: A Randomized Controlled Trial

BACKGROUND AND PURPOSE

Treatments that improve function in late phase after stroke are urgently needed. We assessed whether multimodal interventions based on rhythm-and-music therapy or horse-riding therapy could lead to increased perceived recovery and functional improvement in a mixed population of individuals in late phase after stroke.

METHODS

Participants were assigned to rhythm-and-music therapy, horse-riding therapy, or control using concealed randomization, stratified with respect to sex and stroke laterality. Therapy was given twice a week for 12 weeks. The primary outcome was change in participants' perception of stroke recovery as assessed by the Stroke Impact Scale with an intention-to-treat analysis. Secondary objective outcome measures were changes in balance, gait, grip strength, and cognition. Blinded assessments were performed at baseline, postintervention, and at 3- and 6-month follow-up.

RESULTS

One hundred twenty-three participants were assigned to rhythm-and-music therapy (n=41), horse-riding therapy (n=41), or control (n=41). Post-intervention, the perception of stroke recovery (mean change from baseline on a scale ranging from 1 to 100) was higher among rhythm-and-music therapy (5.2 [95% confidence interval, 0.79-9.61]) and horse-riding therapy participants (9.8 [95% confidence interval, 6.00-13.66]), compared with controls (-0.5 [-3.20 to 2.28]); P=0.001 (1-way ANOVA). The improvements were sustained in both intervention groups 6 months later, and corresponding gains were observed for the secondary outcomes.

CONCLUSIONS

Multimodal interventions can improve long-term perception of recovery, as well as balance, gait, grip strength, and working memory in a mixed population of individuals in late phase after stroke.

CLINICAL TRIAL REGISTRATION

URL: http//www.ClinicalTrials.gov. Unique identifier: NCT01372059.

Psychosocial status 10 years after temporal lobe resection for epilepsy, a longitudinal controlled study

Knowledge about long-term psychosocial outcome of temporal lobe resection (TLR) for epilepsy is limited. The aims of this study were to describe vocational outcome 10 years after TLR and to analyze the effect on the vocational situation by seizures, laterality of resection, verbal memory, and mood. Fifty-one patients were prospectively followed 10 years after TLR. Psychosocial and neuropsychological data were ascertained at baseline and 10 years after surgery and at corresponding time points for 23 controls. Fewer patients worked 10 years post-operatively compared with controls (TLR patients: 61% and controls: 96%). However, seizure-free patients were more likely to retain employment (71%) than patients who had seizures (41%). The odds of working full-time were 9.5 times higher for patients with seizure freedom than for those with continuing seizures. There were no associations between working at 10 years and side of resection or mood, and impairment of verbal memory did not have an influence on vocational outcome.

The Barrow Neurological Institute screen for higher cerebral functions in cognitive screening after stroke

The objective of this study was to evaluate the Barrow Neurological Institute Screen for Higher Cerebral Functions (BNIS) in screening for cognitive dysfunction at long-term follow-up after stroke in young and middle-aged patients. Within the Sahlgrenska Academy Study on Ischemic Stroke Outcome, the BNIS and the Mini-Mental State Examination (MMSE) were administered to 295 consecutive surviving patients seven years after ischemic stroke. All participants were less than 70 years at index stroke. BNIS score less than 47 and an MMSE score less than 29 were chosen to indicate cognitive dysfunction. Two hundred eighty-one (95%) patients completed both tests. The 2 test scores were moderately correlated, and both tests correlated to disability as measured by the modified Rankin Scale. The distribution of the MMSE score was skewed toward the top scores, with a marked ceiling effect, whereas the BNIS score was more normally distributed. Most BNIS subscales showed mean performance around the mid of the scale without ceiling effects. Both tests identified a large proportion of the subjects as cognitive impaired, however, with a substantially larger proportion for the BNIS (89%) compared with the MMSE (65%). We conclude that the BNIS may be a useful screening instrument for cognitive dysfunction after ischemic stroke and that a large proportion of young and middle-aged ischemic stroke survivors showed signs of cognitive dysfunction long after index stroke. Further validations of BNIS against formal neuropsychological testing and studies of the determinants and consequences of long-term cognitive outcome in this patient group are warranted.

Verbal memory decline is less frequent at 10 years than at 2 years after temporal lobe surgery for epilepsy

We investigated individual short- and long-term verbal memory changes after temporal lobe resection for epilepsy. Fifty-one patients (23 operated on the speech-dominant temporal lobe, DTL and 28 on the non-dominant temporal lobe, NDTL) were tested on learning/immediate recall and delayed recall of word-list and word-pairs preoperatively, 2 years postoperatively and 10years postoperatively. Changes were defined using reliable change indices of 23 healthy controls assessed at corresponding intervals. Fewer patients had reliable declines at 10 years than at 2 years (DTL: 13-35% vs 35-44%; NDTL: 0-4% vs 7-21%). Four DTL patients (17%) had reliable declines in ≥2 tests at 10-year follow-up. More NDTL patients had improvement at 10 years than at 2 years (18-30% vs 4-22%). The only risk factor for decline both short and long term was DTL resection. In conclusion, most patients had stable verbal memory postoperatively. A few DTL patients had a lasting decline at long-term follow-up, but more patients showed partial recovery, especially in the NDTL group.

Virtual rehabilitation after stroke

The purpose of this project was to investigate the effects of Virtual Reality technology and haptics for stroke rehabilitation. Twenty-nine stroke subjects, 17 women, and 12 men aged 44-85 years, participated in three different studies. All participants responded favorable to the use of the VR activity station. A change of attitude took place after the subjects were exposed to playing computer games. The general experience with the VR application approach suggests that this treatment concept is promising in stroke rehabilitation, with a wide range of applicability.

Verbal cognition and attention deficits do not explain the verbal memory decline associated with pharmacoresistant partial epilepsy

The aim of this study was to explore whether change in verbal memory with time in patients with epilepsy is influenced by performance on tasks assessing verbal cognition or attention/processing speed. Thirty-six patients and twenty-five healthy controls were tested twice with median retest intervals of 4.8 and 3.1 years, respectively. Aspects of verbal memory, verbal cognition, and attention/processing speed were assessed. Decline in one verbal memory variable (Cronholm-Molander Memory Test Paired Associates -- Delayed Recall) was the strongest correlate of epilepsy. The second strongest correlate was a decrease in one attention/processing speed variable (Digit Symbol). The relationship between decline in verbal memory and epilepsy was not influenced by the decline in attention/processing speed, and the results did not support the notion that limited mental reserves as reflected in impaired verbal cognition or attention/processing speed can explain the relationship between verbal memory and epilepsy.

Neglect assessment as an application of virtual reality

OBJECTIVE

In this study a cancellation task in a virtual environment was applied to describe the pattern of search and the kinematics of hand movements in eight patients with right hemisphere stroke.

METHODS

Four of these patients had visual neglect and four had recovered clinically from initial symptoms of neglect. The performance of the patients was compared with that of a control group consisting of eight subjects with no history of neurological deficits.

RESULTS

Patients with neglect as well as patients clinically recovered from neglect showed aberrant search performance in the virtual reality (VR) task, such as mixed search pattern, repeated target pressures and deviating hand movements. The results indicate that in patients with a right hemispheric stroke, this VR application can provide an additional tool for assessment that can identify small variations otherwise not detectable with standard paper-and-pencil tests.

CONCLUSION

VR technology seems to be well suited for the assessment of visually guided manual exploration in space.

Transplantation of mesenchymal stem cells to enhance engraftment of hematopoietic stem cells

Seven patients underwent treatment with mesenchymal stem cells (MSCs), together with allogeneic hematopoietic stem cell transplantation (HSCT). MSCs were given to three patients for graft failure and four patients were included in a pilot study. HSCT donors were three human leukocyte antigen (HLA)-identical siblings, three unrelated donors and one cord blood unit. The conditioning was myeloablative in four patients and reduced in three patients. MSC donors were HLA-identical siblings in three cases and haploidentical in four cases. Neutrophil counts >0.5 x 10(9)/l was reached at a median of 12 (range 10-28) days. Platelet counts >30 x 10(9)/l was achieved at a median of 12 (8-36) days. Acute graft-versus-host disease (GVHD) grade 0-I was seen in five patients. Two patients developed grade II, which in one patient evolved into chronic GVHD. One severe combined immunodeficiency (SCID) patient died of aspergillosis, the others are alive and well. One patient, diagnosed with aplastic anemia had graft failure after her first transplantation and severe Henoch-Schönlein Purpura (HSP). After retransplantation of MSCs and HSCs, she recovered from both the HSP and aplasia. Thus, co-transplantation of MSC resulted in fast engraftment of absolute neutrophil count (ANC) and platelets and 100% donor chimerism, even in three patients regrafted for graft failure/rejection.

Serial cognitive change patterns across time after temporal lobe resection for epilepsy

Longitudinal cognitive outcome with respect to general cognitive status and memory at the group and individual levels was studied 10 years after temporal lobe resection for epilepsy. Twenty-five patients who had undergone a medium-term follow-up (T2, median = 2.7 years) also underwent a long-term follow-up (T3, median = 9.8 years). At the group level, there was a significant increment across time, partly due to practice, in IQ (P value from 0.049 to <0.0001) but not in memory variables. On the basis of the normative interval of reassessed matched controls, the analysis at the individual level of change from baseline to T2 disclosed decrements in 12-29% of the patients and increments in 8-21%. These proportions diminished at T3 (0-12 and 0-16%) and the dominating pattern of Performance IQ and verbal memory was a return toward baseline. These findings make the interpretation of an initial (T2) postoperative increment or decrement more problematic and underline the need for a comprehensive evaluation across time, including both at the group and individual levels.

Visual neglect and cognitive impairment in elderly patients late after stroke

OBJECTIVES

To investigate the prevalence of visual neglect and its relationship to cognitive impairment and dementia in elderly stroke patients 20 months after stroke.

METHODS

Of 243 stroke patients aged 70-91 years, 149 underwent neuropsychiatric testing, 138 with the Star Cancellation Test for visual neglect.

RESULTS

Fifteen per cent (n = 21) had visual neglect, 9% (n = 12) severe and 9% (n = 12) lateralized. Cognitive impairments were twice as common in patients with neglect as in patients without it and threefold more common when the neglect was severe. Neglect was related to apraxia, impaired visual field, and a previous stroke. Severe neglect was related to dementia, amnesia and impaired visual field.

CONCLUSIONS

Chronic neglect is common after stroke in elderly patients. So are cognitive impairments, especially in those with neglect. This calls for high alertness to impairments in spatial attention when treating patients with dementia and other cognitive impairments.

Verbal memory decline and adverse effects on cognition in adult patients with pharmacoresistant partial epilepsy: a longitudinal controlled study of 36 patients

The aim of this study was to delineate possible longitudinal cognitive changes in adult patients with a long history of pharmacoresistant partial epilepsy. Thirty-six patients and thirty healthy controls were investigated at baseline. A reassessment was conducted, with median test intervals of 4.8 years for the patients and 3.1 years for controls. A standardized battery was used for assessment of general cognitive level and memory. At baseline, patients performed at a significantly lower level on general cognition, immediate recall of pairs of associated words, and retention of learned words and visuospatial stimuli, compared with controls. Analyses of change over time in the patients disclosed significant verbal memory decline in retention of pairs of associated words. Group comparisons of change over time revealed adverse effects in the performance aspect of general cognition on the patients. Also, group comparisons indicated impaired performance across time for the patients in retention of pairs of associated words and retention of visuospatial stimuli. The adverse effect on memory and general cognition in this patient group over the period was clear-cut when compared with the longitudinal changes in an adequate control group.

Search pattern in a verbally reported visual scanning test in patients showing spatial neglect

The present study of right hemisphere stroke patients showed that presence of visuospatial neglect in conventional neglect tests at the postacute stage was strongly associated with an aberrant search pattern in a verbally reported visuo-perceptual scanning test. Compared with normal controls, patients with visuospatial neglect showed a greater proportion of repeated readings of the same target, shorter search sequences, more shifts between horizontal, vertical, and diagonal search, and lower proportion of horizontal search. The relation between spatial neglect and a deficient search pattern was strongly influenced by the asymmetric allocation of attention in the scanning test, with the exception for the proportion of repeated reading which was not influenced by this asymmetry. At follow-up, a significant recovery was noted in the neglect group for the proportion of repeated readings and for the asymmetry in the allocation of attention. However, a high number of omitted targets in the search test was still a common finding in the neglect group and it was suggested that a non-lateralized attentional deficit may have played an important role behind the ineffective search at this point of time.

Nonlateralized attentional deficits: an important component behind persisting visuospatial neglect?

Simple reaction time was examined in a consecutive series of 60 right hemisphere stroke patients at the postacute stage and at 6 to 7 months poststroke. Reaction times to auditory stimuli were measured within the ipsilesional side of space. Patients showing contralateral neglect in conventional tests of neglect showed significantly increased reaction times at the postacute stage and at the follow-up compared to those not showing neglect and to those in a group of normal controls. The results suggest that a lowered general attentional capacity may constitute a central component behind persistent neglect. An additional analysis of the CT scans of the patients showed that a large lesion including the paraventricular white matter in the temporal lobe was the most important anatomical correlate of persisting slow reactions.

Anatomical and neurological correlates of acute and chronic visuospatial neglect following right hemisphere stroke

Anatomical and neurological correlates of visuospatial neglect were studied in 53 patients with a CT-documented right hemisphere stroke. Evidence of neglect at the acute stage poststroke was strongly related to large lesions involving the middle temporal gyrus and/or the temporo-parietal paraventricular white matter. Thus, out of 18 patients with evidence of visuospatial neglect at the acute stage, 12 showed a lesion in the middle temporal gyrus and/or the deep temporo-parietal white matter. Among the 35 patients that failed to show visuospatial neglect, only one patient had a lesion within these areas. Comparing those patients who recovered from neglect with those that did not, a high correlation was found between persisting neglect and a lesion involving the paraventricular white matter in the temporal lobe. On the basis of above findings, it was suggested that a simultaneous damage to the cortico-thalamic system for regulation of arousal and to the neural systems mediating visual orienting, is likely to be followed by persisting neglect symptoms.

Concentrations of morphine and morphine metabolites in CSF and plasma during continuous subcutaneous morphine administration in cancer pain patients

Plasma and cerebrospinal fluid (CSF) steady-state concentrations (Css) of morphine (M) and the main metabolites morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G), were determined by high performance liquid chromatography (HPLC) in 21 cancer patients treated with chronic subcutaneous morphine infusion. There was a moderate, but statistically significant correlation between the daily dose of morphine and the concentrations of morphine, M3G and M6G in CSF. A poorer correlation to concentrations were seen in plasma. The mean +/- SEM CSF/plasma morphine concentration ratio was 0.36 +/- 0.07. In plasma and CSF, the mean steady state concentration of M3G but not M6G substantially exceeded that of morphine where the mean CSF M/M3G/M6G ratio was 1:15:0.5 (molar basis), and the mean plasma ratio was M/M3G/M6G 1:31:3 (molar basis). The mean M3G and M6G concentrations in CSF were approximately 8 and 10% of those found in plasma, but there was a wide interindividual variation. Plasma concentrations of both morphine glucuronides were positively correlated to serum creatinine. Neither pain intensity, evaluated by visual analogue scale (VAS), nor side effects showed any relationship to the CSF M3G concentrations, M3G/M or the M3G/M6G ratios. We conclude that during steady state subcutaneous administration of morphine, there is a large interindividual variation in plasma morphine with poor relationship to the daily administered dose. In CSF this correlation was more evident. Plasma and CSF concentrations of M3G and CSF concentrations of M6G correlated with administered morphine dose. There was an accumulation of both morphine glucuronides in patients with elevated serum creatinine. Measurements of morphine, M3G and M6G in CSF did not show any overt relationship to analgesia or side effects.

Outcomes of epidural morphine treatment in cancer pain: nine years of clinical experience

The outcome of epidural morphine therapy is described in 146 consecutive cancer patients who were treated by a community hospital-based pain service. The routine procedure used a standard epidural catheter that was tunneled subcutaneously. One hundred and twenty-one patients improved and stayed on lifelong or chronic epidural opioids. Mean treatment time was 92 days (median, 47; range, 2-2040); 49% of the time was spent as outpatients. Twenty-five patients failed to respond to the treatment. The oral daily morphine-equivalent dose prior to inclusion was 164 mg. The mean daily epidural start dose of morphine was 18 mg (range, 6-120), and the mean daily dose at termination was 69 mg (range, 2-540). The dose escalations, described as the ratio of the maximum dose to the minimum maintenance start dose, were moderate, with a mean of 4.1 (median, 2.5), which corresponded to a percent increase of 5.1 (median, 2.7) per patient per day. Lack of effect due to the character of the original symptoms or progression of pain was the main reason for withdrawal from epidural opioid therapy (N = 27), followed by catheter-related problems (N = 9) and drug-related complications (N = 5). Also due to drug-related complications, epidural morphine therapy was changed to buprenorphine or methadone in 19 patients. Adjuvant systemic opioids were given to ten patients and epidural local anesthetics were administered to 17 of the subjects. Neuropathic pain, certain visceral pain types, incident pain on movement, and pain from cutaneous ulcerations were characteristics of poor responders.(ABSTRACT TRUNCATED AT 250 WORDS)

CSF neuropeptides in cancer pain: effects of spinal opioid therapy

The cerebrospinal fluid (CSF) levels of the opioid peptides met-enkephalin (ME), beta-endorphin (BE) and dynorphin (DYN) as well as the putative sensory neuropeptides substance P (SP), somatostatin (SOM), calcitonin gene related peptide (CGRP) and vasoactive intestinal polypeptide (VIP) were determined in 10 patients with severe nociceptive pain due to malignancy, before and after initiation of spinal opioid therapy, and in 10 control patients. Pain intensity, evaluated by means of a 100-mm visual analog scale (VAS), was reduced from 39 +/- 9 to 18 +/- 10 for continuous pain and from 70 +/- 10 to 10 +/- 8 for intermittent pain (means +/- s.e.mean). Lumbar CSF immunoreactive ME and DYN concentrations were significantly increased (P = 0.05) and BE and VIP were significantly decreased (P < or = 0.05) in the pain patients. A slight, but non-significant (P = 0.06) decrease in SP-like immunoreactivity was found after initiation of spinal opioid therapy. Visceral pain seemed to be associated with low immunoreactive SP and ME concentrations compared to somatic pain. A highly significant correlation was found between SP and ME (P < 0.001) and to a lesser extent also between other peptides. We conclude that the concentrations of the endogenous opioids were more affected by nociceptive pain states than the non-opioid peptides. The origin of pain may also influence the results. The postulated inhibition of peptide release by spinal opioid application seemed to be present for SP, but could otherwise not be confirmed.

Secondary electron conduction camera tube for space applications

A camera tube based on the SEC (secondary electron conduction) effect has been developed for space applications. The background to the initiation of this development is briefly mentioned and anticipated applications are reviewed. These comprise the use as a detector in astronomical instruments (cameras and spectrographs), in a star field camera, and in special instruments for earth observation. The tube construction is described where it concerns the modifications made to the original standard tube produced by the firm Heimann GmbH. Finally, a first assessment of the tube performance is summarized as measured in a standard test facility operating in the standard European scan format.

Performance testing of electrostatically focused uv-visible image converters with deflection capability

Two prototype uv to visible image converter tubes with image deflection capability, produced by the En- glish Electric Valve Company, Ltd., have been tested with respect to performance parameters related to the photometric and imaging properties of the tubes. The two converters were electrostatically focused with a triode structure and were magnetically deflectable. The tests were executed at a facility for abso- lute intensity calibrations in the visible and vacuum uv spectral region available at the Max-Planck-Institut für Extraterrestrische Physik. Test procedures and results are reported.