Astheno-emotional disorder after aneurysmal SAH: reliability, symptomatology and relation to outcome

OBJECTIVES

Neuropsychiatric symptoms commonly found after aneurysmal SAH are covered in the astheno-emotional disorder (AED) of Lindqvist & Malmgrens diagnostic system for organic psychiatry. This study aims to describe the reliability and symptomatology of AED and its relationship with social outcome.

MATERIAL AND METHODS

Patients referred due to aneurysmal SAH (n=78) were assessed after 1-6 months for AED inter-rater reliability (n=36) and after 12 months for AED severity grade, symptomatology and Glasgow Outcome Scale (GOS) (n=63).

RESULTS

There was no systematic error in diagnosing and grading AED, and the agreement was 85% and 67% respectively (kappa=0.65 and 0.52). Fatigability, concentration difficulties and memory difficulties were the most frequent symptoms of AED. The relationship between AED and "moderate disability" of GOS was highly significant (P<0.00006).

CONCLUSIONS

AED affects social outcome, and can be diagnosed with high reliability even without neuropsychological testing. Use of the AED diagnosis for evaluation of organic mental symptoms is encouraged.

[When insight on disease is halting. I. Clinical assessment of impaired insight--current research summarized]

This review explores the definition, assessment and possible restoration of impaired insight in psychosis. Hypotheses concerning the neuropsychological correlates of insight impairment are discussed. The distinction between impaired insight in psychosis and impaired awareness and psychological denial in other medical conditions is emphasised.

[When disease insight is halting. II. The neurobiological underpinnings]

This review examines the neurobiological underpinnings of impaired insight and awareness in psychosis. Crucial mainly dopaminergic pathways are discussed in relation to delusions and hallucinations. Thirty percent of psychotic patients with impaired insight will not respond to traditional neuroleptic drug treatment, and the possibility that multifocal brain etiology might underlie such cases is discussed. It is suggested that severe cases of thought process disorder in psychosis may result from such multifocal processes.

Analysis of interobserver disagreement in the assessment of subarachnoid blood and acute hydrocephalus on CT scans

The purpose of this study was to analyse factors for interobserver disagreements in two scales used for the assessments of the amount of blood in subarachnoid space (Fisher grading) and of acute hydrocephalus on computerized tomographic (CT) scans. The assessments made by four neuroradiologists on 59 CT scans obtained in the acute stage after subarachnoid hemorrhage were analysed by a statistical method by Svensson and Holm. This method permits the separation of the inter-observer disagreements in their random and systematic components. The overall consistency of the assessments was significant (p < 0.0005) but the neuroradiologists disagreed on half of the CT-scans. The kappa values were 0.50-0.63. The analysis showed that the main reason for disagreements was systematic inter-observer differences in their use of the clinically most important parts of staging, i.e. subarachnoid clot or intraventricular blood (Fisher grading) and too low categories (hydrocephalus). The main conclusion from this study is that the proper remedy for Fisher grading and for grading of hydrocephalus is a sharpening of the criteria of specific category levels and given this improvement both grading systems will show a high level of reliability.

Quantitative EEG analysis as a supplement to the clinical coma scale RLS85

BACKGROUND

The aim of the study was to investigate the correlation between EEG indicators and clinical scores based on the RLS85 (Reaction Level Scale 85) in comatose patients. The results of a simple visual assessment of the EEG, using an arbitrary scale with typical EEG patterns, were compared with those obtained by quantitative electroencephalography (qEEG).

METHOD

The RLS85 scores were examined in 34 patients with impaired consciousness due to brain tumours, vascular lesions or head injuries. The EEG was recorded shortly before or after the clinical examination. The semiquantitative assessment was made by visual inspection of the tracings, using an arbitrary scale where 12 EEG patterns with increasing proportion of slow activity were displayed. Parallel to the visual analysis, the EEGs were processed by means of EEG spectrum analysis and the power/amplitude in slow frequency bands was used as an indicator. The results were based on correlation between various types of EEG variables and the RLS scores which were obtained in the same patients.

RESULTS

The correlation between the visual EEG indicators and coma scores ranged between 0.53 and 0.57 (P < 0.01). As regards the computerised EEG analysis, the correlation between the clinical scores and various EEG spectrum values did not exceed 0.45 (P < 0.01). A higher correlation could be obtained by combining eight EEG variables; the multiple correlation coefficient was then 0.68.

CONCLUSIONS

The amount of EEG slow activity is significantly correlated to the RLS85 score. This means that the EEG also provides information on the level and not only on the changes of the coma degree. Surprisingly, the indicators based on quantitative EEG, as used in commercially available instruments, did not give better results than the visual assessment. However, the results of the computerised analysis could be improved using multivariate statistical methods. The study also showed a way to improve communication between the neurophysiologist and clinician by presenting the EEG findings in terms similar to those used in the clinical scales. However, the clinician should be aware of the fact that the "EEG score" and the clinical score is not the same: the intention is to supplement rather than to simulate the clinical observation.

The neuronal environment after subarachnoid haemorrhage--correlation of amino acid and nucleoside levels with post-operative recovery

The study explores biochemically the neuronal environment adjacent to a subarachnoid haemorrhage in 11 patients after neurosurgical clipping of an arterial aneurysm. Extracellular fluid (ECF) from the rectus gyrus and subarachnoid fluid (SAF) were sampled with microdialysis probes. The concentrations of amino acids and nucleosides were monitored in 60 min samples collected over 2-4 days. The patients were 33-67 years of age. Surgery was performed 0-5 days after rupture of the aneurysm in 8 patients. One patient was operated on after 15 months. Clipping of aneurysms without prior haemorrhage was performed in two cases. Markedly elevated concentrations of the excitatory amino acid glutamate was observed in the ECF of only one patient who underwent surgery within 8 hours after the haemorrhage. Moderate glutamate elevations were seen in two patients and of aspartate in another patient. Five patients displayed periods of varying length of specifically elevated taurine concentrations in ECF or SAF. Transient periods of high concentrations of glycine and serine were seen in two patients. Even though average concentrations of all amino acids were fairly similar in the ECF and SAF, the pattern of changes vs. time differed markedly in the two compartments. Presently, we conclude that the level of consciousness in the post-operative phase was inversely related to total amino acid concentration in the ECF. Furthermore, while the ECF concentrations of taurine and glycine increased both specifically and transiently in several patients, excitatory amino acid levels were not appreciably elevated subsequent to the neurosurgical intervention.(ABSTRACT TRUNCATED AT 250 WORDS)

[Operational manual of the reaction level scale (RLS85)]

The Reaction Level Scale (RLS85) is a range scored coma scale (8 levels) for the assessment of responsiveness in patients with acute brain disorders. Its feasibility in clinical practice and for research studies has been verified in a multicentre study and by comparison with other current coma scales. Range scoring and absence of pseudoscoring are its most significant advantages over the other current scales. An operative manual of the RLS85 in Portuguese is standardized in this text which also provides a selected bibliography on the subject.

A compound score for estimating the influence of inattention and somnolence during the intracarotid amobarbital test

Alterations in the level of consciousness may render the interpretation of the memory test results from the intracarotid amobarbital procedure difficult. The present study was designed to investigate the impact of inattention and somnolence on memory performance during the Amytal test. Nineteen consecutive patients undergoing the test were investigated. The memory test was constructed to comprise two consecutive parts with identical design, so as to make possible comparisons over time in the same patients. Reaction level and somnolence were continuously assessed during the procedure and a stimulus-task response test to evaluate the degree of attention was used. On the basis of these parameters a compound 'inattention score' was constructed. The results indicate that inattention and somnolence negatively influence memory performance and should be taken into account when evaluating the Amytal memory test results. In cases with poor memory results high inattention scores may speak in favour of preoperative hemisphere memory testing or a repeat injection with reduced Amytal dosage before deciding upon the extent of a planned resection. On the other hand, low inattention scores together with amnesia for the testing procedure may indicate that the memory test results can be relied on.

Severe amitriptyline overdose: relationship between toxicokinetics and toxicodynamics

The clinical features and toxicokinetics of amitriptyline were studied in nine patients with severe amitriptyline poisoning. Amitriptyline and amitriptyline metabolites were studied in plasma, red blood cells, and cerebral spinal fluid. Eight patients were intubated and six required assisted ventilation. Two patients had ventricular arrhythmias, three patients convulsions and two were hypotensive. All complications developed within four hours of admission. Early in the course of the intoxication the QRS duration correlated with plasma, unbound and red blood cell nortriptyline concentration. The QRS duration also correlated with unbound but not the plasma amitriptyline concentration. The level of consciousness correlated with the plasma and unbound amitriptyline both in alpha and beta phase and with red blood cell amitriptyline in alpha phase. There was no correlation between nortriptyline concentration and level of consciousness. No correlation between coma grade or QRS duration and cerebral spinal fluid concentration of amitriptyline was found. There was no correlation between any hydroxymetabolite in blood or cerebral spinal fluid and QRS duration or coma grade. The beta half-life for amitriptyline was shorter for two patients with high concentrations of hydroxymetabolites. Although intubated, neither patient required assisted ventilation or developed complications. Because of the wide range of concentrations of amitriptyline and amitriptyline metabolites observed between individuals, it is not possible to predict outcome based on a single tricyclic antidepressant concentration.

[A new reaction level scale is recommended in Sweden]

Assessment of the reaction level is the single most important investigation in patients with acute cerebral disorders. The Reaction Level Scale, RLS-85, a recently developed and scientifically based method, is recommended for introduction in Sweden.

A comparison of the Glasgow Coma Scale and the Reaction Level Scale (RLS85)

The Glasgow Coma Scale (GCS) and the Reaction Level Scale (RLS85) were compared for rating neurosurgical patients in regard to ranking order of deficit severity, interobserver variability, and coverage for relevant factors. Four physicians, four registered nurses, and four assistant nurses performed 72 pairwise ratings on 47 neurosurgical patients. The rank correlation between the GCS sum score and the RLS85 was -0.94, suggesting the same ranking order of severity and indicating that the underlying concepts of somnolence, delirium, and motor responses in coma are evaluated in the same way. By the sign test, the RLS85 was shown to have better interobserver agreement than the GCS sum score and the eye-motor-verbal (EMV) profile. The interobserver grading disagreements in both scales were distributed over the entire range of responsiveness, and for the GCS sum score they were slanted to combined segments 9 to 15. The RLS85 showed full coverage of relevant factors, while 43 (60%) of the 72 test occasions in the GCS sum score and the EMV profiles showed untestable features, most often because of patient intubation. The pseudoscore (that is, the choice of value given to untestable features) affects interobserver agreement as well as the estimated overall patient responsiveness in the GCS sum score. Assessment by the order of applying the scales showed a significant effect on the GCS eye-opening scale (p = 0.01) and the GCS sum score (p = 0.03), indicating a sensitivity to environmental stimuli unrelated to the patient's status. This study demonstrates that basically the same information as that found in the separate eye, motor, and verbal scales of the GCS can be combined directly into the RLS85, which has better interobserver agreement and better coverage than the GCS sum score.

Current reporting of responsiveness in acute cerebral disorders. A survey of the neurosurgical literature

One hundred sixty-six papers published in seven neurosurgical journals from 1983 through 1985 have been surveyed to determine the methods used for assessment of overall patient responsiveness in acute cerebral disorders (coma grading). Fifty-one different coma scales or modifications were found. The Glasgow Coma Scale (GCS) sum score (that is, the sum of the scores of the individual eye, verbal, and motor scales) dominated (54%), and was used in 73 (76%) of 96 of the head-injury studies; in 56 (77%) of these 73 studies it was the single method of grading neurological status. The GCS sum score was used in 16 (23%) of 70 studies in patients with other etiologies. The Hunt and Hess scale was used in 26 (57%) of 46 reports of patients with subarachnoid hemorrhage. In 31 (55%) of the 56 studies of head injuries using the GCS alone, it was not obvious if the 12- or 13-grade scale was used. In 13 studies (23%) no reference to methodological investigations was made. In 44 papers (79%) the handling of untestable features, such as intubation or swollen eyes, was not reported. In the 56 studies using the GCS alone, coma was defined in many different ways and in 22 studies the definition of coma was not specified. In 63% of reports, the GCS sum score scale was combined in one to five groups of scores and this was done in 32 different ways. No information was available to describe the procedure of data aggregation or the reliability of the 13-grade GCS sum score. The lack of standardization makes it unnecessarily difficult to perform valid comparisons between different series of patients. Since the GCS sum score is the most widely used scale, it is suggested that the reporting of the GCS sum score should be standardized regarding pseudoscoring, coma definition, and use of combined scores. Further studies on the reliability of the GCS sum score are needed.

Severity grading in self-poisoning

1. The reliability and validity of three different coma scales was studied in 26 patients with acute drug overdose. 2. A comparison of six painful stimulation techniques showed that sternal rubbing and retromandibular pressure were most effective. 3. The improper use of stimulation techniques may underestimate level of responsiveness in 4-19% of cases. 4. The Reaction Level Scale (RLS) was the most reliable scale. 5. Both the RLS and the Glasgow Coma Scale may be unnecessarily complicated for the evaluation of the drug overdose patient, but should be chosen if concomitant brain injury is suspected. 6. This study confirms the basic concepts and shows the reliability of the Matthew-Lawson scale for use in the poisoned patient.

Assessment of responsiveness in acute cerebral disorders. A multicentre study on the reaction level scale (RLS 85)

A new scale for assessment of overall responsiveness, the Reaction Level Scale (RLS 85), which has been shown to have better reliability than the Glasgow Coma Scale (GCS), has been tested in four neurosurgical departments regarding inter-observer agreement and coverage i.e. the proportion of patients that could be assessed by the scale. In a carefully designed study 51 observers pairwise performed 164 tests on 88 patients. Reliability was studied by the Kappa method, which is defined as inter-observer agreement corrected for agreement by chance. The inter-observer agreement measured as overall Kappa was good (K = 0.69 +/- 0.05) and there were no significant differences between the departments, professional categories or aetiologies. Regarding the separate RLS 85 levels the Kappa values were above 0.65, except for withdrawing (K = 0.51) and flexor responses (K = 0.55). There was good inter-observer agreement on coma (K = 0.71). In conclusion, the RLS 85 proved to be easily learnt, it showed full coverage without pseudoscoring, and it was used in a consistent way by doctors, nurses and assistant nurses of four different neurosurgical departments in two Scandinavian countries.

The Reaction Level Scale (RLS85). Manual and guidelines

The Reaction Level Scale (RLS85) is a "coma scale" for the direct assessment of overall reaction level in patients with acute brain disorders. It is devised for reliable use even in the management of patients who are difficult to assess, such as intubated patients and patients with swollen eyelids. We here present the manual of the RLS85 and the guidelines for its use. The underlying concepts as well as limitations are outlined. Condensed information of known reliability and validity is presented. A training scheme for presumed observers (doctors, nurses and assistant nurses) is outlined. It is suggested that users of the RLS85 refer to these guidelines and in scientific reports clearly state any deviations from this present manual in order to facilitate valid comparisons between different studies and different groups of patients.

Alprazolam compared to amitriptyline in the treatment of major depression

In a double-blind randomized study the therapeutic effect and safety of alprazolam was compared with amitriptyline in 81 outpatients suffering from major depression. Variable dosages of both drugs were used, the mean final dose of alprazolam being 3.05 and that of amitriptyline 130 mg. Both treatment groups improved steadily, assessed weekly with the use of the Hamilton Rating Scale for Depression, and no significant differences were found between the groups, either on comparison between single items or total scores. On several of the criteria used for assessment of treatment response, however, more patients responded to amitriptyline than to alprazolam. In an analysis of specific subgroups, patients whose depression was accompanied by retardation, those in whom there were no precipitating factors and those with low levels of anxiety, responded better to amitriptyline. Considerably fewer side effects were reported by patients receiving alprazolam. In particular, there was a significantly lower incidence of dry mouth, light-headedness, tremor and tachycardia in patients receiving alprazolam compared with amitriptyline.

Abscesses following prolonged intramuscular administration of perphenazine enantate

In an investigation of 109 patients on neuroleptics in a vegetable oil base, four of the patients developed abscesses at the site of deposits of perphenazine enantate given intramuscularly in large doses every 1-4 weeks. Observations suggested that the risk of such a complication could be minimized by limiting the frequency of administration to once a fortnight, by limiting the dose injected, by frequent variation of the site of injection, and by regular use of a disinfectant.

Exacerbation of psoriasis during lithium treatment

We report three patients with psoriasis and bipolar affective illness who showed marked deterioration of their skin condition when treated with lithium.