Neuropsychology and Neurological Rehabilitation Flashcards
A 63-year-old male presents as aWorld Federation of Neurosurgical Societies (WFNS) grade III subarachnoid hemorrhage and undergoes coiling of a basilar tip aneurysm. After a prolonged Intensive Care Unit (ICU) stay, heis ready to be discharged from theward. He is able to walk with assistance and needs help with toileting and showering. What are his modified Rankin and Glasgow Outcome Scale scores respectively?
a. mRS 2 and GOS 2
b. mRS 2 and GOS 3
c. mRS 3 and GOS 2
d. mRS 3 and GOS 3
e. mRS 4 and GOS 3
f. mRS 4 and GOS 4
e. mRS 4 and GOS 3
Which one of the following Karnofsky performance scores is commonly used as a cutoff for functional independence in
neuro-oncology?
a. 40
b. 50
c. 60
d. 70
e. 80
d. 70
Cerebellar mutism occurs most commonly after resection of which one of the following posterior fossa tumors in children?
a. Ependymoma
b. Hemangioblastoma
c. Medulloblastoma
d. Meningioma
e. Pilocytic astrocytoma
c. Medulloblastoma
Cerebellar mutism is a distinct clinical syndrome
described following surgery for posterior fossa
tumors both in adults and children but most commonly in children. Its incidence varies from 2%
to 40% in different series, particularly with vermian location of the lesion—hence its occurrence
particularly after medulloblastoma resection. It
consists of diminished speech output, hypotonia,
ataxia, and emotional lability. Typically a patient
who is initially fine in the first few days postoperatively develops mutism without any corresponding focal neurological signs. The deficit usually
recovers with time over a period of a few weeks
to 6 months with an immediate return of full
words and sentences. Resolution of the muteness
is often followed by a period of dysarthria, and more recent studies have demonstrated that persistent impairment of motor speech is common
and complete recovery of speech and language
is infrequent. The underlying neuroanatomical
locus may be the dentatothalamocortical outflow
tracts from the cerebellar nuclei through the
brainstem.
Cerebellar cognitive affective syndrome does not generally involve which one of the following?
a. Dysprosodia
b. Impaired executive function
c. Mutism
d. Personality change
e. Visuospatial impairment
c. Mutism
The cerebellum is divided into three parts, based
on the arrangement of the afferent fiber projection: the vestibulocerebellum (equilibrium and
eye movements), the spinocerebellum (posture,
muscle tone, and execution of limb movements),
and the pontocerebellum (coordination of skilled
movements initiated at a cerebral cortical level).
More recently there has been growing appreciation that cerebellar damage can produce cognitive
deficits. In patients with right cerebellar injury
linguistic processing was impaired, while left cerebellar injury produced visual-spatial defects were
noted. Neurpsychological studies have identified
a cerebellar cognitive affective syndrome, predominantly in adults:
* Impairments of executive function
* Visual-spatial disorganization and impaired
visual- spatial memory
* Personality change with blunting of affect
or disinhibited and inappropriate behavior
* Difficulties with language production
including dysprosodia, agrammatism, and
mild anomia
Mutism is considered to be part of the initial presentation of many children with cerebellar cognitive affective syndrome, but is less common in
adults. The major distinction between the two
is the chronicity of the symptoms with cerebellar
mutism being more transient.
Which one of the following domains of cognitive impairment in normal pressure hydrocephalus is LEAST likely to improve with
shunt insertion?
a. Delayed verbal recall
b. Frontal lobe executive function
c. Psychomotor speed
d. Visual memory
e. Visuoconstructional abilities
b. Frontal lobe executive function
Which one of the following statements regarding cognitive decline following cranial irradiation for brain metastasis is most accurate?
a. There is no difference in cognitive decline at 12 months post Whole Brain Radiotherapy (WBRT) compared to controls
b. There is a greater cognitive decline at 12 months in patients with Stereotactic Radiosurgery (SRS) +WBRT compared to SRS alone
c. There is a greater cognitive decline at 12 months in SRS alone compared to WBRT alone
d. There is no difference in cognitive decline at 12 months in patients with SRS +WBRT compared to SRS alone
e. There is no increase in cognitive decline at 12 months in those receiving 36 Gy of irradiation compared to 25 Gy
b. There is a greater cognitive decline at 12 months in patients with Stereotactic Radiosurgery (SRS) +WBRT compared to SRS alone
The efficacy of WBRT for treatment of cerebral
metastasis is well documented but the establishment of SRS for high precision delivery of radiation has questioned its necessity. Given that
survival is comparable between the two modalities, the controversy centers on cognitive and
neurological preservation. Supporters of SRS
point to evidence suggesting that focal radiation
is highly effective in preventing tumor progression in the irradiated volume and that irradiation
of normal or near-normal brain tissue increases
the risk of cognitive decline in a brain that is
already burdened with disease. Equally, proponents of WBRT argue that focal radiation does
not address potential micrometastatic foci that
are invisible to conventional imaging which, in
the absence of radiation treatment, can develop
into larger lesions that compromises the patient’s
neurological and cognitive function. Ultimately,
the debate revolves around the trade-off between
preserving the function of cerebrum that is not
grossly infiltrated with tumor and the harmful
effect of tumor growth from micrometastatic foci.
In summary: * Cognitive impairment at 12 months is 12%
in control and 41% in prophylactic cranial
irradiation (30 Gy)
* Cognitive impairment at 12 months is 62%
for 25 Gy and 85% for 36 Gy prophylactic
irradiation
* Cognitive impairment at 4 months is 24%
in SRS alone vs 52% in SRS +WBRT
Which one of the following statements regarding cognitive outcome in aneurysmal subarachnoid hemorrhage in those patients
treated with clipping versus those treated with coiling is most accurate?
a. Cognitive outcomes are poorer in the coiling group overall
b. Cognitive outcomes are poorer in the clipping group overall
c. Coiling may offer a superior cognitive outcome in the short term and clipping the superior cognitive outcome in the long term
d. Cognitive outcomes are poorer in the clipping group for anterior circulation aneurysms
e. Coiling may offer an inferior cognitive outcome in the short term and clipping the inferior cognitive outcome in the long term
e. Coiling may offer an inferior cognitive outcome in the short term and clipping the inferior cognitive outcome in the long term
The majority of studies suggest that clipped versus coiled patients do not differ in the main
domains of cognitive and functional outcome.
Some (non-randomized) studies suggest a poorer
outcome with clipping at 1 year, with greater
imaging evidence of focal encephalomalacia
and infarction compared to coiled patients.
Equally, some studies have shown poorer cognitive function in coiled patients compared to clipped
patients at 4-6 months. Further studies/longer
term follow up is needed, but each may have different effects on cognitive outcome at different
time points since treatment.
Which one of the following statements regarding return to work in aneurysmal subarachnoid hemorrhage is most accurate?
a. Return to previous occupation is approximately 30% in aneurysmal subarachnoid hemorrhage
b. Return to previous occupation is approximately 40% in aneurysmal subarachnoid hemorrhage
c. Return to previous occupation is approximately 50% in aneurysmal subarachnoid hemorrhage
d. Return to previous occupation is approximately 60% in aneurysmal subarachnoid hemorrhage
e. Return to previous occupation is approximately 70% in aneurysmal subarachnoid hemorrhage
d. Return to previous occupation is approximately 60% in aneurysmal subarachnoid hemorrhage
Which one of the following is currently seen
as the best marker of severity of traumatic
brain injury in survivors?
a. Glasgow coma score
b. Length of coma
c. Mechanism of injury
d. Initial CT scan
e. Post-traumatic amnesia
e. Post-traumatic amnesia
Post traumatic amnesia represents the length of time from injury until return of orientation and continuous memory for events. Its duration has been associated with presence or extent of skull fracture, intracranial hemorrhage, raised intracranial pressure, residual neurological deficits, extent
of neuropathology, as well as with longer-term
functional outcomes and return to employment.
Recent studies investigating individuals surviving
to discharge from hospital provide support for post
traumatic amnesia as a stronger predictor oflongerterm functional outcome, return to employment,
and cognitive impairment than Glasgow Coma
Score (GCS) or length of coma. It also accounts
for more variance in outcome than sociodemographic factors.
Neurorehabiliation in the context of stroke is characterized by which one of the following?
a. Baclofen for dyskinesias resulting from
basal ganglia strokes
b. Botulinum toxin injections to facilitate
physiotherapy to the paretic limb (s)
c. Management in local hospitals by general
medical teams to maximize family support
in the acute stage
d. Outpatient management
e. Task-oriented therapy
e. Task-oriented therapy
The main principles underlying stroke rehabilitation are as follows: * The patient should be under the care of a
specialist stroke rehabilitation unit whilst
in hospital, and a specialist stroke rehabilitation service when back in the community.
* Therapy should be task oriented (i.e. practicing an activity is the best way to improve
at that activity).
* The patient should be set both short- and
long-term goals, and those goals should
be relatively challenging and set at the level
of activities or social participation.
Neurorehabiliation in the context of spinal
cord injury has all of the following goals
EXCEPT:
a. Ensure that required adaptations and
equipment are identified and provided
b. Management of excretion from bowels
and bladder
c. Minimize the risk of preventable complications (e.g. pressure sores)
d. Recognition and management of autonomic dysreflexia
e. Routine recruitment into neural stem cell
transplantation trials for spinal cord injury
e. Routine recruitment into neural stem cell
transplantation trials for spinal cord injury
Rehabilitation has several general goals in SCI:
* It should aim to minimize the risk of all preventable complications, including through
patient education.
* Teach the patient how to manage their
impairments and it needs to ensure that
all required adaptations and equipment
are identified and provided.
* It may need to teach others how to provide
additional support to the patient if necessary. In general patients with lesions below
the cervical level of the spinal cord can live
fully independently, whereas patients with
cervical spinal-cord lesions will need assistance to a greater or lesser extent.
* In patients with spinal cord injury particular
attention needs to be paid to the management of excretion from bowels and bladder,
sexual function, and skin care.
* Medical recognition and management of
autonomic dysreflexia (e.g. treat urinary
retention, blood pressure control with immediate nifedipine).
- Wisconsin card sorting test
Neuropsychological tests:
a. Affect and personality
b. Attention
c. Effort (embedded and free-standing)
d. Executive functions
e. Language
f. Memory
g. Motor processing
h. Visuospatial and visuomotor processing
d. Executive functions
A single neuropsychological test may assess multiple domains of neuropsychological performance,
hence they may be performed as part of a fixed
(e.g. Halstead-Reitan) or flexible battery. Advantages of the fixed battery approach to neuropsychological assessment include: (1) it provides a
comprehensive assessment of multiple cognitive
domains; and (2) it uses a standardized format that
allows the test data to be incorporated into databases for clinical and scientific analysis. Disadvantages of the fixed battery approach include (1)
time and labor intensiveness; and (2) a lack of flexibility in different clinical situations; specifically,
multiple, nonequivalent data sets exist and specific
normative data with TBI patients should be used with caution. Primary advantages of the flexible approach to neuropsychological evaluation
include: (1) a potentially shorter administration
time; (2) economical favorability; and (3) adaptability to differing patient situations and needs.Disadvantages of the flexible approach include: (1) the
need for greater clinical experience; (2) a lack of
standardized administration rules for some tests;
(3) a potential lack of comprehensiveness; and (4)
limitations in establishing systematic databases.
A non-exhaustive list of commonly used tests is
shown below:
- Beck depression inventory
Neuropsychological tests:
a. Affect and personality
b. Attention
c. Effort (embedded and free-standing)
d. Executive functions
e. Language
f. Memory
g. Motor processing
h. Visuospatial and visuomotor processing
a. Affect and personality
A single neuropsychological test may assess multiple domains of neuropsychological performance,
hence they may be performed as part of a fixed
(e.g. Halstead-Reitan) or flexible battery. Advantages of the fixed battery approach to neuropsychological assessment include: (1) it provides a
comprehensive assessment of multiple cognitive
domains; and (2) it uses a standardized format that
allows the test data to be incorporated into databases for clinical and scientific analysis. Disadvantages of the fixed battery approach include (1)
time and labor intensiveness; and (2) a lack of flexibility in different clinical situations; specifically,
multiple, nonequivalent data sets exist and specific
normative data with TBI patients should be used with caution. Primary advantages of the flexible approach to neuropsychological evaluation
include: (1) a potentially shorter administration
time; (2) economical favorability; and (3) adaptability to differing patient situations and needs.Disadvantages of the flexible approach include: (1) the
need for greater clinical experience; (2) a lack of
standardized administration rules for some tests;
(3) a potential lack of comprehensiveness; and (4)
limitations in establishing systematic databases.
A non-exhaustive list of commonly used tests is
shown below:
- Finger oscillation test
Neuropsychological tests:
a. Affect and personality
b. Attention
c. Effort (embedded and free-standing)
d. Executive functions
e. Language
f. Memory
g. Motor processing
h. Visuospatial and visuomotor processing
g. Motor processing
A single neuropsychological test may assess multiple domains of neuropsychological performance,
hence they may be performed as part of a fixed
(e.g. Halstead-Reitan) or flexible battery. Advantages of the fixed battery approach to neuropsychological assessment include: (1) it provides a
comprehensive assessment of multiple cognitive
domains; and (2) it uses a standardized format that
allows the test data to be incorporated into databases for clinical and scientific analysis. Disadvantages of the fixed battery approach include (1)
time and labor intensiveness; and (2) a lack of flexibility in different clinical situations; specifically,
multiple, nonequivalent data sets exist and specific
normative data with TBI patients should be used with caution. Primary advantages of the flexible approach to neuropsychological evaluation
include: (1) a potentially shorter administration
time; (2) economical favorability; and (3) adaptability to differing patient situations and needs.Disadvantages of the flexible approach include: (1) the
need for greater clinical experience; (2) a lack of
standardized administration rules for some tests;
(3) a potential lack of comprehensiveness; and (4)
limitations in establishing systematic databases.
A non-exhaustive list of commonly used tests is
shown below:
