Évolution des séquelles cognitivo-comportementales d'un traumatisme cranio-cérébral modéré à sévère plusieurs années après sa survenue. Synthèse et perspectives.

Résumé Chaque année, 150 000 nouveaux cas de traumatismes cranio-cérébraux (TCC) sont recensés en France. Les TCC représentent une cause majeure de handicap chez les sujets jeunes. De nombreuses études se sont intéressées aux conséquences d'un TCC durant les premiers mois, en mettant en évidence des difficultés somatiques et cognitivo-comportementales qui impactent la vie sociale, affective et professionnelle des personnes victimes. Selon la sévérité du TCC, ces difficultés peuvent, totalement ou en partie seulement, régresser durant les premiers mois et jusqu'à deux ans après le TCC. L'évolution puis la consolidation des séquelles cognitivo-comportementales peuvent se poursuivre jusqu'à cinq ans après le TCC. Peu d'études ont porté sur l'évolution des séquelles cognitivo-comportementales avec l'avancée en âge des personnes victimes d'un TCC. Celle-ci semble être influencée par des facteurs spécifiques comme l'âge de survenue du TCC, le sexe, être porteur du gène ApoE4 mais également des facteurs environnementaux comme, la qualité des interactions cognitives et sociales. Abstract Traumatic Brain Injuries (TBI) result in cognitive and behavioral impairment inducing a disability in daily life for the TBI victims, but also for the families in social, professional and emotional domains. Evolution of these consequences has been widely described during the first few months after TBI (up two years after the TBI), but few studies are carried on the becoming of these impairments when TBI subjects are growing old. Evolution seems to be affected by endogenous factors such as gender, age, and ApoE4, and exogenous factors such as social interactions. Some studies suggest that TBI is a risk factor to develop a neurodegenerative disease.

Construction and pilot assessment of the Lower Limb Function Assessment Scale.

BACKGROUND: Stroke often leads to upright standing and walking impairments. Clinical assessments do not sufficiently address ecological aspects and the patient's subjective evaluation of function. OBJECTIVE: To perform a pilot assessment of the psychometric properties of the Lower Limb-Function Assessment Scale (LL-FAS). METHODS: The LL-FAS includes 30 items assessing the patient's perception (in a questionnaire) and the examiner's perception (in a practical test) of upright standing and walking impairments and their impact on activities of daily living. We analyzed the LL-FAS's reliability, construct validity, internal consistency, predictive validity and feasibility. RESULTS: Thirty-five stroke patients were included. The scale's mean ± SD completion time was 25 ± 6 min. Intra-observer reliability was good to excellent (intraclass correlation coefficients (ICC >0.82). Interobserver reliability was moderate (0.67 < ICC < 0.9). The questionnaire and test items showed excellent construct validity for neuromotor disabilities (p < 0.05), postural ability (Postural Assessment Scale for Stroke; p < 10-5), severity of gait disorders (Gait Assessment and Intervention Tool; p < 10-3), walking ability (New Functional Ambulation Categories, 10 m walk test, Rivermead Mobility Index; p < 10-3) and functional level (Barthel Index; p < 10-3). Internal consistency (Cronbach-α >0.9) and predictive validity were excellent. CONCLUSIONS: The LL-FAS showed fair psychometric properties in this pilot study and may be of value for evaluating post-stroke lower limb impairment.

Onabotulinumtoxin-A injection for disabling lower limb flexion in hemiplegic patients.

BACKGROUND: Hemiplegic patients with supraspinal spasticity can present with a flexor pattern at the hip and knee that hampers both passive and active functions. OBJECTIVE: To investigate the efficacy of OnabotulinumtoxinA injections on this flexor scheme. METHODS: This open-label observational study included eleven patients who had suffered a unilateral stroke or traumatic brain injury. All had impairment in the activities of daily living caused by severe hip and knee flexion. OnabotulinumtoxinA injections of 300-400U (total dose) were administered to the iliopsoas (iliacus) and knee flexors and, when necessary, to other muscles of the hip and knee. Evaluations were performed pre-treatment (weeks -4 to -8, and day 1) and post-treatment (week 10 and week 21): spasticity, range of motion, limb positioning, passive functions and pain. RESULTS: A modest improvement in hip and knee extension was observed, as evidenced by the Modified Ashworth Score and range of passive extension movements. Limb positioning was also improved. Clear benefits were found on passive functioning, including toileting, dressing and bed facilities, as well as pain levels. Active functions remained unchanged. More definite improvement was found in patients with severe difficulties. CONCLUSIONS: OnabotulinumtoxinA injection can contribute to reducing the consequences of disabling lower limb flexion.

Communication in conversation in stroke patients.

In stroke patients, it has been suggested that communication disorders could result from lexical and syntactic disorders in left hemisphere lesions and from pragmatics problems in right lesions. However, we have little information on patient behaviour in dyadic communication, especially in conversation. Here, we analyzed the various processes participating in communication difficulties at the rehabilitation phase (1-6 months) post-stroke, in order to define the main mechanisms of verbal and non-verbal communication (VC, NVC) disorders and their relationship with aphasic disorders. Sixty-three patients were recruited, who belonged to six groups, with left or right cortico-sub-cortical (L-CSC, R-CSC) or sub-cortical (L-SC, R-SC), frontal (Fro) or posterior fossa (PF) lesions. They were compared with an equivalent control group (gender, age, education level). We used the Lille Communication Test, which comprises three parts: participation to communication (greeting, attention, engagement), verbal communication (verbal comprehension, speech outflow, intelligibility, word production, syntax, verbal pragmatics and verbal feedback) and non-verbal communication (understanding gestures, affective expressivity, producing gestures, pragmatics and feedback). We also used the Functional Communication Profile and the Boston Diagnostic Aphasia Examination (BDAE). Decrease in participation was found in L-CSC, R-CSC and Fro patients. Verbal communication was essentially disrupted in L-SCS and L-SC groups, including by verbal pragmatic disorders, and to a lesser degree in frontal patients. Nonverbal communication was mainly affected in R-CSC patients, especially by pragmatic difficulties. L-CSC patients showed an increase in gesture production, compensating for aphasia. In conclusion, communication disorders were relatively complex and could not be summarised by syntactical and lexical difficulties in left stroke and pragmatic problems in right stroke. The former also showed severe verbal pragmatic difficulties. Frontal stroke also resulted in evident verbal and non-verbal disorders.

Long-term effect of tibial nerve neurotomy in stroke patients with lower limb spasticity.

OBJECTIVES: We investigated the long-term effects and predictive indices of efficacy of tibial nerve neurotomy in a large series of patients with post-stroke hemiplegia. METHODS: Fifty-one patients were prospectively included, who showed disabling lower limb deformity (equinus, varus, clawing toes). The motor branches of the tibial nerve were selected according to the type of deformity, and partially resected at the posterior part of the calf. Patients were regularly assessed, before surgery and from the third month to the second year post surgery, for spasticity (primary outcome measure), motor control, range of active and passive movements, balance, walk, gait parameters, Rivermead Motor Assessment (RMA), subjective improvement and satisfaction. RESULTS: Neurotomy definitely reduced spasticity and improved motor control on antagonist muscles, while improving balance, walk, and the RMA. These effects were clearly perceived in daily living. A discrete decline was at times observed at 2 years. Functional improvement was greater in patients more severely impaired. Side effects, consisting in sensory disorders, were observed following neurotomy of the motor fascicles of the flexor digitorum longus. CONCLUSIONS: Tibial nerve neurotomy showed great and lasting effects, and can be proposed to improve walking and balance in stroke patients with disabling lower limb deformity.

An evaluation of cognitive disorders after anterior choroidal artery infarction.

Anterior choroidal artery infarction (AChAI) can be the source of aphasia and spatial neglect, but we have no idea of the other possible cognitive disorders. Here, we investigated these disorders in a relatively large cohort of AChAI patients. Twenty patients with relatively recent infarction (left side: 13; mean delay = 47.4 days; 10 men; mean age = 59.6; mean education level, EL = 10.3) were included. We assessed nonspatial attention (alertness, Go Nogo, divided attention and visual vigilance from the computerized test TEA), spatial attention (bell test), language (BDAE) orientation (time, place), short-term memory (forward and backward digit spans, spatial span), executive functioning (WCST, TMT A and B, categorial evocation), delayed memory (Buschke verbal test, Rey figure test), and retrograde memory (questionnaire on famous events). The performance level was compared with that of 20 control subjects matched in age and EL. AChAI patients were impaired in several tests of attention (slowness, increase in omission and error rate), executive functioning (TMT B; categorical evocation) and delayed memory. Conversely, we found preservation of spatial attention, language, orientation, short-term memory, WCST, and retrograde memory. In conclusion, at the secondary phase post-stroke, these patients can present with moderate disorders of attention, memory and executive functioning, which are clearly less severe than what is usually observed following thalamic or cortical lesions.

Ineffectiveness of prism adaptation on spatial neglect signs.

BACKGROUND AND PURPOSE: To evaluate the effect of prism adaptation (PA) on spatial neglect signs. METHODS: Ten patients (hemianopia in 6) and 8 control subjects were included. Tasks were reading single words, nonwords, and a text, bell cancellation, line bisection, and scene drawing, before and after adaptation, with either deviating or neutral prisms. RESULTS: Errors were more frequent in patients but without any specific effect of PA. We found partial improvement at the late sessions, independent of prisms. CONCLUSIONS: We did not confirm the efficacy of PA on spatial neglect.

Variability and predictability of functional efficacy of botulinum toxin injection in leg spastic muscles.

Botulinum toxin injection reduces spasticity level. However, the effects on gait parameters and daily living activities remain controversial, and the prediction of results remains poorly evaluated. The aim of this open study was to investigate these effects, and the predictability of results. Forty-seven injections were given to 47 patients with stroke (males: 24; mean age: 51.7), in the soleus, gastrocnemius, tibialis posterior and anterior, and flexor digitorum longus, with a global dose of 300 U (Botox). Each was evaluated at day 1 (D1), day 15 (D15), month 2 (M2) and month 5 (M5). We observed a significant but moderate reduction in spasticity (Ashworth) of the ankle plantar flexors (0.72/5) and dorsiflexors, which was greater at D15, and an improvement in distal positioning in the upright situation. Upright balance and gait (Functional Ambulation Categories) were improved, especially at M2 and in the barefoot condition. Gait velocity and step length with usual aids (10 m) were discretely increased, and this was especially evident in about 15 patients. We also found improvement in the Rivermead Motor Assessment. Patients reported better foot positioning, facilitation in limb propulsion, and better static and dynamic balance. For each assessment, high variability in the effects was also shown. Improvement in functional tests was partially predicted by age (negative relation), delay since stroke (negative relation), gender (better in men), spasticity of hip adductors and knee extensors (negative relation), active ankle dorsiflexion (positive relation) and heel-ground distance (positive relation). In conclusion, the effects on spasticity, balance and gait were relatively modest, and with a large variability between patients. Functional improvement could be partially predicted by several general or specific factors, the knowledge of which is important in the selection of patients to be injected, and for future trials aiming to demonstrate the efficacy of botulinum toxin injection.

Effects of subthalamic nucleus stimulation on parkinsonian dysarthria and speech intelligibility.

Subthalamic stimulation is known to improve tremor, akinesia and rigidity in Parkinson's disease. However, other signs such as hypophonia and swallowing disorders can be relatively resistant to this technique. The effect on dysarthria remains unclear. The aim of this study was to investigate the effects of implantation of electrode and stimulation of the subthalamic nucleus (STN) on parkinsonian dysarthria. Seven patients were prospectively included. Electrodes (Medtronic) were implanted in both STN. The electrode contacts and stimulation parameters were adjusted to provide best relief of symptoms with fewest side effects. Assessment used global scales (Unified Parkinson Disease Rating Scale, UPDRS II and III), dyskinesia scale, exhaustive dysarthria assessment (bucco-facial movements, voice, articulation, intelligibility) and the 'dysarthria' item from the UPDRS III. Evaluations were performed in six conditions: before and three months after surgery (pre-op, post-op) stimulation turned off or on (off-stim, onstim), and without or with a suprathreshold levodopa dose (offdrug, on-drug). Performance level on the UPDRS III significantly improved following electrode implantation and stimulation. For dysarthria, modest beneficial effects were observed on several motor parameters, especially lip movements. Voice mildly improved, especially for the modulation in loudness and pitch. Articulation was not affected. Furthermore, intelligibility was slightly reduced in the on-stimulation condition, especially when patients received levodopa. At an individual level, negative effects on intelligibility were observed in two patients, and this was associated with a discrete increase in facial and trunk dyskinesias, but not with the electrode position or stimulation parameters. In conclusion, surgery had weak effects on dysarthria. Intelligibility can be worsened, especially in the on-drug condition. Thus, adaptation of the stimulation parameters can be difficult.

Efficacy of botulinum toxin A in upper limb function of hemiplegic patients.

Botulinum toxin A has been reported to reduce spasticity and increase the comfort of hemiplegic patients. The aim of this study was to assess the efficacy of the treatment on disability, especially in manual activities, and to attempt to identify predictive factors of improvement. Twenty patients (mean age: 54.4 years; M: 14; right hemiplegia: 12) were included, with a delay of at least three months after unilateral hemispheric stroke. Botulinum toxin A (BOTOX) was injected into the arm adductors (8 cases), forearm flexors (17 cases), pronators, wrist and finger flexors (20 cases),with a total dose of 200 to 300 U. Examination (day 1 and 15, month 2 and 5) consisted of spasticity assessment (modified Ashworth scale), muscle strength, passive range of motion (goniometry), and pain, followed by functional tests, especially the Rivermead Motor Assessment (RMA) and Nine-hole Peg Test (NHPT). Performance in daily living was assessed with the Functional Independence Measure (FIM), and an original analysis of hand grasp, grip and pinches used in domestic activities (9 items), and of comfort of patients and caregivers. Significant reduction in spasticity was observed on the elbow flexors, pronators, wrist and fingers flexors, especially at day 15 (mean 0.90 to 1 point), with wide variations in effect. Muscle strength was increased in wrist and fingers extensors, with concomitant increase in the opening of the thumb to index finger space. There was no effect on the NHPT requiring distal manipulation, but the RMA, which especially concerned picking up and releasing a tennis ball, showed significant improvement. Furthermore, use of the upper limb in daily living increased, particularly for internal grasping of objects, and for grasping by the top, transporting and releasing of objects. Patients and caregivers re ported facilitation in dressing, and in proximal and distal care of the upper limb. The global flexor position of the limb improved. Ad verse reactions were rare and mostly consisted of transitory pain during injection. The improvement in the RMA was better explained by the quality of the initial motor command on distal prehension (positive correlation with motor strength), and that in hand using in domestic activities by a lower level of spasticity on pronators and wrist flexors (negative correlations with spasticity). Conversely, the severity of the motor deficit (negative correlations with motor strength) and a high level of spasticity before injection (positive correlations with spasticity) mostly explained the improvement in comfort. In conclusion, botulinum toxin A is efficient in improving hand use in patients with relatively preserved distal motricity, and in increasing comfort in patients with severe global disorders.

Levodopa and bromocriptine in hypoxic brain injury.

BACKGROUND: Postanoxic encephalopathy is frequent in patients presenting with abrupt cardiac arrest or respiratory failure. Little is known about the effectiveness of oral medications on the cognitive and motor consequences. OBJECTIVE: To present data suggesting partial improvement after administration of levodopa/benserazide. METHODS: After observing partial benefit in one case, each patient admitted to rehabilitation following brain anoxia was systematically treated with levodopa/benserazide (200/50 to 400/100 mg/day), then bromocriptine (15 mg/day). RESULTS: In the first patient, brain anoxia was severe, with secondary agitation, quadriparesis, involuntary movements, inattention and communication disorders. Introduction of levodopa/benserazide resulted in reduction of agitation and involuntary movements and improvement of communication, thus facilitating care and rehabilitation efforts. A weaning test resulted in rapid worsening. The four following patients also presented with anoxia of variable severity. Marked improvement was observed in case 2, presenting with agitation, loss of orientation, amnesia, postural disorders, involuntary movements and dysphagia, with a withdrawal test resulting in immediate re-enhancement of symptoms. Modest improvement was observed in patient 3, who had hypokinesia, rigidity, adynamia, impaired attention, and reduced verbal fluency. Patient 4 presented with memory disorders without motor difficulties: mild improvement was observed in daily life and memory tests. In patient 5 who also presented with severe memory disorders, the benefit was absent. In each case, bromocriptine was introduced 3-4 weeks following levodopa, but without additive effect. Both treatments could be interrupted after a few months, without worsening. CONCLUSIONS: Levodopa and benserazide can be of benefit in the few months following brain anoxia, especially on some of the motor disorders and apathy, but the benefit is inconstant and modest on memory disorders. Anoxia could alter dopaminergic mesencephalic systems, which activate the striatal and mediobasal frontal cortex, and these disorders could be partially reversible by medical treatment.