A randomised double-blind controlled study of Deep Brain Stimulation for dystonia in STN or GPi - A long term follow-up after up to 15 years.

AIM: This is a long-term open follow-up of a prospective double-blind crossover study, where electrodes were bilaterally implanted in both the Subthalamic nucleus (STN) and internal pallidum (GPi) in patients with isolated dystonia. METHODS: Patients with isolated dystonia were included to undergo surgery with Deep Brain stimulation (DBS) and after randomization, in a double-blind cross-over study, receiving bilateral stimulation of either STN or GPi for 6 months in each target. Preoperative and postoperative assessments with the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) and the 36-item Short Form Health Survey (SF-36) were performed. In this long-term follow-up (LFU), these ratings were repeated, and patients were evaluated with cognitive tests. RESULTS: 21 patients were included in the protocol, 9 patients with generalized dystonia, 12 with a diagnosis of cervical dystonia. The mean duration of disease was 19.3 years, age at time of surgery 50.1 years. Fourteen patients participated in the LFU. At a mean follow-up of 10.2 years (range 4.8-15.4), BFMDRS movement score was improved with a mean of 36% (p < 0.05) compared with baseline. At LFU both a statistically significant improvement of stimulation in STN on BFMDRS movement score (p = 0.029) and Gpi (p = 0.008) was demonstrated, no significant difference was found between the two targets (p = 0.076). SF-36 improved for both targets. CONCLUSION: In this study we performed a long-term follow-up in 14 patients with cervical or generalized dystonia, who received stimulation in GPi, STN or both. The mean follow-up time was more than 10 years. Our data support a long-term effect of both STN-DBS and GPi-DBS in dystonia with equal effect and safety for up to 15 years. STN has been proven a viable safe and effective target and may be used as an alternative to GPi in both adult-onset cervical dystonia and generalized dystonia.

The Effects of Computer Based Cognitive Rehabilitation in Stroke Patients with Working Memory Impairment: A Systematic Review.

OBJECTIVES: To evaluate benefits and harms for computer based cognitive rehabilitation (CBCR) on working memory impairment after stroke. METHODS: PRISMA guidelines were followed. Four electronic databases were systematically searched: Embase, Pubmed/Medline, PsycInfo and Cochrane Library. Authors of relevant studies were contacted to detect unpublished data or articles not found by searching databases. SELECTION CRITERIA: Studies were eligible for inclusion in the systematic review if they 1) investigated the effects of CBCR on working memory after acquired brain injury in a patient sample which consisted of at least 50% stroke-patients, 2) it was possible to isolate the effects of CBCR-training by comparison to passive or active control groups, and 3) if the outcome assessment included a quantitative working memory outcome measure either isolated or as part of a general outcome measure. Included studies were further eligible for the meta-analysis if 1) they were conducted as a randomized controlled trial, 2) they included only stroke patients, and 3) the effects of CBCR on working memory could be isolated. RESULTS: Literature is limited and reported effects of CBCR on working memory after stroke are very heterogeneous. A meta-analysis was not performed as all studies used different measures of working memory. An additional analysis was performed in order to cautiously estimate the difference between the control interventions (whether passive or active) and CBCR interventions. The analysis revealed no meaningful differences in increase of working memory measures between control conditions and intervention conditions. However, this additional analysis should be interpreted with caution as it does not take the heterogeneity of outcome measures or the differences in sample sizes between studies into account. No harms were observed. CONCLUSION: There is insufficient evidence to conclude if CBCR is beneficial for patients with working memory deficits after stroke. SYSTEMATIC REVIEW NUMBER: This systematic review is registered in Prospero with registration ID: CRD42018087437.

Computer-Based Cognitive Rehabilitation in Patients with Visuospatial Neglect or Homonymous Hemianopia after Stroke.

OBJECTIVES: The purpose of this pilot study was to investigate the feasibility and effects of computer-based cognitive rehabilitation (CBCR) in patients with symptoms of visuospatial neglect or homonymous hemianopia in the subacute phase following stroke. METHOD: A randomized, controlled, unblinded cross-over design was completed with early versus late CBCR including 7 patients in the early intervention group (EI) and 7 patients in the late intervention group (LI). EI received CBCR training immediately after inclusion (m = 19 days after stroke onset) for 3 weeks and LI waited for 3 weeks after inclusion before receiving CBCR training for 3 weeks (m = 44 days after stroke onset). RESULTS: CBCR improved visuospatial symptoms after stroke significantly when administered early in the subacute phase after stroke. The same significant effect was not found when CBCR was administered later in the rehabilitation. The difference in the development of the EI and LI groups during the first 3 weeks was not significant, which could be due to a lack of statistical power. CBCR did not impact mental well-being negatively in any of the groups. In the LI group, the anticipation of CBCR seemed to have a positive impact of mental well-being. CONCLUSION: CBCR is feasible and has a positive effect on symptoms in patients with visuospatial symptoms in the subacute phase after stroke. The study was small and confirmation in larger samples with blinded outcome assessors is needed.