On the prognosis of outcome after stroke.

OBJECTIVES: The study was aimed at improving the accuracy of prognosis for recovery of function in patients suffering a first stroke. MATERIALS AND METHODS: Two-hundred and forty-eight patients were enrolled. The mean interval since the stroke was 23 days. Patients entered a rehabilitation program lasting 60 days. The predictive value of 12 factors were analysed, namely motor, cognitive and sphincter subitems of Functional Independence Measure at admission (FIM-a), age, sex, education, body mass index (BMI), depression, neglect, aphasia, ideomotor and constructive apraxia. FIM score at discharge was the dependent variable. RESULTS: A multiple regression revealed that only age, cognitive and sphincter subitems of FIM-a, neglect and ideomotor apraxia were significantly associated with outcome. Moreover, these factors accounted for only 72% of the variance in outcome scores. A decision of unfavourable prognosis on the basis of a FIM-a value lower than 40 was incorrect in 2.8% of the patients in this study and in 8.2% of those having a FIM score lower than 40. CONCLUSIONS: The use of statistical methods to examine the outcome after stroke is useful for expressing probability on a group basis but is unsuitable for determining the prognosis of individual patients. Such data should not be used for fiscal management. A significant minority of patients presenting with a FIM lower than 40 can regain a useful measure of independence. The errors in prognosis based upon available methods, although small, have unacceptable effects in human terms if they lead to the clinical decisions which deny patients rehabilitation. All of the patients should therefore be admitted for rehabilitation after their first stroke. Severe comorbidity requires special attention.

Cognitive rehabilitation of the hemineglect disorder in chronic patients with unilateral right brain damage.

Thirteen patients with a stabilized hemineglect symptomatology due to right-hemisphere lesions were subjected to a rehabilitation training specifically aimed at reducing the scanning deficit. The training consisted of four procedures (visual-spatial scanning, reading and copying training, copying of line drawings on a dot matrix, and figure description) which lasted 40 sessions. By the end of therapy, the patients as a group showed significant improvements on several standard tests of hemineglect. The results on a Semi-structured Scale for the Functional Evaluation of Hemineglect pointed to the extension of exploratory improvements to situations similar to those of daily life. In contrast, patients improved very slightly on a variety of standard visual-spatial tests, indicating the specificity of training in reducing the scanning defect. Seven patients were examined at a follow-up several months after the end of therapy and appeared stable on both standard and functional tests of neglect.

Incidence and evolution of the hemineglect disorder in chronic patients with unilateral right brain damage.

One hundred four patients with a unilateral right hemispheric lesion, consecutively admitted to a rehabilitation clinic, were examined to evaluate: 1. the incidence of patients with severe hemineglect at least two months after the CVA; 2. the role of the length of time from the onset of disease in predicting the severity of the disorder. Estimates of the disorder varied according to the test used, ranging from 26.7% to 52.0%. On the basis of an overall clinical judgment, approximately 20% of patients had very severe hemineglect. Consistent with earlier findings, the severity of the disorder was unrelated to the duration of the disease when examined by means of correlational analyses. However, a subdivision of patients into subgroups according to the length of time from the onset of the disease showed a trend for a moderate reduction of the severity of the deficit starting from the 3-month subgroup for two tests (Barrage Test and Wundt-Jastrow Area Illusion Test).