Search

Objective: The study objective was to perform a randomized trial of brain protection during total aortic arch replacement and identify the best way to assess brain injury., Methods: From June 2003 to January 2010, 121 evaluable patients were randomized to retrograde (n = 60) or antegrade (n = 61) brain perfusion during hypothermic circulatory arrest. We assessed the sensitivity of clinical neurologic evaluation, brain imaging, and neurocognitive testing performed preoperatively and 4 to 6 months postoperatively to detect brain injury., Results: A total of 29 patients (24%) experienced neurologic events. Clinical stroke was evident in 1 patient (0.8%), and visual changes were evident in 2 patients; all had brain imaging changes. A total of 14 of 95 patients (15%) undergoing both preoperative and postoperative brain imaging had evidence of new white or gray matter changes; 10 of the 14 patients had neurocognitive testing, but only 2 patients experienced decline. A total of 17 of 96 patients (18%) undergoing both preoperative and postoperative neurocognitive testing manifested declines of 2 or more reliable change indexes; of these 17, 11 had neither imaging changes nor clinical events. Thirty-day mortality was 0.8% (1/121), with no neurologic deaths and a similar prevalence of neurologic events after retrograde and antegrade brain perfusion (22/60, 37% and 15/61, 25%, respectively; P = .2)., Conclusions: Although this randomized clinical trial revealed similar neurologic outcomes after retrograde or antegrade brain perfusion for total aortic arch replacement, clinical examination for postprocedural neurologic events is insensitive, brain imaging detects more events, and neurocognitive testing detects even more. Future neurologic assessments for cardiovascular procedures should include not only clinical examination but also brain imaging studies, neurocognitive testing, and long-term assessment., (Copyright © 2015. Published by Elsevier Inc.)

Loring et al. (Journal of clinical and experimental neuropsychology, 2005:27;610–617) observed relationships between VSVT hard item performance and IQ and memory indices in epilepsy surgical candidates, with a potential confound of low FSIQ on VSVT performance. The present study replicated the Loring et al. study in a larger sample and extended their findings by examining the relationships among VSVT performance, FSIQ, and working memory. A total of 404 patients with medically intractable epilepsy completed a comprehensive neuropsychological assessment. Differences in WAIS-III and WMS-III performance were examined as a function of VSVT hard score categories as determined by Grote et al. (2000)--that is, valid, > 20/24; questionable, 18–20; or invalid, < 18. Quantile regression models were constructed to compare the strength of the relationship between FSIQ and VSVT at various points of the FSIQ distribution. Linear regression analyses examined working memory as a potential mediator between FSIQ and VSVT performance. The invalid group performed more poorly than the valid and questionable groups on multiple measures of intelligence and memory. The strength of the relationship between FSIQ and VSVT hard item performance decreased as FSIQ increased, and working memory mediated this relationship. Results suggest VSVT hard item scores may be impacted by working memory difficulties and/or low intellectual functioning.

This study sought to determine if word-finding difficulties (WFDs), which are common in adults with dominant temporal lobe epilepsy (TLE), are related to performance on verbal cognitive measures, including memory. One hundred six individuals with left TLE and pathologically confirmed mesial temporal sclerosis completed comprehensive preoperative neuropsychological evaluations. Patients were divided into two groups based on the degree of benefit received from phonemic cueing on a confrontation naming task. Cognitive performance was then compared between patients with greater and fewer WFDs. Patients with greater WFDs demonstrated poorer performance on many verbal cognitive measures compared to those with fewer WFDs. In contrast, there were no significant differences between groups on any of the nonverbal cognitive measures. Chi-square analyses indicated that below average verbal memory performance occurred at a significantly higher rate for patients with greater WFDs (42-46%) as compared to patients with fewer WFDs (18-24%). Results showed that WFDs confound performance on verbal cognitive measures in adult patients with left TLE, particularly on measures with high demands for lexical retrieval. This suggests that when patients have word-retrieval difficulties, measures of verbal memory and verbal intelligence may be underestimated and potentially lead to misinterpretation of test performance and misinformation regarding risk of declines after surgical resection., (Wiley Periodicals, Inc. © 2013 International League Against Epilepsy.)

Little is known about the effects of epilepsy surgery on memory in older adults. The purpose of this study was to determine if older adults exhibit greater memory decline than younger adults after anterior temporal lobectomy (ATL). Patients 55 years and older at time of surgery (23 left, 14 right ATL, range 55-66 years) were compared to patients age 25-35 years (44 left, 33 right ATL) to assess differences in preoperative to postoperative change in WMS-III index scores. Repeated-measures ANOVAs and ANCOVAs revealed that older patients did not demonstrate greater decline than younger patients across any of the memory indices. Rather, in the left ATL group, older patients showed less decline than younger patients on the Auditory Delayed Memory Index. Similarly, in the right ATL group, older patients showed less decline than younger patients on the Visual Delayed Memory Index. These patterns were also apparent in frequency of individual change. Results provide preliminary evidence that older adults who are good candidates for ATL are not at greater risk for memory decline when measured at 7 months postoperatively.

This joint position paper of the American Academy of Clinical Neuropsychology and the National Academy of Neuropsychology sets forth our position on appropriate standards and conventions for computerized neuropsychological assessment devices (CNADs). In this paper, we first define CNADs and distinguish them from examiner-administered neuropsychological instruments. We then set forth position statements on eight key issues relevant to the development and use of CNADs in the healthcare setting. These statements address (a) device marketing and performance claims made by developers of CNADs; (b) issues involved in appropriate end-users for administration and interpretation of CNADs; (c) technical (hardware/software/firmware) issues; (d) privacy, data security, identity verification, and testing environment; (e) psychometric development issues, especially reliability, and validity; (f) cultural, experiential, and disability factors affecting examinee interaction with CNADs; (g) use of computerized testing and reporting services; and (h) the need for checks on response validity and effort in the CNAD environment. This paper is intended to provide guidance for test developers and users of CNADs that will promote accurate and appropriate use of computerized tests in a way that maximizes clinical utility and minimizes risks of misuse. The positions taken in this paper are put forth with an eye toward balancing the need to make validated CNADs accessible to otherwise underserved patients with the need to ensure that such tests are developed and utilized competently, appropriately, and with due concern for patient welfare and quality of care.

This study examined pre-surgical depressed mood as a predictor of post-surgical memory change in adults who underwent temporal lobe resections (TLRs; n = 211). Patients completed the Wechsler Memory Scale-III and Beck Depression Inventory-Second Edition (BDI-II) before and after TLR (left = 110, right = 101) and were divided into two groups (clinically elevated depressive symptoms or not depressed) based on BDI-II score. Left-TLR patients with poorer pre-surgical mood had greater verbal memory declines after surgery compared with nondepressed left- or right-TLR patients and right-TLR patients with poor mood. Further, pre-surgical BDI-II score demonstrated incremental validity in predicting post-surgical memory change in left-TLR patients beyond pre-surgical memory scores. Differences in seizure outcome and post-surgical mood change could not account for memory decline. Results suggest that elevated pre-surgical depressive symptomatology is a risk factor for post-surgical memory decline and indicate that mood should be considered when advising patients about cognitive risks associated with temporal lobectomy. Results are discussed in terms of poor pre-surgical mood as an indicator of reduced cognitive reserve.

This study examined the extent to which the Family Pictures (FP) subtest of the Wechsler Memory Scale-Third Edition (WMS-III) is related to verbal memory measures and right mesial temporal integrity. Epilepsy patients who underwent temporal lobectomy did not differ in the extent to which FP scores changed from before to after surgery, although postoperative FP performance was worse in those who underwent right temporal lobectomy than in those who underwent left temporal lobectomy. FP was most strongly related to the Logical Memory subtest from the WMS-III. Results suggest that FP measures both verbal and visual memory and is minimally sensitive to lateralization of temporal lobectomy.

This study examined the relationship between the APOE epsilon4 allele and postictal confusion in patients with medically intractable temporal lobe epilepsy (TLE). Patients with at least one epsilon4 allele (n=22) were three times more likely to exhibit postictal confusion (68%) than the 63 patients without epsilon4 (43%). These preliminary results demonstrate that APOE epsilon4 is associated with an increased risk of postictal confusion in patients with medically intractable TLE, suggesting possible dysfunction in neuronal recovery mechanisms.

Studies have shown a lower risk for verbal memory decline following dominant anterior temporal lobectomy (ATL) among patients with poor, presurgical verbal memory scores. It is unclear however, if the risk of decline is increased in patients who also have reduced visual memory. Objective and subjective memory outcome following left ATL was examined in twelve patients with reduced presurgical visual and verbal memory scores. Only one patient demonstrated a meaningful decline in memory scores, with a decline in visual memory following surgery. Presurgically, this patient demonstrated poor memory bilaterally on Wada testing and small discrepancy in hippocampal volumes. She was also one of two patients who continued to have seizures post-surgery. This preliminary study suggests that patients with unilateral, left TLE and poor verbal and visual memory are unlikely to show meaningful memory declines following left ATL, particularly if they demonstrate expected patterns on Wada testing, hippocampal volume discrepancy (left < right), and postsurgical seizure-freedom.

Previous research demonstrated a relationship between preoperative memory measured by the Wechsler Memory Scale-Revised (WMS-R) and postsurgical memory change in patients who underwent left (LATL), but not right (RATL) anterior temporal lobectomy. The current study replicated previous efforts using the Wechsler Memory Scale-Third Edition (WMS-III) in a larger sample. The WMS-III was administered to 161 patients with medically intractable epilepsy prior to and approximately 6 months following LATL or RATL. Correlations between presurgical memory on WMS-III indices and memory change following surgery were calculated for each group. Significant negative relationships were found between pre- and postsurgical memory scores in patients who underwent LATL on all WMS-III measures (r=-0.31 to -0.43). Significant negative correlations were observed in patients who underwent RATL only on visual memory measures (r=-0.24 to -0.44). Findings support previous conclusions using the WMS-R showing that patients who undergo LATL with higher presurgical memory ability are at greater risk for memory decline following temporal resection than patients with lower presurgical memory scores.

The purpose of this study was twofold: (1) to examine the relationships among measures of cognitive symptom exaggeration (i.e., response accuracy and response latency) and (2) to examine the relationship between measures of cognitive and psychopathological symptom exaggeration. It was expected that Victoria Symptom Validity Test (VSVT) accuracy and latency measures would be significantly correlated, with invalid responders demonstrating longer response latencies. VSVT scores were also expected to correlate significantly with the Negative Impression Management (NIM) and Infrequency (INF) subscales of the Personality Assessment Inventory (PAI). VSVT and PAI data were collected from 300 patients during routine clinical neuropsychological evaluations. Results indicated that VSVT accuracy and latency measures were significantly and moderately correlated, and both types of VSVT scores were significantly, but modestly, related to NIM, but not INF. These findings suggest that VSVT response latencies may supplement accuracy scores in identifying patients who are exerting suboptimal effort on cognitive measures. These findings further suggest that measures of cognitive symptom validity only partially overlap with measures of psychopathological symptom exaggeration.

Previous studies have focused on the ability of cognitive symptom validity tests to identify simulated malingering or distinguish between clinical samples of individuals at low or high risk of cognitive symptom exaggeration. However, no published studies have examined the latent structure of negative response bias on cognitive tests: measures of cognitive symptom exaggeration may evaluate a continuum of poor effort/invalid responding or a dichotomy of adequate versus inadequate effort. The present study examined whether Victoria Symptom Validity Test (VSVT) indices evaluate a latent dimension or category of response distortion. The VSVT and personality data were obtained from 300 individuals who participated in neuropsychological evaluations as part of standard clinical care. Results indicated that VSVT accuracy scores measure a latent category of inadequate/adequate effort. Individuals classified as taxon members showed significantly poorer performance IQ and memory relative to individuals not classified as exhibiting distortion. The base rate of the identified cognitive symptom exaggeration taxon was estimated to be approximately .13-.14 in the present sample. Likelihood ratios are presented to assist clinical detection of individuals exhibiting the category of cognitive symptom exaggeration.

The question of whether attention-deficit/hyperactivity disorder (ADHD) represents a continuum of attentional and executive dysfunction or a natural category has yet to be extensively investigated. Subjective report and neuropsychological data from 437 individuals referred for neuropsychological evaluation were analyzed using latent class and taxometric analyses (mean above minus below a cut [MAMBAC], maximum eigenvalue [MAXEIG], and latent mode [LMODE]). Results indicated no significant evidence for a taxonic representation of ADHD across multiple procedures and indicator sets. Similarly, there was no evidence that ADHD subtypes represent a qualitative distinction. These findings may suggest that current diagnostic conceptualizations are inadequate for accurately identifying and characterizing individuals with problems related to attention and executive dysfunction. Alternatively, the null findings may have resulted from inadequate indicator selection. A dimensional model may better facilitate accurate identification of individuals at risk for functional impairment., ((c) 2007 APA, all rights reserved.)

Purpose: Although anterior temporal lobectomy (ATL) is an effective treatment for many patients with medically refractory temporal lobe epilepsy (TLE), one risk associated with this procedure is postsurgical decline in memory. A substantial number of past studies examined factors that predict memory decline after surgery, but few have investigated multiple predictors simultaneously or considered measures that are currently in use., Methods: This study compared the relative contributions made by presurgical neuropsychological test scores, MRI-based hippocampal volumetric analysis, and Wada test results to predicting memory outcome after ATL in a group of 87 patients., Results: Logistic regression analyses indicated that noninvasive procedures (neuropsychological testing and MRI) made significant contributions to improving the prediction of memory outcome in this sample. The results from the Wada procedure did not significantly improve prediction once these other factors were considered. The only exception was in predicting memory for visual information after a delay, in which Wada results improved prediction accuracy from 78% to 81%., Conclusions: Current neuropsychological tests and MRI volumetric measures predict changes in verbal and visual memory after ATL. The relatively small change in correct classification rates when Wada memory scores are considered calls into question the benefits of using Wada test results to predict memory outcome when the results of noninvasive procedures are available.

The 160-item short form of the Personality Assessment Inventory (PAI) was developed for situations in which respondents complete only the 1st half of the test. The present study evaluates the adequacy and comparability of the full and short forms of the PAI in terms of a wide range of psychometric characteristics. In all, 421 participants completed the full form as part of a neuropsychological evaluation. Results indicated slightly lower internal consistency reliability of the short compared with the full form. Group-level agreement of short and full form scales ranged from adequate to excellent. However, within-subject agreement was somewhat more variable. Low levels of within-subject agreement were strongly associated with elevated validity scale scores. The factor structures of the full and short forms showed high congruence for a 3-factor solution. These findings suggest that many scales of the short form have adequate comparability with their respective full form scales. However, low levels of reliability across less impaired ranges of the latent trait, diminished content coverage, and altered validity detection may limit the utility of some of the short form scales.

Objective: We sought to evaluate magnesium as a neuroprotectant in patients undergoing cardiac surgery with cardiopulmonary bypass., Methods: From February 2002 to September 2003, 350 patients undergoing elective coronary artery bypass grafting, valve surgery, or both were enrolled in a randomized, blinded, placebo-controlled trial to receive either magnesium sulfate to increase plasma levels 1(1/2) to 2 times normal during cardiopulmonary bypass (n = 174) or no intervention (n = 176). Neurologic function, neuropsychologic function, and depression were assessed preoperatively, at 24 and 96 hours after extubation (neurologic) and at 3 months (neuropsychologic, depression). Neurologic scores were analyzed using ordinal longitudinal methods, and neuropsychologic and depression inventory data were summarized by principal component analysis, followed by linear regression analysis using component scores as response variables., Results: Seven (2%) patients had a postoperative stroke, 2 (1%) in the magnesium and 5 (3%) in the placebo group (P = .4). Neurologic score was worse postoperatively in both groups (P < .0001); however, magnesium group patients performed better than placebo group patients (P = .0001), who had prolonged declines in short-term memory and reemergence of primitive reflexes. Three-month neuropsychologic performance and depression inventory score were generally better than preoperatively, with few differences between groups (P > .6); however, older age (P = .0006), previous stroke (P = .003), and lower education level (P = .0007) were associated with worse performance., Conclusions: Magnesium administration is safe and improves short-term postoperative neurologic function after cardiac surgery, particularly in preserving short-term memory and cortical control over brainstem functions. However, by 3 months, other factors and not administration of magnesium influence neuropsychologic and depression inventory performance.

Purpose: One risk associated with epilepsy surgery is memory loss, but perhaps more important is how patients perceive changes in their memories. This longitudinal study evaluated changes in memory self-reports and investigated how self-reports relate to changes on objective memory measures in temporal or extratemporal epilepsy patients who underwent surgery., Methods: Objective memory (Wechsler Memory Scale-Revised) and subjective memory self-reports (Memory Assessment Clinics Self-Rating Scale) were individually assessed for 136 patients approximately 6 months before and 6 months after surgery. A measure of depressive affect (Beck Depression Inventory-2nd Edition) was used to control variance attributable to emotional distress., Results: Despite a lack of significant correlational relationships between objective and subjective memory for the entire sample, significant correlations between objective memory scores and self-reports did emerge for a subset of patients who evidenced memory decline. Differences also were found in the subjective memory ratings of temporal lobe versus extratemporal patients. Temporal lobe patients rated their memories more negatively than did extratemporal patients and were more likely to report significant improvements in their memory after surgery., Conclusions: In general, patients were not accurate when rating their memories compared to other adults. However, patients with significant declines in their memories were sensitive to actual changes in their memories over time relative to their own personal baselines.

Ipsative approaches to neuropsychological assessment typically involve interpreting difference scores between individual test scores. The utility of these methods is limited by the reliability of neuropsychological difference scores and the number of comparisons between scores. The present study evaluated the utility of difference scores using factor analytic methods, including reliable components analysis (RCA), equally weighted composites and individual neuropsychological measures. Data from 1,364 individuals referred for neuropsychological assessment were factor analyzed and the resulting solutions were used to compute composite scores. Reliabilities and confidence intervals were derived for each method. Results indicated that RCA outperformed other factor analytic methods, but produced a slightly different factor structure. Difference scores derived using orthogonal solutions were slightly more reliable than oblique methods, and both were more reliable than those from equally weighted composites and individual measures. Confidence intervals for difference scores were considerably smaller for factor methods relative to those for individual test comparisons, due to the greater reliability of factor based difference scores and the smaller number of comparisons required. These findings suggest that difference scores derived from orthogonal factor solutions, particularly RCA solutions, may improve reliability for clinical assessment purposes.

We examined performances on the Wechsler Memory Scale-3rd Edition (WMS-III) among patients who underwent temporal lobectomy for the control of medically intractable epilepsy. There were 51 right (RTL) and 56 left (LTL) temporal lobectomy patients. All patients were left hemisphere speech-dominant. The LTL and RTL patients were comparable in terms of general demographic, epilepsy, and intellectual/attention factors. Multivariate analyses revealed a significant crossover interaction (p <.001), with the RTL group scoring significantly lower on the visual than auditory indexes while the LTL group scored significantly lower on the auditory than visual memory indexes. Within-group pairwise analyses revealed statistically significant auditory versus visual index score comparisons (all p <.001) for both surgical groups. Discriminant analysis (p <.001) identified Verbal Paired Associates I, Faces I, and Family Pictures II to significantly discriminate RTL and LTL patients, with an overall correct classification rate of 81.3%. Our findings suggest that the WMS-III is sensitive to modality-specific memory performance associated with unilateral temporal lobectomy.

A neuropsychological evaluation can help in narrowing the differential diagnosis of cognitive dysfunction, choosing treatments, and evaluating the efficacy of an intervention on an ongoing basis. In patients with documented neurologic disorders, information from neuropsychological assessment can define the patient's functional limitations or residual cognitive strengths. Proper use of neuropsychological assessment can improve the quality of care.

We examined whether differences between the expanded standardization protocol (SP) used to derive norms for the final published version (PB) of the Wechsler Memory Scale - Third Edition (WMS-III; Wechsler, 1997a) would result in differences on the Primary Indexes in a neurologic sample. Specifically, we examined the comparability of the performances of 63 patients with temporal lobectomy (TL) who were administered either the expanded SP protocol (n = 33: 22 left TL and 11 right TL) or the PB battery (n = 30: 11 left TL and 19 right TL). Patients who were administered the SP or PB were comparable in terms of age, sex, education, seizure duration, postsurgical seizure status, and Full Scale IQ. Postoperative intervals were significantly longer for the SP group, although correlational analyses demonstrated no significant relationship between postoperative follow-up interval and WMS-III performance. A series of t tests revealed no significant differences on any of the eight Primary Index scores between patients taking the two versions of the WMS-III for either left or right TL groups. Furthermore, repeated measures analyses of variance failed to show significant differences on modality-specific memory scores between the SP and PB for the left and right TL groups. The current study indicates that temporal lobectomy patients obtained comparable scores on the two versions of the WMS-III.

Performance of 200 mixed neuropsychiatric patients on the WAIS-R were compared to the summary scores for Kaufman's Brief Intelligence Test (K-BIT) and a seven subtest short form of the WAIS-R. Correlations between verbal, non-verbal, and composite of the full WAIS-R with the K-BIT were significantly lower than the correlations with the WAIS-R shore form. The percentage of cases on the short forms that fell within 5 points of the full WAIS-R was higher for the seven subtest version of the WAIS-R than the K-BIT. Specifically, Verbal, Nonverbal/Performance, and Composite/Full Scale scores on the WAIS-R short form feel within 5 points for 89%, 74%, and 92% of the cases while on the K-BIT only 52%, 40%, and 50% fell within 5 points.

Purpose: Considerable debate exists concerning whether the presence of low preoperative IQ should be a contraindication for focal resective epilepsy surgery., Methods: We examined the relationship between baseline IQ scores and seizure outcome in 1,034 temporal lobectomy cases from eight epilepsy surgery centers participating in the Bozeman Epilepsy Consortium., Results: Those patients who continued to have seizures following surgery had statistically lower preoperative IQ scores than those who were seizure-free (p < 0.009), but only by 2.3 points. This small but statistically significant relationship was fairly robust; it was observed across seven of the eight centers, and indicates that the findings can be generalized. Among patients with IQ scores of < or = 75, 32.8% continued to have seizures following surgery, whereas 23.8% and 16.9% were not seizure-free when IQ scores were between 76 and 109 and > or = 110, respectively. Relative risk analyses revealed no significant increase in risk among patients with low IQ scores who had no structural lesions other than mesial temporal sclerosis. However, patients with IQ scores of < or = 75 had nearly a fourfold (390%) increase in risk for continued seizures as compared with those with higher IQ scores if structural lesions were present., Conclusions: While our results suggest that preoperative IQ scores alone are not good predictors of seizure outcome and should not be used to exclude patients as potential surgical candidates. IQ scores can be useful for counseling patients and their families concerning the relative risks of surgery.

Traditional methods for assessing the neurocognitive effects of epilepsy surgery are confounded by practice effects, test-retest reliability issues, and regression to the mean. This study employs 2 methods for assessing individual change that allow direct comparison of changes across both individuals and test measures. Fifty-one medically intractable epilepsy patients completed a comprehensive neuropsychological battery twice, approximately 8 months apart, prior to any invasive monitoring or surgical intervention. First, a Reliable Change (RC) index score was computed for each test score to take into account the reliability of that measure, and a cutoff score was empirically derived to establish the limits of statistically reliable change. These indices were subsequently adjusted for expected practice effects. The second approach used a regression technique to establish "change norms" along a common metric that models both expected practice effects and regression to the mean. The RC index scores provide the clinician with a statistical means of determining whether a patient's retest performance is "significantly" changed from baseline. The regression norms for change allow the clinician to evaluate the magnitude of a given patient's change on 1 or more variables along a common metric that takes into account the reliability and stability of each test measure. Case data illustrate how these methods provide an empirically grounded means for evaluating neurocognitive outcomes following medical interventions such as epilepsy surgery.

Memory testing during the intracarotid amobarbital procedure (IAP) is used extensively to identify temporal lobe surgery candidates "at risk" for developing severe postoperative anterograde amnesia. However, the utility of the IAP in predicting commonly observed material-specific memory deficits has not been thoroughly investigated. We examined the utility of contralateral IAP memory testing, as an index of the functional capacity of the surgical temporal lobe, to predict postoperative material-specific memory changes on the Wechsler Memory Scale-Revised (WMS-R) in patients with left hemisphere speech dominance undergoing left (n = 32) and right (n = 31) temporal lobectomy (TL). Left TL patients who "passed" contralateral IAP memory testing (> or = 68% recognition of memory items) had significantly greater verbal memory decrements than those who "failed" the IAP, presumably as a result of removal of functional tissue. A similar relationship between contralateral IAP performance and visual memory performance was not observed among right TL patients. Thus, the functional adequacy of the tissue to be resected appears to be inversely related to postoperative verbal memory decrement, at least among left TL patients. This relationship is consistent with results of recent studies demonstrating an inverse relationship between verbal memory decrements after left TL and preoperative neuropsychological verbal memory performance, magnetic resonance imaging (MRI) hippocampal volumes, and degree of mesiotemporal sclerosis (MTS).

To determine the utility of the Wechsler Memory Scale-Revised (WMS-R) in measuring material-specific memory changes, within-subject comparisons of the Verbal-Visual Memory Index discrepancy and discrepancy scores using short-term and delayed Logical Memory and Visual Reproduction subtests from the WMS-R were studied prior to and following temporal lobectomy among 30 patients with left temporal lobectomy, 30 with right temporal lobectomy, and 50 epileptic, non-surgical controls. The groups were matched on age, sex, handedness, age at seizure onset, duration of epilepsy, and presurgical Verbal and Performance IQ; the right temporal group had a higher mean educational level (p <.05). All surgical patients were left hemisphere dominant for speech; those who had persistent postoperative seizures were excluded from study. On retesting, left temporal lobectomy was associated with a marked change in short-term and delayed memory discrepancy scores primarily due to a drop in verbal memory. Right temporal lobectomy was not associated with a drop in visual memory, suggesting that the WMS-R appears to reflect decrements in material-specific memory following left but not right temporal lobectomy. The nonsurgical controls showed increases in both short-term and delayed memory discrepancy scores due to increases in short-term and delayed verbal memory. Relative to these controls, the absence of comparable increases in verbal memory among the right temporal patients suggests that right temporal lobectomy may be associated with risk to verbal memory.

The psychosocial adjustment of 50 male patients to intractable seizures was assessed by comparing their responses to a combined version of the Minnesota Multiphasic Personality Inventory (MMPI) and the California Psychological Inventory (CPI) to the responses of 50 medical, psychiatric, or nonclinical controls who denied seizures. The two groups were significantly different (p < .01) on one MMPI and 10 CPI scales. Significant (p < .01) between-group differences were also reflected in 29 of the 704 personality inventory items. Those items were rationally clustered according to content into six conceptually identifiable subscales; 30 additional items with similar content that were significant at the .05 level were added to those subscales. Comparison of subscale scores of an additional 30 seizure and 30 nonseizure subjects using analysis of variance revealed F values that reached statistical significance (p < .05) in four cases and approached significance (p = .07) in another. Applying coefficients derived from discriminant analysis of the first samples correctly classified 99% of the original patients and 85% of the validation subjects. Results reveal a logical, understandable, and largely adaptive response to intractable seizures and offer little support for the concept of a dysfunctional or pathological interictal personality style.

The preservation of visuospatial ability relative to verbal ability following right middle cerebral artery stroke was assessed in 19 left- and 19 right-handed male patients who were group-matched on the basis of age, education, and time elapsed since stroke. Analysis of covariance (covarying education) indicated that the left- and right-handed groups were significantly different with regard to the discrepancy between Verbal IQ and Performance IQ, with the left-handed patients showing a smaller difference than the right-handers. These results provide further evidence that sinistrality may be associated with less hemispheric specialization.

The relationship between preoperative ability levels and postoperative changes in cognitive function was examined among 23 left (LTL) and 19 right (RTL) temporal lobectomy patients using a battery of memory, language, and visuospatial tasks administered approximately 3 months before surgery and at 6 months follow-up. Higher preoperative performances on the memory and language measures were associated with larger decrements in postsurgical scores among the LTL patients. The RTL group showed no consistent relationship between preoperative ability levels and subsequent postsurgical cognitive changes. Based on the present data, we constructed base-rate tables for the Wechsler Memory Scale-Revised indicating the likelihood of measurable gains or losses in memory as a function of presurgical ability level for patients undergoing LTL. While tentative, these data provide a useful and practical guide for counseling prospective epilepsy patients of the attendant cognitive risks of LTL.

Some researchers have speculated that left-hand dominance is more prevalent among patients suffering from dementia of the Alzheimer's type which began prior to age 65 yr. and that, in those patients, the disease runs a more rapid course. In the present study, seven left-handed dementia patients were matched with seven right-handed dementia patients on the basis of age and years of education and were compared with regard to neuropsychological compromise. While the left-handed group was somewhat more impaired than the right-handed subjects, the difference between the two groups was not statistically significant.

We present correlations of extent of temporal lobectomy for intractable epilepsy with postoperative memory changes (20 cases) and abnormalities of visual field and neurologic examination (45 cases). Postoperative magnetic resonance imaging (MRI) in the coronal plane was used to quantify anteroposterior extent of resection of various quadrants of the temporal lobe, using a 20-compartment model of that structure. The Wechsler Memory Scale-Revised (WMS-R) was administered preoperatively and postoperatively. Postoperative decrease in percentage of retention of verbal material correlated with extent of medial resection of left temporal lobe, whereas decrease in percentage of retention of visual material correlated with extent of medial resection of right temporal lobe. These correlations approached but did not reach statistical significance. Extent of resection correlated significantly with the presence of visual field defect on perimetry testing but not with severity, denseness, or congruity of the defect. There was no correlation between postoperative dysphasia and extent of resection in any quadrant. Assessment of extent of resection after temporal lobectomy allows a rational interpretation of postoperative neurologic deficits in light of functional anatomy of the temporal lobe.

The Mini-Mental State (MMS) Examination is perhaps the most frequently used bedside screening measure of cognition of psychiatric and neurologic patients. It represents a formal, more standardized qualitative approach to determining mental status than an unstructured interview. Initial validation efforts comparing MMS scores of psychiatric patients to the results of more informal mental status interviews were very encouraging. Subsequent research comparing the scale to other criteria has suggested some limitations of its use, however. It has been found to overestimate impairments in persons over age 60 and in persons with less than nine years of education. The MMS scale has been reported to be insensitive to cognitive impairments resulting from right hemisphere dysfunction as well as milder forms of cognitive dysfunction irrespective of cortical origin. Case studies that demonstrate its inaccuracy in identifying cognitive impairments in individuals with average and low-average verbal IQs are reviewed. These limitations have far-reaching implications for both research and clinical applications of the measure. Proper use of the MMS requires that the user be aware of instances when the scale is likely to produce misleading data.

The neurologic and neuropsychologic sequelae of Acquired Immune Deficiency Syndrome (AIDS) have received an increasing amount of attention recently. A variety of neurologic disorders are now associated with AIDS or AIDS-Related Complex (ARC). To date, however, there have been no detailed accounts of the behavioral sequelae or course of illness of AIDS/ARC victims who have suffered brain trauma. This paper describes the case of a 39 year old male patient who tested positive for the retrovirus now associated with AIDS/ARC (Human T-Lymphatropic Virus Type III or "HTLV-III") and suffered a closed head injury as a consequence of a physical assault. His course was rapid and his symptomatology more profound than would be expected on the basis of his injury alone. The assault is regarded as a second, catalytic injury and is presumed to derive its pronounced effect from the ongoing neurologic disorder resulting from or associated with the HTLV-III virus. The possible role of head injury in the exacerbation of diffuse and subclinical cortical dysfunction is discussed. Relevant contributions from sports medicine literature and Alzheimer's Disease research are reviewed.

Several investigators have reported cognitive deficits associated with symptomatic carotid artery disease. This paper reports the findings of a study investigating cognitive deficits associated with asymptomatic carotid stenosis. Experimental subjects consisted of six patients who, in the course of routine physical examinations, showed carotid bruits and, on carotid ultrasound studies, showed 70% or greater stenosis in one or both arteries. No clinical symptoms had been associated with that stenosis. Six control subjects who were group-matched in terms of age and years of education were drawn from a control group evaluated previously for comparison with a transient ischemic attack (TIA) sample. All patients received a battery of tests consisting of a Wechsler Adult Intelligence Scale-Revised, abbreviated Halstead-Reitan Neuropsychological Battery, Revised Wechsler Memory Scale, and a written word fluency measure. Findings were converted to Rating Equivalents according to standard guidelines and an average Impairment Index was computed for each subject. ANOVA revealed that the two groups were significantly different in terms of the average Impairment Index. The clinical significance of these findings is discussed and implications for future research are reviewed.

Neuropsychological assessment data from 138 Alzheimer's disease patients were cluster-analyzed to yield five separate subgroups. These clusters are best described as follows. Cluster I is a low-functioning subgroup characterized by severe generalized deficits (N = 25), cluster II is a subgroup characterized by a higher level of visual-spatial skills relative to the other groups (N = 39), cluster III (N = 21) and cluster IV (N = 42) are virtually indistinguishable in terms of verbal ability and memory, but do differ with regard to visual-spatial skills, and cluster V is a subgroup which presented with relatively better preserved verbal abilities (N = 11). Despite their different neuropsychological profiles, the subgroups did not differ significantly with regard to those complaints that were noted early in the course of the disease process. However, they were found to differ significantly with regard to the patients' educational backgrounds, the distribution of males and females, and the age of the patients at the time of onset of the disease. Analysis of the degree and lateralization of cortical atrophy using volumetric techniques suggested little relationship with neuropsychological examination results. Ventricular volume differences among the five subgroups were not found to be statistically significant after the effect of age had been partialled out. Results are discussed in relation to the multiple factors relating to brain structure and cognition in Alzheimer's disease.

Groups of presenile (n = 41) and senile (n = 97) dementia patients were compared on neuropsychological measures and volumetric estimates of atrophy and ventricular enlargement as depicted on computerized axial tomography. Despite their significantly greater age, the senile patients were not markedly significant different on neuropsychological measures when the effect of education was covaried. Likewise, there were no significant differences between the two groups in terms of cortical atrophy despite that variable's known relationship with age. Ventricular size was not significantly different between groups when age effects were statistically controlled. It is concluded that the pathologic effects of presenile dementia are roughly equivalent to the total of the effects of both the disease and aging processes in senile dementia. Therefore, the disease appears to be more dramatic when it occurs in younger patients. It may be that younger patients are less healthy than older patients presenting with the disease and, consequently, are less able to withstand its effects. The present sample is compared with those of other studies reporting a markedly more pathologic presentation associated with presenile relative to senile dementia.

Utilizing volumetric measures of brain morphology, the relationship between cortical atrophy and ventricular dilation was examined in a sample of 59 Alzheimer's Disease patients and 48 closed head injury patients. Correlation matrices were constructed and factor analyses performed in order to elucidate the various relationships. In the Alzheimer Disease sample there appeared to be a moderately strong relationship between cortical atrophy and ventricular volume. However, analyses also lent support to the position that cortical atrophy and ventricular dilation reflect processes which are related yet somewhat independent. Results obtained from the closed head injury sample indicated that focal damage effects were more evident in cortical atrophy measures, while generalized effects were relatively more important in ventricular dilation. Finally, the relationships between neuropsychological performance and various combinations of high and low cortical atrophy and ventricular volume measures were modest.