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2014 JOURNAL OF NEUROLOGY AND NEUROSCIENCE

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Neuropsychological decits after decompresive craniectomy in middle cerebral artery malignant infarction

Aida Antua-Ramos1, Marco Antonio lvarez-Vega2-3, Manuel Menndez Gonzlez3-4, Benjamin Fernndez-Garca3, Miguel Surez-Surez5
1  Servicio de Neurociruga. Complejo Hospitalario Universitario de Albacete. 2  Servicio de Neurociruga. Hospital Universitario Central de Asturias. 3 Departamento de Morfologa y Biologa Celular, Universidad de Oviedo. 4  Unidad de Neurologa, Hospital lvarez-Buylla, Mieres. 5 Servicio de Ciruga Ortopdica y Traumatologa. Hospital de Cabuees. *Corresponding author: aida_ar20@hotmail.com

Abstract
Introduction: The functional outcome in patients after decompressive craniectomy in malignant middle cerebral artery infarction has been widely reported. But there are no many studies about the neuropsychological decits in these patients. Our main aim is to analyse this neuropsychological sequelae.

Methods: Neuropsychological test in these patients focused on language, visuospatial and visuo-constructive abilities, apraxia, agnosia, attention, memory and calculus.

Results: Visuo-spatial and visuo-constructive disabilities, attention and memory

decits are prominent in patients with left middle cerebral artery infarction. Language disturbances, memory decits, apraxia and agnosia are all present in patients after right decompressive surgery in middle cerebral artery infarction. Conclusion: The neuropsychological decits are different in patients with dominant or non dominant hemisphere infarction. It is necessary an intense and specic rehabilitation treatment protocol to keep the efciency of the decompressive surgery for these patients.

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Keywords: Middle cerebral artery, decompressive surgery, hemicraniectomy,

dominant hemisphere, malignant stroke, neuropsychological decits.

Introduction
Malignant middle cerebral artery infarction is a large hemisphere infarction with poor outcome due to massive cerebral oedema that causes an early rise in intracranial pressure and consequent brain herniation and death [1-5]. Mortality rates are around the 80% under conventional therapeutic measures [6, 7]. Because of the limitations of medical therapies, decompressive surgery has been proposed for patients with space-occupying hemispheric infarction. There have been three randomized trials to investigate the efcacy of decompressive surgery in these patients: DESTINY [3], DECIMAL [7] and HAMLET [8]. The meta-analysis that Copyright iMedPub

combines the results of these three studies [9] allowed providing evidence level A to the recommendation of this procedure to reduce mortality. While the prognosis for functional aspect has been extensively studied, there are few publications that analyze the neuropsychological defects [10]. The higher cortical functions are differently located in both hemispheres cerebrals [11] therefore we expect to nd different decits in patients with dominant or non dominant hemisphere infarct. One of the rst studies that evaluates the benets of decompressive craniectomy and the neuropsychological decits of patients with non-dominant hemisphere stroke is the one

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2014 JOURNAL OF NEUROLOGY AND NEUROSCIENCE

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published by Leohnardt in 2002 [12]. They conclude that attention is the most affected cognitive function limiting the possibility of returning to the former job. Visuo-spatial and constructive disturbances are moderately affected and better compensated by the patients with higher level of forma education [12]. Kastrau publishes in 2005 [13] a study analyzing patients undergoing decompressive craniectomy after a massive stroke ACM dominant hemisphere. The 92.8% of their patients improved the results of the aphasia test. Benjamin and col. [14] demonstrated in their work that negative symptoms like decreased spontaneous speech, verbal apraxia, decreased spontaneity, apathy or inattention are the most frequently found in this patients. In 2011, Schmidt [15] described in her study the neuropsychological decits, the quality of life and the extent of depression and other psychiatric symptoms in patients after complete media infarction of the non-speech dominant hemisphere. They observed that patients with nonspeech dominant hemispheric infarctions and decompressive hemicraniectomy are at high risk of depression and severe cognitive impairment. The purpose of our study is to analyse in detail the neuropsychological decits in patients with space-occupying infarction one year after the surgery and to further evaluate the possible benets of this procedure by giving more details information on the quality of life of the surviving patients.

Visuo-spatial and visuo-constructive abilities: The negligence is the failure to direct attention to a stimulus from the environment or from himself. When the individual presents this perceptive defect, he can only recognizes visual or tactile stimulation from one side when actually when stimulate the both. This is call visual or tactile extinction and it can be evaluated by the bi-section lines test or Alberts Test. Praxias: apraxia is dened as the inability to execute a learned movement in response to an appropriate visual or verbal stimulus [11]. Depending on where the fault to response to the stimulus is localized, we will name ideomotor apraxia (or inability to do simple actions because of the failure to perform temporal or spatial sequence of movements), ideatory apraxia (or inability to plan an ordered sequence of actions which are intended to an action), and constructive apraxia (or the difculty for copying a draw or for build a gure). For their study used a battery of different specic tests complex depending on the level of schooling of patient. Memory: It can be dened as the brain ability to register new experiences, and to remember the older ones [11]. In the process of memory can be distinguished a rst learning phase, a second storage phase and nal phase of memory. The individual can lose the ability to learn new information, but not forget the old consolidated memory. We evaluated the short-term or primary memory requesting the patients for repeating digits or a list of word. We study the secondary or long-term memory by asking the patient for personal autobiographical, historical or cultural events. Attention: The attention is the ability to voluntarily centralize our psychic ability on an environmental stimulus which turns into the highest concentration point in our consciousness. We evaluated the attention watching the patients general attitude when we make a general questioning to him. Gnosias: It can be dened as the inability to recognize the meaning of a stimulus that we perceive correctly [11]. Depending on where the inability to recognize stimulus is located, we mean tactile, visual or auditory agnosia. We evaluated the tactile agnosia by asking the patient for recognize everyday objects by touching them. To study the visual agnosia we ask the patient for identify the shapes and colour of some daily objects. The auditory agnosia was evaluated by using various sound stimuli. Calculation: It can be dened as the mechanical process by which we understand the consequences that result from a previously known data. For their study we provide the patient increasingly difcult math problems depending on his cultural level.

Patients and metods

Twenty-one patients operated after suffering with malignant MCA infarction between 2005 and 2010 were evaluated one year after surgery. The mean score on the IB in the group of right MCA infarcts was 63 points and in the group of patients with left hemisphere involvement was 67 points. Three patients were lost to follow-up. There were excluded of the study patients with less than 50 points in the IB score because a minimal cooperation is needed by the patient to undergo the neuropsychological test battery. Finally a total of 14 patients were evaluated, 6 patients with right hemisphere stroke and 8 of them with left hemisphere infarction. The variables studied and the tests applied were: Language: we used two specic tests:  Bostons Test, which evaluates conversational speech, listening comprehension, oral expression, written language comprehension and writing;  Token Test which studies the verbal comprehension.

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2014 JOURNAL OF NEUROLOGY AND NEUROSCIENCE

Vol. 5 No. 1:1 doi: 10.3823/340

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Results
The average age of the group was 49.76 13.88 years. The 52% of patients were male and the 48% were women. The left hemisphere was affected in the 57% of patients and 43% showed involvement of the right hemisphere. The result on the initial score in the Glasgow Coma Scale was a median of 11.52 2.38 points. The average score in the NIHSS at the hospital admission was 17.76 4.90 points. To analyze the results we divided the patients between those who suffered infarction of the right or left MCA. Language: None patient with non-dominant hemisphere infarction presented language disorders. We observed among patients with speech dominant hemisphere infarction:  The 25% of this patients preserved verbal uency with a small difculties in the nomination. The 62,5% presented no-uent aphasia and the 12.5% showed global aphasia.  A 12.5% of these patients had stern language comprehension disorders. The 87.5% could understand simple orders; the 50% was able to repeat words correctly. Only the 25% differentiated appropriate between left and right sides.  Verbal and non-verbal reasoning test were appropriate in the 37.5% and in the 50% of these patients respectively.  The majority of our patients had several reading disabilities owing to that they presented some type of visual decit because of the stroke. Only the 25% of patients were able to read aloud. A 37.5% of them preserved the silent reading but they were not able to read aloud.  Written language comprehension was the strongest affected function: only the 12.5% preserved it completely and just a 25% could identify some letters.  The presence of upper right limb paresis made difcult the handwriting. The 50% of these patients showed dysgraphia, only the 12.5% kept adequate handwriting. Visuo-spatial and visuo-constructive abilities: All the patients with right hemisphere infarction presented contralateral spatial neglect; they left uncrossed the lines located on the left side. None patient with dominant hemisphere infarction showed visuo-spatial and visuo-constructive decits. Praxias: None ofthe patients with right hemisphere stroke had apraxia disorders. Among the left hemisphere infarction patients, 50% of them presented spatial and verbal constructive apraxia, and the ideomotor apraxia was observed in the

62.5% of these patients. Buccofacial apraxia was detected in the 75% of them. Memory: The short-term or primary memory was preserved among non-dominant hemisphere strokes, but it was impaired in the 75% of patients with dominant hemisphere strokes. The secondary or long-term memory was reduced in the 67% of the right hemisphere and in the 75% of the left hemisphere infarction patients. Attention: We detected profound attention decits in all patients with non-dominant hemisphere malignant strokes. The 37.5% of patients with left stroke could cope with the test of divided attention and selective attention test. Gnosias: Only dominant hemisphere malignant stroke patients had disorders in these neuropsychological tests. The 50% of them could not recognize acoustic and optic stimuli when them were presented, and they also could not identify objects and volumes by touch. Calculation: All patients with right infarction could solve simple arithmetic calculus but only the 50% of left hemisphere infarction could resolve it. None patient could do complex operations.

Discussion
Decompressive craniectomy is a life-saving procedure for patients with malignant middle cerebral artery infarctions. However, the neuropsychological sequelae in the survival patients have been received little attention [16]. In this context, aphasic symptoms cause an important disability. Historically, the literature shows that dominant malignant strokes treated by decompressive craniectomy had been four times fewer than the non-dominant strokes [17]. Involvement of the dominant hemisphere has often been used in the past as an excuse to deny patients hemicraniectomy [18]. The benet of the surgical treatment in dominant hemisphere malignant infarctions is still now a matter of debate. While some authors consider that global aphasia is a fate worse than death [19-22], a majority number of authors hold that neglect resulting from non-dominant lesions limits the degree of active participation in rehabilitation programs and is associated with poor functional recovery and social reintegration, thus making it just disability as aphasia. Moreover, signicant improvement in aphasia can occur in dominant hemisphere stroke treated with hemicraniectomy. Involvement of the dominant hemisphere is no longer an acceptable reason for withholding hemicraniectomy from otherwise appropriate candidates [14, 23, 24].

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HAMLET [2] included in their study patients with a large infarct in the dominant hemisphere and severe aphasia because it is unproven that they will fare worse than patients with an infarct in the non-dominant hemisphere. In fact, it has been shown that with the exception of the ability to communicate, the long term quality of life of patients with left-side lesion is slightly better than that of patients with a lesion in the right hemisphere [2]. The relationship between intensity of aphasia therapy and aphasia recovery has been recently studied by some authors. Kastrau [13] showed that a signicant improvement of aphasic symptoms can be observed in a preselected group of patients after a massive stroke of the speech-dominant hemisphere treated by consecutive hemicraniectomy. Bhogal demonstrated that intense therapy over a short amount of time can improve outcomes of speech and language therapy for stroke patients with aphasia [25]. Therefore, decompressive surgery can be considered for the treatment of left-side stroke [26]. In our study, only patients with left-side malignant infarction presented language decits. Different degrees of aphasia were observed in the 75% of these patients. The reading and the written language comprehension were difcult to evaluate due to the presence of any degree of visual defect due to the malignant stroke. All these patients also had any loss of strength in the right hand but the 50% of them were able to write with the left hand after a year of the stroke. Apraxia and agnosia are typically presented in dominant hemisphere lesions. None of our patients with right hemisphere stroke presented praxia or gnosia disturbances, but these were observed in the half of patients with left hemisphere malignant infarct. Apraxia and agnosia disturbances are better compensated by patients with a higher level of formal education. In all patients with a malignant middle cerebral artery infarctionneuropsychological impairments are highly probable post-surgery. They show neuropsychological impairments in multiple cognitive domains, but preserved ability in others. Effects of laterality of brain function were evident in some domains [27]. However, preserved abilities and social support may serve a protective function against depression and an unacceptably poor quality of life [27]. Despite high rates of physical disability and depression, the vast majority of patients are satised with life and do not regret having undergone surgery [26, 28].

Conclusion
The neuropsychological decits are different depending on the location of the malignant stroke. When the brain damage involves dominant hemisphere, language disorders, apraxias and agnosias would be presented. If the injury affects non-dominant hemisphere, we will nd contralateral spatial neglect and memory and attention will be the most affected cognitive functions. Most of the patients need to be supervised in their daily activities. That permanent supervision causes an important decrease of their quality of life. An intensive cognitive rehabilitation therapy for these patients after malignant middle cerebral artery stroke in addition to the standard neurological rehabilitation therapy is necessary to reduce the long term neuropsychological disturbances.

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