Baseline Neurocognitive Testing Research Articles

What are the Protocols and Resources for Sport-Related Concussion Among Top National Collegiate Athletic Association Football Programs? A Cross-Sectional Survey of A5 Schools.

This study summarizes findings from a cross-sectional survey conducted among National Collegiate Athletic Association (NCAA) Division 1 football programs, focusing on sport-related concussion (SRC) protocols for the 2018 season. Cross-sectional survey study. 65 football programs within the Autonomy Five (A5) NCAA conferences. Athletic trainers and team physicians who attended a football safety meeting at the NCAA offices June 17 to 18, 2019, representing their respective institutions. Electronic surveys were distributed on June 14, 2019, before the football safety meeting. Results for 16 unique questions involving SRC protocols and resources were summarized and evaluated. The survey garnered responses from 46 of 65 programs (response rate = 71%). For baseline testing, 98% measured baseline postural stability and balance, 87% used baseline neurocognitive testing, while only 61% assessed baseline vestibular and/or ocular function. Regarding concussion prevention, 51% did not recommend additional measures, while 4% and 24% recommended cervical compression collars and omega-3 supplementation, respectively. In postconcussion treatment, 26% initiated aerobic exercise 1 day postconcussion if symptoms were stable, 24% waited at least 48 hours, 4% waited for the athlete to return to baseline, 11% waited until the athlete became asymptomatic, and 35% determined procedures on a case-by-case basis. Most institutions assessed postural stability/balance and neurocognitive functioning at baseline and introduced light aerobic exercise within 48 h postconcussion. There was variation in baseline assessment methods and concussion prevention recommendations. These survey findings deepen our understanding of diverse SRC protocols in NCAA football programs.

What are the Protocols and Resources for Sport-Related Concussion Among Top National Collegiate Athletic Association Football Programs? A Cross-Sectional Survey of A5 Schools.

This study summarizes findings from a cross-sectional survey conducted among National Collegiate Athletic Association (NCAA) Division 1 football programs, focusing on sport-related concussion (SRC) protocols for the 2018 season. Cross-sectional survey study. 65 football programs within the Autonomy Five (A5) NCAA conferences. Athletic trainers and team physicians who attended a football safety meeting at the NCAA offices June 17 to 18, 2019, representing their respective institutions. Electronic surveys were distributed on June 14, 2019, before the football safety meeting. Results for 16 unique questions involving SRC protocols and resources were summarized and evaluated. The survey garnered responses from 46 of 65 programs (response rate = 71%). For baseline testing, 98% measured baseline postural stability and balance, 87% used baseline neurocognitive testing, while only 61% assessed baseline vestibular and/or ocular function. Regarding concussion prevention, 51% did not recommend additional measures, while 4% and 24% recommended cervical compression collars and omega-3 supplementation, respectively. In postconcussion treatment, 26% initiated aerobic exercise 1 day postconcussion if symptoms were stable, 24% waited at least 48 hours, 4% waited for the athlete to return to baseline, 11% waited until the athlete became asymptomatic, and 35% determined procedures on a case-by-case basis. Most institutions assessed postural stability/balance and neurocognitive functioning at baseline and introduced light aerobic exercise within 48 h postconcussion. There was variation in baseline assessment methods and concussion prevention recommendations. These survey findings deepen our understanding of diverse SRC protocols in NCAA football programs.

Influence of social determinants of health and adversity on computerized neurocognitive assessment

Introduction: Social determinants of health and adversity, including poverty, maltreatment, and neighborhood deprivation, are individual-level factors that may significantly affect baseline neurocognitive testing and management that have yet to be thoroughly explored within the computerized neurocognitive assessment.Objectives: Examine individual-level experiences of poverty, abuse, neighborhood deprivation, and social mobility on computerized cognitive testing.Methods: The sample included 3,845 student-athletes who completed a baseline Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) and were enrolled in the Child-Household Integrated Longitudinal Data database. Multivariable linear regressions were used to assess independent variables of Supplemental Nutrition Assistance Program enrollment, abuse or neglect cases, Area Deprivation Index scores, and other demographic factors on four baseline ImPACT composite scores: verbal and visual memory, visuomotor, and reaction time.Results: Individual-level factors of persistent poverty and neighborhood deprivation were associated with lower composite scores; however, upward social mobility was not significantly associated with cognitive performance. The effects of mother’s race on computerized cognitive testing performance were attenuated when accounting for measures of adversity.Conclusion: Findings highlight the importance of social determinants of health in computerized neurocognitive testing to ensure more culturally sensitive and precise understanding of athletic baselines.

Collegiate Athletes With Diabetes: Baseline Medical Comorbidities and Preseason Concussion Testing Performance.

People with diabetes mellitus (DM) are at increased risk for adverse health events and complications throughout their lifetime. Whether DM significantly affects collegiate athletes' concussion baseline testing performance remains unclear. To (1) describe the prevalence of DM and associated comorbidities and (2) compare concussion baseline testing performance between student-athletes with DM and student-athletes without DM (NoDM). Retrospective, cross-sectional study. University. Using the Concussion, Assessment, Research and Education (CARE) Consortium research database, we matched athletes with self-reported DM (N = 229) by institution, sex, age, sport, position, testing year, and concussion history to athletes with NoDM (N = 229; total sample mean age = 19.6 ± 1.4 years, women = 42%). Descriptive statistics and χ2 tests of independence with subsequent odds ratios were calculated. Independent-samples t tests compared baseline symptoms, neurocognitive testing, and balance performance between athletes with DM and athletes with NoDM. Effect sizes were determined for significant group differences. At baseline, athletes with DM had higher rates of self-reported pre-existing balance disorders, sleep disorders, seizure disorders, motion sickness, learning disorders, vision and hearing problems, psychiatric disorders, depression, bipolar disorder, nonmigraine headaches, and meningitis than athletes with NoDM (P values < .05). We found balance differences between groups (P = .032, Cohen d = 0.17) such that, on average, athletes with DM had 1 additional error on the Balance Error Scoring System (DM = 13.4 ± 6.5; NoDM = 12.1 ± 5.9). No other comparisons yielded significant results. Although athletes with DM had high rates of self-reported balance disorders, sleep disorders, seizures, and meningitis, their baseline neurocognitive testing results were largely identical to those of athletes with NoDM. Our findings suggested that nonclinically meaningful differences were present in concussion baseline balance testing but no significant differences were noted in cognitive testing; however, the effect of DM on concussion recovery remains unknown.

The prevalence and correlates of scores falling below ImPACT embedded validity indicators among adolescent student athletes

Objective: Valid performance on preseason baseline neurocognitive testing is essential for accurate comparison between preseason and post-concussion test results. Immediate Post-Concussion and Cognitive Testing (ImPACT) is commonly used to measure baseline neurocognitive function in athletes. We examined the prevalence of invalid performance on ImPACT baseline testing and identified correlates of invalid performance. Method: The sample included 66,998 adolescents (ages 14–18, M = 15.51 years, SD = 1.22) who completed ImPACT baseline tests between 2009 and 2019. Invalid performance was determined by the embedded validity indicators (EVI). Associations between invalid performance, demographic characteristics, and health conditions were assessed using chi-square tests and odds ratios (ORs). Results: Overall, 7.2% of adolescents had baseline tests identified as invalid by one or more of the EVIs. Individual validity indicators classified between 0.5% and 3.7% tests as invalid. Higher frequencies of invalid scores were observed among youth with neurodevelopmental, academic, and medical conditions. Youth who reported having learning disabilities (n = 3126), receiving special education (n = 3563), or problems with attention-deficit/hyperactivity disorder (ADHD; n = 5104) obtained invalid baselines at frequencies of 16.4%, 16.0%, and 11.1%, respectively. Moreover, youth who reported receiving treatment for a substance use disorder (n = 311) or epilepsy (n = 718) obtained invalid baselines at frequencies of 17.0% and 11.1%, respectively. Conclusions: The base rate of invalid performance on ImPACT’s EVIs was approximately 7%, consistent with prior research. Adolescents self-reporting neurodevelopmental conditions, academic difficulties, or a history of treatment for medical conditions obtained invalid baseline tests at higher frequencies. More research is needed to better understand invalid scores in youth with pre-existing conditions.

Plasma Serotonin 2A Receptor Autoantibodies Predict Rapid, Substantial Decline in Neurocognitive Performance in Older Adult Veterans with TBI.

Traumatic brain injury (TBI) was associated with increased plasma serotonin 2A receptor (5-HT2AR) autoantibodies in adults who experienced neurodegenerative complications. We tested whether the baseline presence of plasma serotonin 2A receptor (5-HT2AR) autoantibodies was a significant predictor of the two-year rate of cognitive decline in middle-aged and older adult TBI. Plasma from thirty-five middle-aged and older adult veterans (mean 65 years old) who had suffered traumatic brain injury was subjected to protein-A affinity chromatography. One-fortieth dilution of the resulting immunoglobulin (Ig) G fraction was tested for binding (in ELISA) to a linear synthetic peptide corresponding to the second extracellular loop region of the human 5-HT2A receptor. All available patients completed baseline and two-year follow-up neurocognitive tests of memory (St Louis University Mental Status), processing speed (Digit Symbol Substitution Test) and executive function (Trails-making Test, Part B). Change in cognitive performance was computed as (two-year - baseline) raw test score. Eighteen patients completed both baseline and two-year follow up neurocognitive tests. TBI patients harboring plasma 5-HT2AR autoantibodies at the baseline examination (n=13) did not differ significantly in their baseline clinical characteristics (age, education level) compared to TBI patients lacking baseline plasma autoantibodies (n=5). Plasma serotonin 2AR antibody-positive patients experienced a significantly greater post-baseline decline in performance on the St Louis University Mental Status test (P=0.0118) and in the Digit Symbol Substitution Test (P=0.011), but not in Trails-making Part B (P=0.129) compared to serotonin 2AR antibody-negative patients. In multivariable linear regression analyses that adjusted for age, baseline presence of plasma 5-HT2AR autoantibody was a significant predictor of the two-year rate of decline in memory, and processing speed. Binding of plasma autoantibody to the serotonin 2A receptor peptide in the enzyme linked immunosorbent assay was also significantly higher (at 1/160th titer of the protein-A eluate= 1 μg/mL IgG) in TBI patients harboring vs. those not harboring baseline plasma 5-HT2AR autoantibodies. These data suggest that plasma 5-hydroxytryptamine 2A receptor autoantibodies which were increased in approximately two-thirds of middle-aged and older adults following traumatic brain injury predicts rapid and substantial declines in cognitive function (memory and processing speed), independent of age.

Correlations between cerebrospinal fluid biomarkers, neurocognitive tests, and resting-state electroencephalography (rsEEG) in patients with HIV-associated neurocognitive disorders

HIV-associated neurocognitive disorders (HAND) are highly prevalent in people living with HIV (PLWH) despite successful treatment with combination antiretroviral therapy (cART). HAND pathogenesis is complex and definitive surrogate biomarkers are not clearly defined. Brain function has been assessed through the evaluation of cortical source rhythms with delta waves associated with neurological impairment. The aim of this study was to assess the correlation between EEG cortical sources, cerebrospinal fluid (CSF) biomarkers, and neurocognitive tests in PLWH with HAND. PLWH with HAND without significant comorbidities were enrolled. Baseline rsEEG-LORETA waves, CSF biomarkers (t-tau, p-tau, β-amiloid42, neopterin, S100β), and neurocognitive tests were correlated and compared through non-parametric tests (Spearman's rho and Mann-Whitney); data are presented as medians (interquartile ranges). Fifty-four patients were enrolled. Median time of suppressed HIV-RNA and CD4+ T-lymphocyte were 10years (5.5-15) and 691/uL (477-929). Thirty-nine participants (72%) underwent CSF collection: abnormal biomarkers were found in a small percentage. Only neopterin showed a statistically significant correlation with delta activity [parietal (rho 0.579; p < 0.001), occipital (rho 0.493; p = 0.007), and global sources (rho 0.464 p = 0.011)]. Seven patients (12.9%) showed an abnormal neopterin level (> 1.5ng/mL) with significantly higher delta source activity compared to the ones with in-range concentrations. We observed a statistically significant correlation between working memory test Trail Making B with both CSF neopterin levels and delta waves (p values < 0.05). In a small sample of PLWH with HAND, we observed that higher CSF neopterin levels were associated with higher EEG delta waves and worse working memory tests.

Impact of Psychiatric Illnesses and Selective Serotonin Reuptake Inhibitor Medications on Baseline Neurocognitive Testing.

Neurocognitive tests are an integral component of sport-related concussion (SRC) workup. A history of psychiatric illness (HPI) is common among young athletes. Investigations of factors that influence athletes' baseline neurocognitive function are crucial for an accurate assessment of SRC. In this study, we aim to elucidate the effect of HPI and selective-serotonin reuptake inhibitor (SSRI) medication use on baseline neurocognitive performance in young athletes. We conducted a retrospective cross-sectional study of Immediate Post-Concussion Assessment and Cognitive Testing assessments. A total of 268 athletes with HPI and a control group of 6,364 athletes were included. The outcomes were total symptom score based on post-concussion symptom scale, verbal memory, visual memory, visual motor, reaction time, and impulse control scores with self-reported HPI status and SSRI use. Athletes with HPI had an elevated symptom score in both univariate analysis (p < .0001) and multivariate analysis (p < .0001). HPI influence on visual memory score was not robust to multivariate analysis (p = .24). Athletes with HPI who reported SSRI medication use had the same baseline neurocognitive performance as other athletes with HPI. HPI influences athletes' baseline neurocognitive performance by elevating symptom scores. HPI does not alter any of the objective neurocognitive composite scores in contrast to previous work. Clinicians should consider the impact of HPI on baseline neurocognitive performance during the assessment of a suspected SRC. Additional research is required to bolster our findings on SSRI use and ascertain the effects of other drug classes on baseline neurocognitive performance.

Brain amyloid accumulation possibly exacerbates concurrent mild cognitive impairment with subthreshold depression in older adults: A 1-year follow-up study

BackgroundThis study aimed to investigate the 1-year changes in neuropsychological test results in older adults with concomitant late-life depression (LLD) and mild cognitive impairment (MCI) according to the presence or absence of brain amyloidopathy. MethodsAll subjects underwent 18F‐florbetaben‐positron emission tomography and a standardized neuropsychological battery. The subjects were divided based on brain amyloidopathy and severity of depressive symptoms into the following groups: LLD-MCI-A(+), subthreshold depression (STD)-MCI-A(+), major depressive disorder (MDD)-MCI-A(+), LLD-MCI-A(-), STD-MCI-A(-), and MDD-MCI-A(-). After one year, follow-up neurocognitive tests were conducted. Fifty-nine participants completed both the baseline and 1-year follow-up neurocognitive tests. ResultsIn the LLD-MCI-A(+) group, the word list recall and word list recognition scores decreased during the follow-up period. The STD-MCI-A(+) group also showed a significant decrease in word list recall score and the score/Z-score of word list recognition. On the other hand, the word list recall Z-score improved at the 1-year follow-up in the LLD-MCI-A(-) group. In particular, the MDD-MCI-A(-) group showed significant increases in word list memory score/Z-score and word list recall Z-score during the follow-up period. LimitationsConsidering that AD progresses slowly, a longer follow-up period may be required. ConclusionsOur findings showed differences in the extent of change of neuropsychological test results depending on the severity of depressive symptoms and presence or absence of brain amyloidopathy. Our results suggest that clinicians might explore the underlying neuropathology when assessing older adults with concomitant depression and cognitive impairment, even if the symptoms of depression are not severe.

SPORT TYPE AND BASELINE NEUROCOGNITIVE SCORES AMONG HEALTHY HIGH SCHOOL ATHLETES

Background:Athletes who participate in collision sports may experience more repetitive head impacts than other sport types. These repetitive head impacts have been theorized as a potential catalyst for cognitive problems later in life. It is unknown, however, if sport type influences neurocognitive performance.Hypothesis/Purpose:Our purpose was to investigate the association between sport type and baseline neurocognitive scores in a high school athletic population. We hypothesized that athletes participating in collision sports would demonstrate worse scores on baseline neurocognitive tests compared to those in contact or non-contact sports.Methods:We conducted a cross-sectional, observational study using baseline computerized neurocognitive scores of 186,117 high school student-athletes (age: 15.47±2.28 years, height: 168.53±10.77 cm, weight: 63.02±14.83 kg, 45% female) in the state of Massachusetts. The dependent variables were five composite scores (verbal memory, visual memory, visual motor, reaction time, and impulse control) and total symptom score. The independent variables included sport type (collision, contact, non-contact), age, sex, and concussion history. We used univariable one-way ANOVAS to compare composite scores between sport type. We conducted a series of multivariable regression models, controlling for age, sex, and number of previous concussions, to examine the independent association between sport type and composite scores.Results:There was a minimal but statistically significant association between sport type and composite scores, with collision sport athletes performing slightly worse than other athletes on most composite scores. Collision sport athletes had a slightly lower symptom burden. (Tables 1 and 2)Conclusion:While statistically significant, the differences in neurocognitive function and symptom burden between sport type are of questionable clinical significance. In fact, all of them fall within the reliable change index values of each respective score. As participants were in high school at the time of the study, we cannot determine the potential for associations later in life.Tables/Figures:

Sport Contact Level Affects Post-Concussion Neurocognitive Performance in Young Athletes.

Contact level affects the incidence of sports-related concussion. However, the effects of contact level on injury severity and recovery are less clear and are the focus of this study. Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) for athletes aged 12-22 was performed at baseline (n=10,907 for 7,058 athletes), after suspected concussion determined by physicians or athletic trainers (n=5,062 for 4,419 athletes), and during follow-up visits (n=3,264 for 2,098 athletes). Athletes played contact/collision (CC), limited contact (LC), and noncontact (NC) sports. Injury incidence, severity, and recovery were measured using raw and change from baseline neurocognitive test scores. Comparisons between groups used univariate analysis and multivariable regression controlling for demographic variables. Compared to CC athletes, LC and NC athletes showed decreased suspected concussion incidence. At initial post-injury testing, all neurocognitive test scores were similar between groups except changes from baseline for processing speed were improved for LC compared to CC athletes. Upon follow-up testing, raw neurocognitive scores were better for NC compared to the contact collision athletes in verbal memory, processing speed, total symptom score, migraine cluster, cognitive cluster, and neuropsychiatric cluster scores. For change from baseline scores, LC athletes exhibited better performance on verbal memory, processing speed, and reaction time but also showed higher neuropsychiatric scores than CC athletes. Neurocognitive scores between contact levels were similar at the first post-injury test. However, follow up showed many improved scores and symptoms for limited and NC sports compared to CC sports, which may indicate faster recovery.

Do Learning Disorders Impact Clinical Measures Following Concussion?

Evaluate differences in clinical testing following concussion between adolescents with no history of learning disorder (LD) and those with a history of dyslexia and/or ADD/ADHD. Learning disorders, such as ADHD, can affect ImPACT® baseline neurocognitive testing. The effect that ADHD has on other clinical measures is less well understood. Additionally, limited data exists on the effect of dyslexia on these measures. Data were prospectively collected from participants enrolled in the North Texas Concussion Registry (ConTex). Participants ages 10-18 years old, diagnosed with a concussion sustained within 30 days of enrollment were included and assessed for self-reported history of LD type (dyslexia and/or ADD/ADHD). Clinical findings examined included symptom scores (derived from SCAT5™), ImPACT®, King-Devick (KD) test, patient health questionnaire 8(PHQ-8) scores, and generalized anxiety disorder 7(GAD-7) scores. Mann-Whitney tests were used to compare groups. In total, 1,298 participants were included: 58 with dyslexia, 158 with ADD/ADHD, 35 with both (dyslexia and ADD/ADHD), and 1,047 with no LD. There was no difference in age, sex, time since injury, or history of concussion apart from the ADD/ADHD group, which had more males (p < 0.001). The dyslexia group had slower mean KD time (p = 0.011) and increased error scores (p = 0.028). In those with ADD/ADHD, impulse control scores on ImPACT® were significantly higher (p = 0.007), but no other ImPACT® score differences reached significance. PHQ-8 and GAD-7 scores were significantly higher in those with ADD/ADHD (p < 0.001). Participants with both dyslexia and ADHD demonstrated slower KD times (p = 0.009) and had higher PHQ-8 (p < 0.001) and GAD-7 (p = 0.001) scores. Participants with dyslexia and/or ADD/ADHD had worse scores on commonly used concussion clinical measures including ImPACT® impulse control, KD testing, and depression and anxiety screenings. Understanding the differences in these groups will aid providers in their evaluation and assist in counseling families regarding the injury.

The Ability of Baseline and Normative Neurocognitive Testing to Identify Cognitive Impairments Following Concussion: A Critically Appraised Topic

Focused Clinical Question: In a high school, college, and professional athletic population, does individualized baseline tests increase the diagnostic accuracy (e.g., sensitivity and specificity) of identifying cognitive impairments when utilizing neurocognitive testing compared to normative data? Clinical Bottom Line: There was insufficient evidence to definitively suggest the use of individualized baseline data over the use of normative data during a postinjury assessment.

The Relationship Between Neurocognitive Function and Biomechanics: A Critically Appraised Topic.

Clinical Scenario: Neurocognitive performance may put individuals at a greater risk for lower-extremity musculoskeletal injuries. Research has observed the relationship between lower-extremity musculoskeletal injury and baseline neurocognitive performance; however, the understanding of this relationship is lacking. Exploring this relationship may give further insight into musculoskeletal injury and provide innovative directions for musculoskeletal injury prevention. Clinical Question: Is there a relationship between neurocognitive performance and lower-extremity biomechanics during a jumping or cutting task in healthy adult athletes? Summary of Key Findings: The literature was searched for articles that examined the relationship of a baseline neurocognitive test and a biomechanical analysis following a sports-related task. A total of 3 cross-sectional articles were included. All 3 studies concluded that poorer neurocognitive performance was associated with biomechanical faults that are linked to increased risk or rate of lower-extremity musculoskeletal injury. Clinical Bottom Line: Based on the evidence included, there is a moderate-level evidence to support the relationship between neurocognition and lower-extremity biomechanics in healthy adult athletes. Strength of Recommendation: In accordance with the van Tulder approach, there is a moderate level of evidence due to consistent findings from a combination of high- and limited-quality articles.

A-28 Updated Baselines Show Improvement, Even When Athletes Sustain A Concussion Between Assessments

Abstract Objective To explore change across repeated baseline assessments using raw scores and percentile scores, for athletes sustaining and not sustaining a concussion between baselines. Method Athletes (12–23 years) completed two valid, baseline neurocognitive test sessions using ImPACT. Participants were divided into independent groups based on having sustained a concussion between annual baselines (CONCUSSION; N = 269) or no concussion (NO CONCUSSION; N = 270) between baselines. Raw change scores were calculated between the first and follow-up baseline for both groups by subtracting the first baseline score from the updated baseline score on the four ImPACT composite scores. Age- and gender-based percentile scores were then applied for all participants, and percentile change scores were calculated in the same manner. Raw change scores and percentile change scores between groups were compared using 4 ANOVAs with a Bonferroni-corrected p-value of (p &amp;lt; .0125). Results Using raw scores ANOVAs revealed that athletes in the CONCUSSION group showed significantly greater improvement on follow-up testing than athletes in the NO CONCUSSION group on Verbal Memory (p &amp;lt; .001) and Visual Motor Speed (p = .001), but not on Visual Memory (p = .41) and Reaction Time (p = .04). Using percentile ranks, ANOVAs revealed significantly greater improvement in CONCUSSION group on Verbal Memory (p &amp;lt; .001), but not on Visual Memory (p = .34), Visual Motor Speed (p = .03), or Reaction Time (p = .014). Conclusions Athletes sustaining a concussion between annual baseline assessments show increases on Verbal Memory and Visual Motor Speed follow-up testing when using raw composite scores, but only on Verbal Memory when using age- and gender-based percentile ranks.

Carotid Endarterectomy Is Associated With Postoperative Neurocognitive Improvement in Both Symptomatic and Asymptomatic Patients

While stroke after carotid endarterectomy (CEA) is rare, magnetic resonance imaging shows that “silent” microinfarctions after surgery are much more common. These microinfarcts have been correlated with neurocognitive decline. However, there is also evidence that revascularization may improve overall cognition due to improved cerebral blood flow and elimination of embolic source. As part of a trial of remote ischemic preconditioning as a possible neuroprotective mechanism during CEA, we examined the overall impact of carotid revascularization on cognitive function. This is an interim noncomparative analysis of the cohort enrolled in an institutional randomized trial for the role of remote ischemic preconditioning for CEA (RIP-CEA, NCT02808754). All patients underwent baseline neurocognitive testing using the Montreal-Cognitive Assessment (MoCA) and National Institutes of Health Toolbox (Flanker Inhibitory Control and Attention Test, the Dimensional Change Card Sort Test, and the Pattern Comparison Processing Speed Test). These tests specifically assess executive function and processing speed. MoCA was also conducted on postoperative day 1 in the hospital. The full neurocognitive testing battery was conducted again at the 1-month follow-up in the office. Score changes from baseline were examined at the follow-up time points. Eighty patients with a mean age of 71.3 ± 7.1 years (65% male, and 30% symptomatic) were enrolled. The average baseline MoCA score was 24.7 ± 2.8 and this was similar between symptomatic and asymptomatic patients (P = .6). Forty-seven percent of patients met criteria for cognitive decline (MoCA < 26) at baseline. While MoCA scores remained unchanged immediately postoperatively, patients experienced significant improvements in MoCA scores by 1 month after CEA (average MoCA score of 26.3 and only 26% qualifying as cognitive decline; P < .001). Similarly, patients experienced significant improvements in executive function (26.4 ± 4.7 months before CEA vs 28.3 ± 2.3 1 months after CEA; P < .001) and processing speed at 1 month after CEA (31.8 ± 9.2 months before CEA vs 35.8 ± 8.4 1 months after CEA; P < .001) as assessed by the National Institutes of Health toolbox. There was no difference in the number or degree of cognitive improvement between symptomatic and asymptomatic patients. Statin use was a significant predictor of improvement on MoCA score at 1 month (OR, 3.9; P < .05). Carotid revascularization with CEA is associated with significant improvements in neurocognitive function by one month post operatively across multiple domains. Statin use may be further protective. Longer term follow-up is needed to see the magnitude and durability of these cognitive improvements. Neurocognitive improvement following CEA may justify reconsideration of the role of carotid revascularization in asymptomatic patients.

Disparities in baseline neurocognitive testing for student concussion management in Massachusetts high schools.

PurposeThere is evidence of socioeconomic disparities with respect to the implementation of student-sports concussion laws nationally. The purpose of this study was to examine school sociodemographic characteristics associated with the provision of computerised baseline neurocognitive testing (BNT) in Massachusetts (MA) high schools, and to assess whether the scope of testing is associated with the economic status of student populations in MA.MethodsA cross-sectional secondary analysis of surveys conducted with MA athletic directors (n=270) was employed to investigate school characteristics associated with the provision of BNT. Correlation and regression analyses were used to assess whether the scope of testing is associated with the economic status of student populations in MA.ResultsThe scope of BNT was independently associated with the economic disadvantage rate (EDR) of the student population (β=−0.02, p=0.01); whether or not the school employs an athletic trainer (AT) (β=0.43, p=0.03); and school size (β=−0.54, p=0.03). In a multivariable regression model, EDR was significantly associated with the scope of baseline testing, while controlling for AT and size (β=−0.01, p=0.03, adj-R2=0.1135).ConclusionAmong public high schools in MA, disparities in the provision of BNT for students are associated with the economic characteristics of the student body. Schools that have a greater proportion of low-income students are less likely to provide comprehensive BNT. The clinical implications of not receiving BNT prior to concussion may include diminished quality of postconcussive care, which can have short-term and long-term social, health-related and educational impacts.

The ability of CNS vital signs to detect coached sandbagging performance during concussion baseline testing: a randomized control trial

ABSTRACTObjective: Despite widespread use of baseline neurocognitive testing in concussion management, suboptimal performance due to sandbagging still readily occurs without detection. The purpose of this study is to determine CNS Vital Signs validity indicator accuracy in detecting coached sandbagging compared to controls.Method: We compared rates of invalidity and domain composite scores for neurocognitive test performance between two groups of twenty-five college-aged students (age = 20.8 ± 1.1 years, range 18–25, 48% female) completing CNS Vital Signs instructed to either 1) give their best effort (control) or, 2) give suboptimal performance (sandbag). The sandbagging group was given standardized instructions on how to sandbag without detection. All participants rated their effort after completing on a Visual Analog Scale (0–100 mm).Results: Built in invalidity indicators successfully identified 68.0% of sandbaggers, while only 12% in the control group presented with invalid scores. Participants in the sandbagging group on average reported significantly lower effort (sandbag: 51.0 ± 21.0, control: 86.0 ± 12.0, p < .001)Conclusions: Built-in CNS Vital Signs validity indicators have an overall high accuracy in identifying those attempting to purposefully sandbag and are comparable to other computerized neurocognitive tests. Given that 32% of intentional sandbaggers went undetected, clinicians should consider additional safeguards to detect these individuals at baseline.

Influence of Test Environment, Age, Sex, and Sport on Baseline Computerized Neurocognitive Test Performance

Background: Baseline computerized testing is a common component of concussion assessments, and the testing environment has been suggested to influence test performance and validity. Purpose: To compare concussion baseline computerized neurocognitive test performance and validity among adolescent athletes based on testing environment (group, individual), age group (10-12, 13-15, 16-18 years), sex (male, female), and sport type (collision/combat, contact, noncontact). Study Design: Cohort study; Level of evidence, 3. Methods: Through a concussion community outreach program, participants completed baseline computerized neurocognitive testing using Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). A total of 2845 athletes aged 10 to 18 years completed the baseline assessment. A total of 2241 (79%) athletes completed baseline testing in a group environment, and 604 (21%) completed testing in an individual environment. A random subsample of 500 athletes from each group was selected for statistical comparison. Results: No significant differences were supported in baseline computerized neurocognitive test performance between the group and individual administration environments. Test validity was statistically similar across testing environment, age group, and sex. However, patients of older age (16-18 years), female sex, and collision/combat and contact sports performed better on ImPACT. There were differences in total symptom severity scores (t = 2.19, df = 998, P = .03), with participants in the group testing environment reporting lower total symptom severity scores than those in the individual testing environment. The rates of invalid tests were low across all age groups, averaging from 4.0% in the 10- to 12-year age group to 4.8% in the 13- to 15-year age group. Conclusion: The findings indicated that concussion baseline neurocognitive test performance is similar when administered in group and individual testing environments. However, differences based on age group, sex, and sport type should be considered when interpreting baseline computerized neurocognitive test scores. The finding of higher symptom scores in older adolescents in the individual testing environment suggests that they may be less forthcoming about symptoms in a group setting.

The effects of socioeconomic status on baseline neurocognitive testing scores

Baseline neurocognitive testing has been recommended to provide a more accurate representation of the pre-concussion cognitive status of individual athletes. Socioeconomic status is not typically controlled for when obtaining baseline scores, which may lead to inaccurate findings if post-injury scores are compared to normative data. Understanding the role of socioeconomic status in baseline testing is important for the accurate analysis of test scores and proper evaluation of patients if individualized baseline data are not available. Our purpose was to investigate the effects of socioeconomic status, as determined by eligibility for free or reduced cost lunch on baseline neurocognitive test scores in secondary school athletes. 1,788 secondary school athletes (females = 778, males = 1,010, age = 14.96 ± 1.11 years, height = 171.25 ± 17.83 cm, mass = 66.82 ± 21.63 kg) completed the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) upon starting scholastic athletics. ImPACT components (symptom severity scores and composite scores of verbal memory, visual memory, visual motor speed, and reaction time) served as the dependent variables. School administration coded free or reduced cost lunch eligibility (N = 1255 not eligible, N = 563 eligible) for each participant (group), which served as the independent variable. Free or reduced cost lunch eligibility significantly altered the combined dependent variables (multivariate F 5,1780=14.41, p < .001, ɳ2 = .04) when sex and age were controlled. Follow up ANOVAs showed that participants eligible for free or reduced cost lunch scored significantly worse on verbal memory (F 1,1784 = 24.81, p < .001, ɳ2 = .01), visual memory (F 1,1784 = 24.90, p < .001, ɳ2 = .01), and visual motor speed (F 1,1784 = 50.54, p < .001, ɳ2 = .03). In addition, slower reaction times (F 1,1784 = 35.10, p < .001, ɳ2 = .02) and higher symptom severity scores (F 1,1784 = 10.37, p < .01, ɳ2 = .01) were observed in those eligible for free or reduced cost lunch. If normative data are used instead of individual baselines, potential modifiers such as socioeconomic status should be taken into account when analyzing concussion scores to provide accurate diagnoses.