Behavioral Dysexecutive Syndrome Research Articles

Poststroke apathy: Major role of cognitive, depressive and neurological disorders over imaging determinants

Apathy occurs in approximately one third of people after stroke. Despite its frequency and functional consequences, the determinants of apathy have only been partially defined. The major difficulty lies in disentangling the reduction in activity due to apathy itself from those secondary to comorbidities, such as depression, sensorimotor deficits, and cognitive impairment. Here, we aimed to examine the prevalence of apathy, identify confounding sources of hypoactivity, and define its neuroimaging determinants using multivariate voxel lesion symptom-mapping (mVLSM) analyses.We assessed apathy in a subgroup (n = 325, mean age: 63.8 ± 10.5 years, 91.1% ischemic stroke) of the GRECogVASC cohort using the validated Behavioral Dysexecutive Syndrome Inventory, interpreted using GREFEX criteria, as well as confounding factors (depression, anxiety, severity of the neurological deficit, and gait disorders). mVLSM analysis was used to define neuroimaging determinants and was repeated after controlling for confounding factors.Apathy was present for 120 patients (36.9%, 95% CI: 31.7–42.2). Stepwise linear regression identified three factors associated with apathy: depressive symptoms (R2 = .3, p = .0001), cognitive impairment (R2 = .015, p = .02), and neurological deficit (R2 = .110, p = .0001). Accordingly, only 9 (7.5%) patients had apathy without a confounding factor, i.e., isolated apathy. In conventional VLSM analysis, apathy was associated with a large number of subcortical lesions that were no longer considered after controlling for confounding factors. Strategic site analysis identified five regions associated with isolated apathy: the F3 orbitalis pars, left amygdala, left thalamus, left pallidum, and mesencephalon. mVLSM analysis identified four strategic sites associated with apathy: the right corticospinal tract (R2 = .11; p = .0001), left frontostriatal tract (R2 = .11; p = .0001), left thalamus (R2 = .04; p = .0001), and left amygdala (R2 = .01; p = .013). These regions remained significant after controlling for confounding factors but explained a lower amount of variance.These findings indicate that poststroke apathy is more strongly associated with depression, neurological deficit, and cognitive impairment than with stroke lesions locations, at least using VLSM analysis.

Exploring behavioural and cognitive dysexecutive syndrome in patients with focal prefrontal cortex damage

This study’s objectives were to characterize the frequency and profile of behavioral and cognitive dysexecutive syndromes in patients with focal prefrontal cortex damage and how these syndromes overlap. We also examined the contribution of the prefrontal brain regions to these syndromes. Therefore, thirty patients with prefrontal cortex damage and thirty control subjects were compared on their performances using the GREFEX battery assessing the dysexecutive syndromes. The results showed that combined behavioral and cognitive dysexecutive syndrome was observed in 53.33%, while pure cognitive dysexecutive syndrome was observed in 20% and behavioral in 26.67%. Also, almost all behavioral and cognitive dysexecutive disorders discriminated frontal patients from controls. Moreover, correlations and regression analyses between task scores in both domains of dysexecutive syndromes showed that the spectrum of behavioral disorders was differentially associated with cognitive impairment of initiation, inhibition, generation, deduction, coordination, flexibility and the planning process. Furthermore, the patterns of cognitive and behavioral dysexecutive syndrome were both predictors of impairment in daily living activities and loss of autonomy. Finally, frontal regions contributing to different dysexecutive syndromes assessed by MRI voxel lesion symptom analysis indicate several overlapping regions centered on the ventromedial and dorsomedial prefrontal cortex for both domains of dysexecutive syndrome. This study concludes that damage to the frontal structures may lead to a diverse set of changes in both cognitive and behavioral domains which both contribute to loss of autonomy. The association of the ventromedial and dorsomedial prefrontal regions to both domains of dysexecutive syndrome suggests a higher integrative role of these regions in processing cognition and behavior.

Phenotypes associated with MAPT duplications

AbstractBackgroundDuplication of the 17q21.3 region, leading to increased MAPT expression, causes a rare atypical early‐onset dementia (EOD) mimicking Alzheimer’s Disease (AD) clinical presentation. Since our initial report in 2016, the same duplication has been identified in additional patients including 2 progressive supranuclear palsy (PSP) patients. It remains unclear whether MAPT duplication‐associated phenotypes are purely cognitive and if clinical and neuroimaging data are suggestive of a pure tauopathy or an amyloid plus tau underlying pathology.MethodWe report in this study clinical and paraclinical data from 10 MAPT duplication carriers, including 8 with a clinical EOD presentation and two recently identified during the screening of a series of PSP cases. All clinical data were collected as well as family history, neuropsychological assessment, 3D‐structural MRI (n = 7 patients), fluorodesoxyglucose‐PET (n = 5), DaTSCAN SPECT (n = 2), Amyloid‐PET (n = 3) and Tau‐PET (n = 2). Six patients had AD cerebrospinal fluid (CSF) biomarkers measured. Results were interpreted following Amyloid/Tau/Neurodegeneration (A/T/N) classification.ResultAmong the 10 patients, 6 had a positive family history of EOD, with cosegregation in one family. In one of the 4 sporadic patients, we could demonstrate that the duplication occurred de novo. Mean age of onset was 50.4 years [37‐58]. Eight presented a pure cognitive decline with an initial episodic amnesic syndrome. A behavioral dysexecutive syndrome was found in 5 patients (50%). Two patients were diagnosed as PSP but no or minor extrapyramidal signs were found among the 8 cognitive patients, despite 2 DaTSCANS showing presynaptic dopaminergic denervation. MRI of 6 cases (86%) showed hippocampal and temporoparietal bilateral atrophy. All CSF biomarkers were T+ and N+. Amyloid CSF biomarkers were abnormal in 3/6, suggestive of A+, however all three had negative amyloid‐PET. Interestingly, both Tau‐PET imaging showed strong deposits of Tau pathology within mesiotemporal regions and mild frontal cortex uptake in one patient (Figure). The neuropathology of two patients is currently being examined and will be presented.ConclusionThis largest series of MAPT duplications carriers shows a heterogeneous expression with clinical and neuroimaging data suggesting mixed cortical and subcortical impairment with diverse clinical consequences. We will confront these data to the results of the neuropathological examinations.

Association Between Behavioral Dysexecutive Syndrome and the Health-Related Quality of Life Among Stroke Survivors.

AimBehavioral dysexecutive syndrome (BDES) is one common neuropsychiatric comorbidity after stroke. Despite evidences suggesting the adverse effect of BDES on the survivors’ outcome, little is known about the association between BDES and the health-related quality of life (HRQoL) among stroke survivors and how BDES impacts the HRQoL. This study aimed to address these questions.MethodsThis study included 219 patients with acute ischemic stroke consecutively admitted to a regional hospital in Hong Kong. BDES was defined as a Chinese version of the Dysexecutive Questionnaire (DEX) score of ≥20 assessed at three months after stroke. The HRQoL was assessed with the Chinese version of the Stroke-Specific Quality of Life (SSQoL) questionnaire encompassing 12 domains. Multivariate linear regression models were employed to examine the association between BDES symptoms and the SSQoL total and domain scores. Structural equation model (SEM) was further constructed to delineate the linking pathways linking BDES and the HRQoL.ResultsThe study sample compromised mainly older patients with mild to moderate ischemic stroke. Compared with patients without BDES, those with BDES exhibited poorer performances regarding with the summarized SSQoL (226.2 ± 18.8 vs. 200.3 ± 29.8, p < 0.001) and almost all domains. The BDES symptoms were independently contributed to the whole HRQoL (SSQoL total score) (β = −0.20, p = 0.002), specifically to the domains in personality (β = −0.34, p < 0.001), language (β = −0.22, p = 0.01), and work/productivity (β = −0.32, p < 0.001), after adjusting demographic and clinical characteristics in linear models. The impacts of the BDES symptoms on the HRQoL were mainly explained by the indirect path mediated by depression and anxiety (path coefficient = −0.27, p < 0.05) rather than physical disability, while the resting was elucidated by the path directly linking BDES to the HRQoL (path coefficient = −0.17, p < 0.05).ConclusionThe present study preliminarily demonstrated a potential association between BDES and a lower level of the HRQoL, predominantly in domains of personality, language, and work/productivityafter acute ischemic stroke. This study also offered insights into the underlying mechanisms linking BDES and the HRQoL, implicating that integrative psychological therapies were urged to achieve better HRQoL after stroke.

Theory of Mind Impairments Highlighted With an Ecological Performance-Based Test Indicate Behavioral Executive Deficits in Traumatic Brain Injury.

Background: In view of the recent literature, the negative impact of traumatic brain injury (TBI) on social cognition remains a debated issue. On one hand, a considerable number of studies reported significant impairments in emotion recognition, empathy, moral reasoning, social problem solving, and mentalizing or theory of mind (ToM) abilities in patients with TBI. On the other hand, the ecological validity of social cognition tasks is still a matter of concern and debate for clinicians and researchers.Objectives: The objectives of the present study were 2-fold: (1) to assess social cognition in TBI with an ecological performance-based test which focuses on ToM ability, and (2) to study the relationship between performances on this task and behavioral disorders. To this end, 47 patients with moderate to severe TBI in the chronic stage were assessed with a ToM task, the Movie for the Assessment of Social Cognition (MASC), a film displaying social interactions in natural settings and asking for an evaluation of the emotions, thoughts, and intentions of the characters. Behavioral disorders were assessed with the Behavioral Dysexecutive Syndrome Inventory (BDSI), a structured interview of an informant in assessing changes compared with previous behavior in 12 domains.Results: Patients were significantly less accurate in mental state attribution than a demographically matched group of 38 healthy control subjects. Significant others of patients also reported more behavioral executive problems than controls' relatives on most of the domains of the BDSI. In addition, social cognition performance in the MASC was significantly correlated with behavioral dysexecutive problems rated by proxies on the BDSI.Conclusions: This study is the first to find association between impairments in mentalizing abilities in the MASC and behavioral impairments in patients with TBI, confirming the added value of this ecological task and that the recognition of social signals is a key element for adequate behavioral functioning.

Prevalence and Clinical Correlates of Poststroke Behavioral Dysexecutive Syndrome.

BackgroundBehavioral dysexecutive syndrome (BDES) is a common phenomenon following stroke. To date, research has focused mainly on individual behavioral symptoms rather than a more comprehensive characterization of goal‐directed behavior in stroke survivors. This cross‐sectional study evaluated the prevalence and clinical correlates of BDES in Hong Kong stroke survivors.Methods and ResultsA total of 369 stroke survivors were recruited from a regional hospital at 3 months after their index stroke. Patients’ demographic and clinical characteristics were extracted from a comprehensive stroke database. BDES was measured with the Chinese version of the Dysexecutive Questionnaire. Four neurocognitive batteries assessed domains of cognitive executive functions. The prevalence of BDES 3 months poststroke was 18.7%. At that time point, the Hospital Anxiety Depression Scale and Mini‐Mental State Examination scores and the presence of depression were significant predictors of BDES in a multivariate logistic regression analysis. These parameters remained significant predictors of the Dysexecutive Questionnaire score in a linear stepwise regression analysis and together accounted for 28.5% of the variance. Current depression was predictive of the Dysexecutive Questionnaire score in patients with BDES, with a variance of 9.7%. Furthermore, compared with the non‐BDES group, patients with BDES exhibited poor performance‐based executive function in the Chinese version of the Frontal Assessment Battery and color trails, arrow, and category fluency tests.ConclusionsSymptoms of anxiety, current depression, and global cognitive function may be independent predictors of the presence and severity of BDES 3 months poststroke. Stroke survivors with BDES exhibit poor executive functioning, including goal maintenance and semantic memory.

P08.05 Cognitive impairment in patients with newly-diagnosed high-grade gliomas

Abstract BACKGROUND Cognitive dysfunction is frequent in patients with primary brain tumor, impairing attention, memory and executive function. It compromises functional independence, decision making capacity and psycho-social well-being. Cognitive functioning is highly correlated to disease progression and quality of survival, thus cognitive follow-up is essential in the management of the disease. Cognitive screening tools are often used, since a comprehensive battery may be time consuming and challenging for patients. The objective of this study was to identify a pattern of cognitive dysfunction in patients with newly-diagnosed high-grade gliomas and evaluate the sensitivity and specificity of the MoCA (Montreal Cognitive Assessment) as a cognitive screening tool in the clinical practice. MATERIAL AND METHODS We compared performances in tests of memory, action speed, visuospatial ability and executive function of 156 patients with newly-diagnosed WHO Grade III and IV gliomas, after surgery and prior to radiochemotherapy, to those of a group of healthy controls (n=1003). Relatives assessed behavior through a questionnaire of behavioral dysexecutive syndrome. A stepwise logistic regression was performed to select cognitive domains better discriminating patients from healthy controls and we tested the sensitivity and specificity of the MOCA using ROC curve analysis. RESULTS The stepwise logistic regression analysis identified the 3 following factors better discriminating patients from controls: TMT-B completion time (OR: 0.673; 95% CI: 0.511–0.886; p=0.0005), a verbal memory index (OR:0.507; 95% CI: 0.358–0.718; p=0.0001) and a behavioral dysexecutive score (OR:0.616; 95% CI: 0.468–0.812, p=0.001). Prevalence of cognitive-behavioral impairment was of 35.94%; 95% CI: 28.3 - 43.5. The ROC curve analysis for the assessment of the MoCA sensitivity and specificity in detecting impairment yielded 0.795 (95%CI: 0.714–0.875) for the MoCA raw score, and 0.804 (95%CI: 0.727 - 0.881) for the adjusted z score. The optimal discrimination was obtained for a raw score ≤ 25 (sensitivity of 0.526; specificity of 0.832). For the adjusted score, optimal discrimination value was observed with a -0.603 z score (sensitivity of 0.716; specificity of 0.768). CONCLUSION Cognitive impairment and behavioral dysexecutive syndrome is frequent in patients with newly-diagnosed high-grade glioma. The MoCA lacks sensitivity in screening cognitive impairment to discriminate patients from healthy controls in this setting, and a comprehensive neuropsychological assessment is still recommended.

A Prospective Open-Label Pilot Study of Transcranial Direct Current Stimulation in High-Functioning Autistic Patients with a Dysexecutive Syndrome

Background: Executive functions (EF) are often impaired in autism spectrum disorder (ASD). Such dysfunctions are associated with anxiety, depression, and a lack of autonomy. Transcranial direct current stimulation (tDCS) has been shown to enhance EF in healthy adults and clinical populations and to improve working memory − a component of the EF − in adults with high-functioning ASD (HF-ASD). We hypothesized that tDCS could improve the EF of HF-ASD patients. Such enhancement could improve their adaptive behaviors. Method: Eight patients with HF-ASD received 10 consecutive cathodal tDCS sessions (2 mA) over the left dorsolateral prefrontal cortex (F3) for 15 min each in an open trial. EF (with the Stroop test, Trail Making Test [TMT] A and B, Modified Wisconsin Card Sorting Test [mWCST], and Verbal Fluency Test) and behavioral dysexecutive syndrome (with the Behavioral Dysexecutive Syndrome Inventory and the Repetitive and Restricted Behaviour scale) were assessed before and 10 days after treatment. Results: This study showed significant improvement in initiation (TMT-A time: p = 0.018) and cognitive flexibility (TMT-B time: p = 0.009; letter Verbal Fluency Test: p = 0.017; mWCST total errors: p = 0.028) after tDCS. Regarding behavior, the hypoactivity of the patients improved, as well as their repetitive and restrictive behaviors. In addition, this noninvasive neurostimulation technique was well tolerated. Conclusions: Flexibility and initiation are the most impaired EF in autism. These are promising results which justify a randomized and placebo-controlled study in a wider population. If these results were confirmed by a randomized controlled trial, tDCS could be an easy and well-tolerated adjunctive treatment aiming to improve the quality of life and the autonomy of ASD patients.

Therapeutic options for behavioral disorders following traumatic brain injury: A regional cross-sectional overview

To give an overview of the management of behavioral disorders following traumatic brain injury (TBI) in a cohort of 129 patients, in post-acute period. This cross-sectional regional cohort study included 129 adults suffering from moderate-to-severe TBI, in post-acute period, and referred to medical or community-based facilities in our region. A structured interview of patients and proxies collected information regarding socio-demographic data and the ongoing interventions, including psychotherapy and medication. Psychiatric outcomes were assessed by the Hospital Anxiety and Depression scale (HADS), and behavioral disorders by the Behavioral Dysexecutive Syndrome Inventory (BDSI). Each type of intervention was expressed as the prevalence in percentage of the study sample. Chi 2 test, Fisher's exact test or Student's t -test were used to search an association between the type of intervention and behavioral disorders, living area, psychiatric outcomes, psychiatric history, or delay after TBI. Patients were predominantly young men (mean age 26 years and 76% males) having sustained traffic accidents (78%). Forty-four percent received no interventions; 33% received psychotherapy and 43% were on pharmacological medication. Twenty-three percent received medication alone with no other intervention. The prescribed medications were antidepressants (21%), neuroleptics (18%), anxiolytics (16%), mood stabilizers (14%) but no beta-blockers. Polypharmacy concerned 20% of patients. BDSI was completed for 120 patients and 85 (71%) presented current BDS. The main factor that was found to be associated with the different types of prescription was BDS. Patients with current BDS received more frequently interventions ( P = 0.004), psychotherapy ( P = 0.048), medications, all types combined ( P = 0.007), and antiepileptics mood stabilizers ( P = 0.037). Our study highlights that compliance with the current recommendations remains insufficient. Non-pharmacological interventions, like psychotherapy, are inadequately implemented, although they are recommended as a first line treatment. Medications are overused, especially neuroleptics. Recommended medications, such as mood stabilizers and beta-blockers, are poorly used.

Behavioral dysexecutive syndrome after stroke

Behavioral Dysexecutive Syndrome after Stroke Dysexecutive syndrome (DES) is defined as an impairment of executive functions constituting of two domains: behavioral dysexecutive syndrome (BDES) and cognitive dysexcutive syndrome (CDES) which are not accompanied always [1]. A growing body of studies demonstrated that BDES is a common post-stroke neuropsychiatric comorbidity. The prevalence of BDES in stroke survivors varies ranging from 3% to 25% possibly attributed to the lack of standardized diagnosis methods and variances in study sample and study mode.

Disability and cognitive disorder: 4 cases of dysimmune encephalities

Dysimmune encephalitis are neurologic diseases that are more and more diagnosed. Most of patients are young and active. Cognitive and behavior troubles can delay the diagnosis and can cause disability. Functional outcome is not routinely assessed. The aim of this study is to describe the activities and participation several months after the onset. Four cases have been handled in the same multidisciplinary rehabilitation unit. To assess the disability, we used the Glasgow outcome scale extended (GOS-E) at 6 to 12 months after onset. Return to vocational integration, fatigue (FSS), impact (SIP) and quality of life (SF36) were also assessed. 3 women and 1 man aged 25 to 64 at the onset. Diagnosis for dysimmune encephalitis took two to eight weeks. Patients were inpatients in our unit for 5 to 10 weeks. On admission, cognitive and behavioral dysexecutive syndrome, amnesic syndrome, attention disorders, seizures and sleep disorders were noted. Progress was always reported but not complete recovery. After discharge, more than 6 months after the first symptoms, GOS-e scored between 5 and 6. No patients had returned to work. Anxiety and cognitive trouble seem to be the more pronounced symptoms. Fatigue seems not to appear on the foreground. Dysimmune encephalitis can cause persistent neuropsychological impairments that can benefit from a PRM unit.

Executive Functions Deficits After Severe Traumatic Brain Injury: The GREFEX Study.

To assess the sensitivity of traditional neuropsychological tests and of a behavioral inventory of executive disorders in a large sample of patients with chronic severe traumatic brain injury. A total of 112 patients were compared with 780 healthy controls from a larger database. The GREFEX battery included 7 widely used tests and the Behavioral Dysexecutive Syndrome Inventory (proxy rating). A previously described statistical methodology was used, controlling for age, education, and gender. Summary scores were computed and performance was dichotomized on the basis of 5th percentile cutoffs from controls' z scores. The frequency of cognitive impairment was high (55.4%) but lower than that of behavioral changes (81.5%). Double dissociations were observed between cognitive and behavioral assessments. Behavioral changes exhibited larger effect-sizes as compared with cognitive impairments. Logistic regression analysis showed that 3 cognitive tests (verbal fluency, Stroop reading, and Trail Making Test-B) and 3 behavior z scores (hypoactivity, anticipation, and hyperactivity) best discriminated patients from controls. Behavioral changes were more frequent and severe than cognitive deficits, at least as assessed with traditional testing. The present results also suggest that a shortened battery may provide a rapid screening method with reasonable sensitivity to detect deficits of executive functions in patients with severe traumatic brain injury.

The Behavioral and Cognitive Executive Disorders of Stroke: The GREFEX Study.

BackgroundMany studies have highlighted the high prevalence of executive disorders in stroke. However, major uncertainties remain due to use of variable and non-validated methods. The objectives of this study were: 1) to characterize the executive disorder profile in stroke using a standardized battery, validated diagnosis criteria of executive disorders and validated framework for the interpretation of neuropsychological data and 2) examine the sensitivity of the harmonization standards protocol proposed by the National Institute of Neurological Disorders and Stroke and Canadian Stroke Network (NINDS-CSN) for the diagnosis of Vascular Cognitive Impairment.Methods237 patients (infarct: 57; cerebral hemorrhage: 54; ruptured aneurysm of the anterior communicating artery (ACoA): 80; cerebral venous thrombosis (CVT): 46) were examined by using the GREFEX battery. The patients’ test results were interpreted with a validated framework derived from normative data from 780 controls.ResultsDysexecutive syndrome was observed in 88 (55.7%; 95%CI: 48–63.4) out of the 156 patients with full cognitive and behavioral data: 40 (45.5%) had combined behavioral and cognitive syndromes, 29 (33%) had a behavioral disorder alone and 19 (21.6%) had a cognitive syndrome alone. The dysexecutive profile was characterized by prominent impairments of initiation and generation in the cognitive domain and by hypoactivity with disinterest and anticipation loss in the behavioral domain. Cognitive impairment was more frequent (p = 0.014) in hemorrhage and behavioral disorders were more frequent (p = 0.004) in infarct and hemorrhage. The harmonization standards protocol underestimated (p = 0.007) executive disorders in CVT or ACoA.ConclusionsThis profile of executive disorders implies that the assessment should include both cognitive tests and a validated inventory for behavioral dysexecutive syndrome. Initial assessment may be performed with a short cognitive battery, such as the harmonization standards protocol. However, administration of a full cognitive battery is required in selected patients.

Changes in weight after traumatic brain injury in adult patients: A longitudinal study

Although changes in weight have been reported after traumatic brain injury (TBI), their frequency and underlying factors are little known. Our aim was to determine the prevalence of weight changes and the associated factors during the recovery phase after TBI. Longitudinal follow-up of adults with TBI. Multivariate analysis was carried out on weight change, demographic data, dysexecutive syndrome, eating behavior, physical activity, therapeutic classes and metabolic complications. 107 patients (81 males/26 females), age 36 ± 13 yrs, baseline BMI 23.3 ± 3.9, followed for 38 (8-66) months, were included. In intensive care, patients lost a mean 11 ± 6 kg. End of follow-up, mean BMI was not different to pre-TBI BMI, but patients could be categorized in 3 groups: stable (30%), loss (28%, -8 ± 7 kg) and gain (42%, +9 ± 6 kg). Sex, age, severity of TBI, intensive care weight loss, physical activity, therapeutic classes and the occurrence of metabolic syndrome did not differ between the groups. Factors related to weight gain were hyperphagia, OR 4.5 (IC95%, 1.6-12.1) and presence of a dysexecutive syndrome, OR 2.5 (IC95%, 1.03-6.3). Factors related to weight loss were hypophagia, OR 4.1 (IC95%, 1.5-10.9) and higher pre-TBI BMI, OR 4.9 (IC95%, 1.7-14.0). Over a median period of 38 months, 42% of TBI patients gained and 28% lost weight. Factors associated with these changes were the presence of a behavioral dysexecutive syndrome for weight gain, oral food intake and initial BMI, which were inversely associated with weight at end of follow-up. These findings highlight the importance of evaluating the time course of weight changes and providing specific nutritional care.