HOW TO CONDUCT A NEUROLOGICAL ASSESSMENT (THE EXAMPLE CASE OF MARY)

A 17-year-old female named Mary has been referred to my office. She attends Latina High School and has always been popular with other kids, while also performing in the top of her class. One day during a social event with friends, they dared her to jump in a pool from a 2^nd story balcony. When she attempted to complete this dare, she lost her footing and ended up hitting her head on the side of the pool. Friends had to jump in and save her because she was unconscious and she was then rushed to a hospital where ICU and PET scans were given. The results indicated that she had obtained bruising and hemorrhaging in the tissues around her frontal lobes. The medical staff suspected that she may also have further injury and placed her on life support in ICU as a precautionary measure.

After approximately 2 hours, she awoke and started moaning incoherently, along with moving around the room in a restless manner, so she was examined by a neurologist. The results indicated that she could respond to strongly presented verbal and tactile stimuli on a normal cognitive level. Later that evening her overall level of responsiveness seemed to improve and by the next morning, she was able to recognize her parents along with express weak verbal communication. Mary then spent a week in the hospital where she was also scheduled for a 2^nd neurological follow-up that would occur one week from the time she was released. While, at home she seemed to recover with little to no obvious problems and was also cleared after returning for her neurological follow-up.

However, when Mary returned to school, she started experiencing issues with concentration, not being able to take notes as fast as she once could and remembering what her teacher said. She also stated that she was unable to complete an English assignment as fast as the other kids and felt extremely worn out by the end of the day. Since all of these issues had occurred, Mary said that she didn’t want to return to school, so her parents asked the hospital to offer further testing and assessment. The hospital then referred the family to my office. Therefore, in order to best assist Mary, I will need to determine which neurological testing and assessment methods may work best to identify any current cognitive deficits that she may be experiencing due to a TBI, followed by any recommendations for rehabilitation and prognosis of expected recovery.

Testing & Assessment

Normally, it’s best to complete a neurological assessment after a head injury because the scores can measure any cognitive and/or behavior deficits that may have occurred due to traumatic brain damage. When this occurs, the severity can range from having no observable injury with no sequelae, a mild TBI which is 20 minutes or less of unconsciousness, and moderate to severe TBI which may include post-concussional amnesia, along with an observable head or brain injury. When the latter occurs, a long-term course of recovery and rehabilitation will be required. Diagnosing and assessing the level of Mary’s possible TBI may also be difficult because it is depends on coup and contrecoup blows, along with unseen damage that can occur from diffuse axonal shearing.

Since, diagnosis and assessment may be difficult, it is important to choose which tools might work the best for each individual patient. There are also many techniques that can be used from the initial point of unconsciousness or coma until well beyond the time that the injury occurred. For example, one specific test that may have been used by the hospital staff to measure Mary’s initial level of unconsciousness is as follows:

Glascow Coma Scale – According to (Lezak, Howieson & Loring. 2004) this “can be used to describe all posttraumatic states of altered consciousness from the mildest confusional state to deep coma” (p. 719). In Mary’s case, she may have been scored based on whether she could do things like open her eyes, use comprehensible speech and obey commands that were given by hospital staff and family members. One major benefit of this technique is that it could have also been repeated during the early post-trauma period, to determine if there was any improvement in function when compared to her initial score. Since, she did awake after two hours in ICU that would have also been a good time to repeat this test and acquire new scores.

When completing a neuropsychological assessment, there are also several other techniques that I could use to measure Mary’s overall level of cognitive functions. Some of these functions may include working memory, attention, concentration, previous and current premorbid intelligence, achievement and cognitive speed. Specific tests that could also be used are as follows:

Trail Making Test A & B – This can be used to assess Mary’s level of scanning and visuomotor tracking, cognitive flexibility and divided attention. When administered to assess working memory and attention, it will be distributed in two separate parts which are identified as A and B. Part A will require Mary to first draw lines that connect consecutively numbered circles on a work sheet and Part B will require her to connect the same number of these circles on a different worksheet, while alternating between the two sequences. Mary will also be advised to connect these circles as fast as she can without lifting her pencil from the worksheet.

PASAT – This can also be used to assess Mary’s level of working memory and attention but overall, this test is very difficult. Therefore, I don’t believe that this is the best method for Mary because she may show invalid deficits with her working memory and attention due to possible lack of comprehension for difficult tasks.

STROOP – This can also be used to assess Mary’s working memory and attention along with performance of response inhibition, response conflict, and/or selective attention. Since, these additional functions can be measured the scores will also identify Mary’s overall level of concentration effectiveness.

Digit Symbol – This test is a symbol substitution task which can also be used to measure Mary’s current level of working memory and attention. I could acquire scores by asking Mary to fill in each blank space with whichever symbol might be paired with the number. Mary would also be advised to complete this process as fast and as accurately as possible. I would then determine her score based on how many squares she filled in correctly.

WRAT-READ – I could use this test in combination with previous school records and No-Child Left Behind Tests to measure Mary’s overall level of achievement. This is because according to (Lezak, Howieson & Loring. 2004), it provides “a better estimate of the lower ranges of the VSIQ” so it is more applicable to individuals who are at a higher risk of TBI” (p. 93).

NAART – Once, initial estimates of Mary’s pre-morbid level of intelligence is obtained by previous school and no child left behind records, I could then acquire comparable data by using The North American Adult Reading Test (NAART) which is also designed to estimate verbal intellectual ability. This is important because since Mary was in the top percentage of her class, the scores may determine whether she has reduced intellect and/or whether she is ready to re-enter school.

However, one major limitation is that it may need to be combined with other methods in order to measure more accurate estimates of verbal intellectual ability and/or premorbid abilities. Since this is the case and Mary is Latino, one alternative method that could be used is known as the American National Reading Test (ANART). This is more suited for ethnical diversity within the US and it also enhances pre-morbid estimates for verbal testing when compared to the NAART.  

WAIS-IV – I could also use the Wechsler Adult Intelligence Scale IV, to measure Mary’s overall level of intelligence. When using this test, I will acquire measurements via four index scores that represent major components, along with two broad scores. These are as follows:

1. Full Scale IQ (FSIQ) – This is a score that will identify Mary’s total performance of VCI, PRI, WMI, and PSI.

2. General Ability Index (GAI) – This is the score of six subtests which are included in the VCI and PRI. There are also 10 subtests within each of the four components and five supplemental subtests that can be measured, if needed. The four components are as follows:

1. Verbal Comprehension Index (VCI)

This includes: Similarities (subtest) - abstract verbal reasoning, Vocabulary (subtest) - learned, comprehension and verbal expression, Information (subtest) - general information that is acquired from culture, and Comprehension (supplemental) - abstract social conventions, rules and expressions. These scores will identify the overall cognitive degree of verbal comprehension that Mary is exhibiting.

2. Perceptual Reasoning Index (PRI)

This includes: Block Design (subtest) - spatial perception, problem solving, and visual abstract processing, Matrix Reasoning (subtest) - spatial/inductive reasoning, nonverbal abstract problem solving, Visual Puzzles (subtest) - spatial reasoning only, Picture Completion (supplemental) -how quickly one perceives visual details, and Figure Weights (supplemental) -analogical/quantitative reasoning. These scores will identify the overall cognitive degree of perceptual reasoning that Mary is exhibiting.

3. Working Memory Index (WMI)

This includes: Digit Span (subtest) - mental control, concentration and attention, Arithmetic (subtest) - concentration when manipulating mathematical problems, and Letter-Number Sequencing (supplemental) - attention, mental control and concentration. These scores will identify the overall cognitive degree of working memory that Mary has.

4. Processing Speed Index (PSI)

This includes: Symbol Search (subtest) - visual perception, visual analysis and scanning speed, Coding (subtest) - visual/motor coordination, motor/mental speed and visual working memory, and Cancellation (supplemental) - visual and perceptual speed. These scores will identify the overall cognitive degree of processing speed that Mary currently has.

Recommendations

Regardless, of which test method/s may be used, I believe that Mary will show some type of cognitive deficit within certain areas due TBI. This is because she is currently experiencing issues with remembering, concentration, not being able to take notes or complete an English assignment as fast as she once could, and fatigue at the end of the day. In general, it can also be difficult to offer rehabilitation for patients that experience cognitive deficits after TBI. However, in some cases, the patient may re-gain some or most of this lost ability when treated with a combination of medication and rehabilitation. Therefore, if assessment scores determine that Mary has reduced functioning with working memory, attention, concentration, previous and current premorbid intelligence, achievement and/or cognitive speed, along with fatigue, I will make the following recommendations: 

Working Memory - I would teach Mary ways to compensate for any existing memory problems and prescribe a medication that is used for Alzheimer’s to try and increase her current level.

Attention - I would recommend a modification to her classroom so there is less distraction when she is trying to learn or hear the teacher and request that her teacher offers friendly reminders. One other thing that I would do is refer Mary for special assistance classes in English. This way, she would have a less distracting environment in the subject that she is struggling in. This may also build an increased level of overall intelligence and achievement because she will get the additional academic services that are medically needed. If these things do not work over time to improve Mary’s level of attention, I would then prescribe medication that can improve attention.

Fatigue - Since, Mary is experiencing an issue with fatigue or low arousal, and cognitive speed, I would advise her to get plenty of sleep at night, increase her level of physical stimulation with light exercise, and prescribe a low dose stimulant medication. This way, it may increase her level of arousal and the rate at which she is currently able to complete assignments.

Prognosis

If it is confirmed that Mary is suffering from cognitive deficits due to TBI, it is difficult to predict what her long-term condition might be. However, since she initially awoke in the hospital after only 2 hours of unconsciousness and was able to verbally speak and follow commands, she may have a much easier time gaining back some or all of the cognitive abilities that have been lost. One other major advantage is that Mary is only 17 years of age. This is because when TBI occurs, it is often easier to heal and recovery when the patient is younger and in excellent health. Therefore, I am confident that Mary will do well, if she follows all recommendations on a regular basis, and has a good support system among family members, health professionals, and school staff.

Summary

A 17-year-old named Mary was referred to my office after suffering from an open head injury while jumping in a pool. Immediately, after the incident, Mary received ICU and PET scans that indicated that she had obtained bruising and hemorrhaging in the tissues around her frontal lobes. Since, this occurred she was also examined by a neurologist while in the hospital. The results indicated that she could respond to strongly presented verbal/tactile stimuli and she seemed to improve greatly during her week-long stay.

After returning home for two weeks, she also seemed to recover fully with little to no obvious problems, until going back to school. This is because after the first day, she told her parents that she couldn’t concentrate, take notes as fast as she once could or remember what her teacher said. She also stated that she was unable to complete an English assignment as fast as the other kids and felt extremely worn out by the end of the day. Since these issues occurred, Mary said that she did not want to return to school, so her parents asked the hospital to have her set up for further testing and assessment. After addressing several tests that may be used to assess Mary’s current level of cognitive deficit and possible TBI, I also discussed specific recommendations for rehabilitation and prognosis of expected recovery.

Reference:

Lezak, M., Howieson, D., & Loring, D. (2004). Neuropsychological Assessment (4^th ed.).

Oxford: Oxford University Press.