maeshima shinichiro

わが国における高次脳機能障害者に対する診療の広がりについて調査した。第1次調査は、高次脳機能障害者の有無、サービス内容などの基本的な情報を多くの施設から得ることとした。9割を超える施設に高次脳機能障害者がおり、認知症、失語症、半側空間無視などが多かった。失語症に対する言語訓練は過半数の施設で行われていたが、神経心理学的評価および認知リハビリテーションを行っている施設は半数に満たなかった。第2次調査は、各種の高次脳機能障害の種類別に施設の組織・規模、症例数、サービス内容、職種、言語・認知リハビリテーション、社会福祉制度の利用および社会復帰について調査した。失語症がもっとも多く、認知症、記憶障害などが続いた。失語症の言語治療とともに失語症以外の高次脳機能障害に対する認知リハビリテーションは広く行われていたが、就労支援、心理療法は十分普及していなかった。就労率は全般に不良であった。

We examined the communication between recovery rehabilitation hospitals and acute hospitals in terms of access to functional prognosis information of patients at discharge. We enrolled 240 stroke patients (153 men and 87 women) who used the local critical pathway in this study. Collection and completeness of used local critical pathways, physical and cognitive function at transfer, improvement in recovery rehabilitation hospitals, and final outcome were investigated. As results, 46 (22.5%) and 33 (16.2%) pathways were found to be incomplete in acute and recovery rehabilitation hospitals, respectively. Time to transfer to a recovery rehabilitation hospital was 29.5±14.2 days. Mean length of stay in a recovery rehabilitation hospital was 101.1±57.0 days. After discharge, 143 patients (74.5%) returned home, 13 (6.8%) entered a convalescent ward or hospital, 29 (15.1%) went to a nursing care facility, and 7 (3.6%) had other outcomes. There was obvious difference in mean length of stay and ADL improvement per day (FIM efficiency) among the referred recovery rehabilitation hospitals. In conclusion, all healthcare facilities using the local critical pathway need to have a common recognition of stroke rehabilitation. By using the local critical pathway network system, rehabilitation staff in acute hospitals should proactively contribute to the qualitative improvement of rehabilitation in stroke patients during the recovery period.

症例は62歳男性で、30年前より糖尿病を指摘されたが未治療で経過した。1年前よりインスリンを導入し、高血圧、急性心筋梗塞に対し経皮的冠動脈血管形成術を施行され、2枝病変に対しステントを留置された。3年前より記銘力低下を認め1年前よりメモ帳にに記載しないと忘れるようになった。3ヵ月前、右手脱力、右手の感覚異常を認めた。下肢の閉塞性動脈症の精査中に無名動脈の狭窄を指摘され受診した。意識清明で視力、視野、眼球運動に異常を認めず、脳神経系にも異常なかった。右手の軽度な筋力低下と感覚低下を認めた。高次脳機能障害で発症し、盗血現象を主体とする血行動態を呈した無名動脈狭窄症の1例で経皮的血管形成術が有用であった。

To assess the factors in stroke patients with severe disabilities affecting home return from a convalescent rehabilitation ward, we compared various factors in patients returning home (Home group) and those requiring long-term institutionalization (Institution group) as follows: age, severity of motor paresis and cognitive dysfunction, serial changes in their activities of daily living (ADL) level after admission, period of the admission, and number of family members. There was no difference in the ages, paresis and ADL score on admission between the two groups. The Mini-Mental State Examination (MMSE) scores in the Home group were significantly higher than those in the Institution group. The Home group had more family members and showed a significant increase in their ADL score 1 week after admission.

Epileptic seizures are one of the important clinical symptoms, and have the possibility to bring about various dysfunctions after cerebral stroke. Dysphagia is a common complication of stroke, but few investigators have discussed swallowing disorders in patients with poststroke epilepsy (PSE). We report the clinical features of swallowing function in PSE to clarify those relationships.<br>The study subjects were 15 patients (10 males and 5 females) with PSE, who were receiving rehabilitation on an inpatient basis. The age ranged from 59 to 95 years old and the underlying disease was cerebral infarction in all cases. The mean duration from stroke onset to seizures was 37.5±31.7 months. Patients were evaluated for swallowing function using bedside swallowing in the acute phase. Dysphagia based on the patient's type of diet and outcomes were assessed on discharge.<br>As results, 6 of 15 patients consuming a regular diet (including porridge) could return home on discharge, but 3 patients were nutritionally managed with a dysphagia diet and 5 patients with enteral feeding were referred to another hospital. One patient died.<br>In conclusion, up to 50% of patients with PSE had swallowing problems and it influenced their outcome. We suggest that careful correspondence is necessary for patients with PSE with evaluation for swallowing disturbance.

Background and Purpose: Most patients who have an internal carotid artery (ICA) stenosis with cerebral lesion have some cognitive dysfunction. To clarify the clinical efficiency of the Auditory Verbal Learning Test (AVLT) and to assess the relationship between AVLT and cerebral damage, we examined AVLT in patients with ICA stenosis.<br>Methods: 44 patients (35 males and 9 females) with ICA stenosis aged 56 to 83 (69.6±6.5) years old were evaluated. The educational periods were from 9 to 16 (12.3±2.8) years. Their activities of daily living (ADL) were independent. We assessed cognitive function with neurosychological tests including AVLT, Mini-mental State Examination (MMSE), Raven's coloured progressive matrices (RCPM) and Frontal Assessment Battery (FAB), etc. We assessed cerebral damage (periventricular high intensity; PVH and white matter hyperintensity; WMH) with MRI. Then, we investigated the relationship between AVLT and other neuropsychological tests, and the relationship between AVLT and carotid/cerebral lesion.<br>Results: There was no association with lesion side of ICA stenosis and the scores of AVLT. In patients with ICA stenosis and cerebral damage (PVH and/or WMH), there was a significant relationship between the severity of cerebral damage and the scores in AVLT. AVLT had a significant relationship to other neuropsychological tests.<br>Conclusions: AVLT might be a good cognitive assessment for patients who have cerebral damage due to ICA stenosis.