title: Metacognition in stroke: bedside assessment and relation to location, size, and stroke severity.
abstract: BACKGROUND
  Frontal syndromes are poorly represented on stroke scales, yet may constitute an important component of the neurologic deficit impacting treatment and rehabilitation efforts.
  
  
  OBJECTIVE
  To validate an assessment of a frontal network syndrome score (FNSS) in stroke and to ascertain the relationship of the FNSS to lesion location, volume, and severity in young people with stroke.
  
  
  METHODS
  Accrual through a cognitive stroke registry of young, alert, nonaphasic, nonencephalopathic, nonsubstance abuse prone people who were tested with the 16 domain FNSS within 4 weeks of their stroke. Lesion location was determined by the Cerefy 3-dimensional, digital, coxial brain atlas identifying 6 regions of cerebral interest. Lesion severity was assessed by the National Institute of Health Stroke Score and infarct volume was measured in cubic centimeters.
  
  
  RESULTS
  From a sample of 456 cases in the registry after exclusions of encephalopathy, depression, and aphasia, cases with frontal network syndrome encompassed 132 of 341 persons (39%). Of these patients (n=80) with mean age 45.7 years [confidence interval (CI): 43.4, 48.1], educational level 13.1 years (CI:12.5, 13.6), mean National Institute of Health Stroke Score of 3.3 (CI: 2.6, 4.0), and mean lesion volume 30.3 mL (CI: 13.7, 46.9), had full testing with the FNSS battery yielding sensitivity (93%), specificity (74%), positive predictive value (79%), negative predictive value (90%), and a good interrater reliability (kappa=0.89, P=0.001). Construct validity testing with 15 frontal neuropsychologic tests revealed good to excellent significant Pearson r values in 14 of 15 of the tests. There was no correlation (Pearson's) for lesion volume (r=0.07, P=0.52) but significant correlation with stroke severity (r=0.23, P=0.03). Analysis of variance testing of the FNSS revealed significant differences for all 6 domains without intergroup significant differences for frontal network syndrome domains in the stroke group.
  
  
  CONCLUSIONS
  The FNSS is a valid, practical measure of frontal syndromes in stroke. Frontal syndromes are common in young people with stroke and may be present no matter where the lesion, are not dependent on size of stroke and have a low correlation with stroke severity.
authors.affiliation: Department of Neurology, Stroke Center, University of South Florida and Tampa General Hospital, 12901 Bruce B. Down's Boulevard, Tampa, FL 33612, USA. mhoffman@hsc.usf.edu
authors.forename: Michael
authors.initials: M
authors.lastname: Hoffmann
authors.forename: Frederick
authors.initials: F
authors.lastname: Schmitt
mesh_terms: D000293:Adolescent; D000328:Adult; D000704:Analysis of Variance; D003072:Cognition Disorders / Q000175:diagnosis* / Q000209:etiology / Q000473:pathology; D005260:Female; D005625:Frontal Lobe / Q000473:pathology*; D006801:Humans; D008297:Male; D008609:Mental Status Schedule; D008875:Middle Aged; D009434:Neural Pathways / Q000473:pathology; D009483:Neuropsychological Tests; D019095:Point-of-Care Systems; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D018709:Statistics, Nonparametric; D020521:Stroke / Q000150:complications* / Q000473:pathology; D013577:Syndrome