Search Results (159)

Background/Objectives: Single-sided deafness (SSD) impairs speech perception, reduces spatial hearing, decreases quality of life, and is frequently accompanied by tinnitus. Cochlear implantation (CI) has become an established treatment option, but long-term prospective evidence across multiple functional and psychological domains remains limited. This study investigated auditory performance, subjective hearing outcomes, tinnitus burden, and psychological well-being over a two-year follow-up in a large SSD cohort. Methods: Seventy adults with SSD underwent unilateral CI. Assessments were conducted preoperatively and at 6 months, 1 year, and 2 years postoperatively. Outcome measures included the Freiburg Monosyllable Test (FS), Oldenburg Inventory (OI), Nijmegen Cochlear Implant Questionnaire (NCIQ), Tinnitus Questionnaire (TQ), Perceived Stress Questionnaire (PSQ), Generalized Anxiety Disorder scale (GAD-7), and General Depression Scale (ADS-L). Longitudinal changes were analyzed using Wilcoxon signed-rank tests with effect sizes; Holm-adjusted p-values were applied for baseline-to-follow-up comparisons. Results: Speech perception improved markedly within the first 6 months and remained stable through 2 years, with large effect sizes. All OI subdomains demonstrated early and sustained improvements in subjective hearing ability. Several hearing-related quality-of-life domains assessed by the NCIQ, particularly social interaction, self-esteem, and activity participation, showed medium-to-large long-term improvements. Tinnitus severity decreased substantially, with marked reductions observed by 6 months and maintained thereafter; the proportion of tinnitus-free patients increased at follow-up, although tinnitus symptoms persisted in a substantial subset of participants. Perceived stress was reduced initially at the early follow-up and remained below baseline thereafter. Anxiety and depressive symptoms mostly stayed within nonclinical ranges, showing no lasting changes after adjusting for multiple comparisons. Conclusions: In this prospective cohort, cochlear implantation was associated with durable improvements in auditory outcomes, tinnitus burden, and selected patient-reported quality-of-life domains over two years. Although significant functional and patient-centered improvements were noted, persistent tinnitus and diverse psychosocial outcomes underscore the need for personalized counseling and comprehensive follow-up that incorporate patient-reported outcomes and psychological assessments. Full article

NF2-related Schwannomatosis (NF2-SWN) remains a disorder with few effective treatment options. Patients develop vestibular schwannomas (VSs) on both auditory nerves, which gradually impair hearing and often result in significant communication difficulties, social withdrawal, and higher rates of depression. Progress in understanding NF2-SWN biology and translating discoveries into therapies has been slowed by the absence of robust animal models that faithfully reproduce both tumor behavior and the associated neurological deficits. In this review, we summarized the development of animal models that not only reproduce tumor growth in the peripheral nerve microenvironment but also reproduce tumor-induced neurological symptoms, such as hearing loss and ataxia. We further highlight the currently available organotypic models for NF2-SWN. Together, these systems provide an essential foundation for advancing mechanistic studies and accelerating the development of effective therapies for this devastating disorder. Full article

Background: Sudden, non-traumatic hearing loss has been associated with vascular or inflammatory disorders. Hearing loss in Neuromyelitis optica spectrum disorder (NMOSD) is a very rare presentation. Methods: In this paper, we describe the case of a 58-year-old female patient with aquaporin-4-positive NMOSD exhibiting bilateral tinnitus and right-sided deafness in the context of a relapse. The auditory brainstem responses pointed to a lesion of the right peripheral auditory pathway (cochlea and/or auditory nerve). The patient’s hearing failed to improve after high-dose intravenous steroids; however, it showed slight improvement after plasmapheresis. We also conducted a systematic literature review in databases MEDLINE and Scopus in English, searching for all reported cases of hearing loss in NMOSD. Results: We included 10 studies reporting 15 cases of NMOSD with hearing loss. The vast majority of patients were female (11 out of 15, 73.3%), with an age range of 26 to 70 years. Hearing loss, ranging from mild to severe, seems more frequent in AQP4-positive cases, and it can even be the presenting symptom. It can present isolated or in combination with tinnitus, ataxia, and/or intractable vomiting. The auditory pathway impairment in NMOSD seems to be localized either centrally, i.e., cochlear nuclei or higher brainstem levels, or peripherally, i.e., in the cochlea or cochlear nerve itself. Intravenous methylprednisolone in high doses, followed by oral tapering, was the most common treatment option, resulting in a gradual improvement. Conclusions: This paper describes a rare case of peripheral auditory pathway affection in NMOSD, which is an inflammatory astrocytopathy mainly affecting the central nervous system. Early recognition of hearing loss in the context of an NMOSD relapse and subsequent treatment have a crucial impact on the hearing outcome of NMOSD patients. This expands our knowledge of NMOSD as an autoimmune aquaporin-4 channelopathy. Full article

Background: Rhythmic sensory stimulation, including structured musical interventions, has gained renewed interest as a non-pharmacological strategy that may modulate cortical excitability and network stability in focal epilepsy. Although several small studies have reported changes in seizure frequency or epileptiform activity during rhythmic or music exposure, the underlying mechanisms and translational relevance remain insufficiently synthesized. Objective: This narrative review summarizes clinical evidence on music-based and rhythmic sensory interventions in focal epilepsy, outlines plausible neurophysiological mechanisms related to neural entrainment and large-scale network regulation, and discusses emerging opportunities for digital delivery of rhythmic protocols in everyday self-management. Methods: A structured search of recent clinical, neurophysiological, and rehabilitation literature was performed with emphasis on rhythmic auditory, tactile, and multimodal stimulation in epilepsy or related conditions. Additional theoretical and translational sources addressing oscillatory dynamics, entrainment, timing networks, and patient-centered digital tools were reviewed to establish a mechanistic framework. Results: Existing studies—although limited by small cohorts and heterogeneous methodology—suggest that certain rhythmic structures, including specific musical compositions, may transiently modulate cortical synchronization, reduce epileptiform discharges, or alleviate seizure-related symptoms in selected patients. Evidence from neurologic music therapy and rhythmic stimulation in other neurological disorders further supports the concept that externally delivered rhythms can influence timing networks, attentional control, and interhemispheric coordination. Advances in mobile health platforms enable structured rhythmic exercises to be delivered and monitored in real-world settings. Conclusions: Music-based and rhythmic sensory interventions represent a promising but underexplored adjunctive approach for focal epilepsy. Their effectiveness likely depends on individual network characteristics and on the structure of the applied rhythm. Digital integration may enhance personalization and adherence. Rigorous clinical trials and mechanistic studies are required to define optimal parameters, identify responders, and clarify the role of rhythmic stimulation within modern epilepsy care. Full article

Background/Objectives: Hearing impairment in middle-aged adults is a significant, modifiable risk factor for cognitive decline and dementia, and therapy with hearing aids or cochlear implants has been suggested to reduce this risk. However, most research on auditory rehabilitation and cognition has focused on older adults, and evidence regarding cognitive outcomes in middle-aged adults remains scarce despite this group being identified as critical for dementia prevention. Thus, this study aimed to assess cognitive skills in middle-aged hearing-impaired individuals 1 year after receiving a cochlear implant (CI) as part of auditory rehabilitation. Methods: Thirty-two patients with a mean age of 52.4 were enrolled in a prospective pre-post study. Hearing was tested using the Freiburg Monosyllable Test (FS) and the Oldenburg Inventory (OI). Cognitive performance was assessed using the WAIS-IV, operationalized through the Working Memory Index (Digit Span, Arithmetic) and Processing Speed Index (Symbol Search, Coding). Quality of life was assessed with the NCIQ, tinnitus-related distress with the Tinnitus Questionnaire (TQ), and depressive symptoms with the ADS-L. Results: After one year, speech intelligibility (FS) improved from a median of 0 to 70.0 (Wilcoxon Z = −4.864, p < 0.001, r = −0.61), and subjective hearing from a median of 2.55 to 3.18 (Wilcoxon Z = −3.072, p = 0.002). The NCIQ score increased from 52.3 to 60.6 (Z = −3.899, p < 0.001), and tinnitus-related distress decreased from 25 to 21 (Wilcoxon Z = −2.209, p = 0.027). Depressive symptoms declined numerically, although this change did not reach statistical significance. Working memory improved from 82.0 to 89.0 (Wilcoxon Z = −4.090, p < 0.001), and processing speed from 89.5 to 95.5 (Wilcoxon Z = −2.533, p = 0.011). Before CI, WMI and PSI showed a strong correlation (ρ = 0.533, p = 0.002), and WMI correlated moderately with education level (ρ = 0.452, p = 0.012). One year after CI, correlations strengthened between PSI and NCIQ (ρ = 0.510, p = 0.006), PSI and OI (ρ = 0.400, p = 0.039), and WMI and TQ (ρ = –0.459, p = 0.021), indicating emerging associations between cognitive outcomes and auditory or psychosocial measures. Conclusions: One year of CI-based auditory rehabilitation improves auditory function, quality of life, tinnitus distress, and—critically—working memory and processing speed in middle-aged adults. These findings address a previously unfilled research gap and support the relevance of CIs for preserving cognitive health during midlife. Full article

Background/Objectives: Retrocochlear auditory dysfunctions (RADs), including auditory neuropathy (AN) and auditory processing disorders (APD), encompass disorders characterized by impaired auditory processing beyond the cochlea. This narrative review critically examines their distinguishing features, synthesizing recent advances in classification, pathophysiology, clinical presentation, and treatment. Methods: This narrative review involved a comprehensive literature search across major electronic databases (e.g., PubMed, Scopus) to identify and synthesize relevant studies on the classification, diagnosis, and management of AN and APD. The goal was to update the view on etiologies (genetic/non-genetic) and individualized rehabilitative strategies. Diagnosis relies on a comprehensive assessment, including behavioral, electrophysiological, and imaging tests. Rehabilitation is categorized into bottom-up and top-down approaches. Results: ANSD is defined by neural desynchronization with preserved outer hair cell function, resulting in abnormal auditory brainstem responses and poor speech discrimination. The etiologies (distal/proximal) influence the prognosis for interventions, particularly cochlear implants (CI). APD involves central processing deficits, often with normal peripheral hearing and heterogeneous symptoms affecting speech perception and localization. Rehabilitation is multidisciplinary, utilizing bottom-up strategies (e.g., auditory training, CI) and compensatory top-down approaches. Remote microphone systems are highly effective in improving the signal-to-noise ratio. Conclusions: Accurate diagnosis and personalized, multidisciplinary management are crucial for optimizing communication and quality of life. Evidence suggests that combined bottom-up and top-down interventions may yield superior outcomes. However, methodological heterogeneity limits the generalizability of protocols, highlighting the need for further targeted research. Full article

Background: Clinical practice suggests that objective assessment tools are needed to assess adults with inattention or hyperactivity, informed by the underlying pathophysiology of attention-deficit and hyperactivity disorder (ADHD). This systematic review comprehensively evaluates the current objective assessment methods as an adjunct diagnostic tool for these adults. Methods: We conducted a systematic review of studies investigating various objective diagnostic methods to assess adults with ADHD and healthy controls. The database search occurred from its inception to 23 December 2024. Results: Our search yielded 46 studies that reported on various objective methods to assess adults with ADHD. The MOXO-distracted Continuous Performance Test (MOXO-d-CPT), eye-tracker with MOXO-d CPT, Conners’ Continuous Performance Test—3rd edition (CCPT-3), and oculomotricity can differentiate between true and feigned ADHD or other diagnostic possibilities. The Quantified Behavior Test (Qb Test+) can detect hyperactivity and differentiate it from other psychiatric disorders. Mono-d, CCPT-3, Qb Test+, Test of Variables and Attention (TOVA), Integrated Visual and Auditory Continuous Performance Test (IVA-CPT), and oculomotricity can monitor pharmacotherapy response. Functional near-infrared spectroscopy (fNIRS) offers more promise than structural imaging and demonstrates a moderate level of sensitivity and specificity to differentiate adults with and without ADHD by performing the verbal fluency test. Notwithstanding, electroencephalography (EEG)/event-related potential (ERP) shows potential in diagnosis and treatment monitoring (e.g., neurofeedback training). In addition, transcriptome-based biomarkers have also been explored as diagnostic tools. Conclusion: The diagnosis and monitoring of ADHD in adults come with a unique set of challenges due to psychiatric comorbidity, including depression and anxiety; fluctuation of symptoms over time; and lack of consensus among clinicians and professional organizations to adopt objective tests in the diagnostic process. Our findings support the notion that a combination of clinical assessment and objective biomarkers targeting distinct pathophysiological aspects may enhance the accuracy of ADHD diagnosis. Full article

Background: Aural fullness is a common symptom in routine otolaryngological practice. Although it is most commonly attributed to cerumen impaction, other, less frequent conditions may present similar symptoms and are often initially misdiagnosed as cerumen. These include keratosis obturans (KO) and external auditory canal cholesteatoma (EACC). Accurate differentiation among these entities is crucial for appropriate management. These distinctions are crucial for appropriate management. Methods: We retrospectively reviewed 100 patients who presented with a chief complaint of aural fullness from 2021 to 2025. All patients underwent microscopic and/or micro/endoscopic otologic evaluation and were subsequently treated with outpatient otologic procedures. These procedures ranged from simple cerumen removal for CI cases to aural toilettage of the external auditory canal for KO and initial debridement attempts for EACC. Results: Among 100 patients, 87 were diagnosed with CI, 10 were diagnosed with KO, and 3 were diagnosed with EACC. In 97 patients, outpatient microscopic management was effective and successful, leading to the complete removal of the underlying condition and resolution of the ear fullness. In the remaining 3 cases—all diagnosed with EACC—microscopic outpatient debridement was not sufficient. These patients were subsequently scheduled for surgical intervention following audiological and temporal bone CT evaluations. Conclusions: Our findings confirm that CI is the most frequent cause of aural fullness and that microscopic outpatient removal represents an excellent standard of care. However, clinicians should remain aware that KO and EACC may present similar symptoms. Their management is often more complex, potentially requiring multiple sessions and, in the case of EACC, can necessitate surgical intervention. Accurate diagnosis is, therefore, essential to ensure effective and appropriate treatment. Full article

Background: Noise-induced hearing loss (NIHL) is one of the most common types of hearing impairment, even though it is preventable. However, awareness and protective behaviors among young adults remain limited. This study explored the knowledge, attitudes, and behaviors of young adults in Greece regarding exposure to high-noise environments and the risk of NIHL. Methods: A cross-sectional survey was conducted with 104 participants aged 18–30 years in Patras, Greece. A 27-item questionnaire was used to collect data on demographics, patterns of noise exposure, use of personal listening devices, auditory symptoms, and preventive behaviors. Descriptive statistics and chi-square tests were used to examine relationships between demographic variables and participants’ responses. Results: Most participants (93.3%) recognized that prolonged exposure to high noise levels can harm hearing. However, only 6.7% reported having regular hearing checks, and almost half (45.2%) had never been tested. Remarkably, 19.2% of participants experienced tinnitus, while more than half (54.8%) reported fatigue after exposure to loud sounds. Younger participants (aged 18–22 years) were significantly more likely to listen at high volumes compared to older groups (p < 0.05). Males reported higher rates of tinnitus and ear discomfort, whereas females more often experienced headaches. Although general awareness of NIHL was high, preventive behaviors such as using hearing protection were rarely practiced. Conclusions: These findings highlight the need for targeted educational campaigns and preventive screening programs to promote safe listening practices and reduce the overall prevalence of NIHL. Full article

Background and Objectives: To evaluate the surgical management and outcomes of lateral semicircular canal fistulas (LSCFs) in patients with middle ear cholesteatoma, focusing on hearing preservation and vestibular function. Materials and Methods: A retrospective study was conducted on nine adult patients diagnosed with LSCFs secondary to cholesteatoma who underwent surgery at a tertiary referral center between 2018 and 2024. The preoperative evaluation included otoscopy, audiometry, vestibular testing (HINTS), and high-resolution CT (HRCT) of the temporal bone. Surgical techniques included canal wall up (CWU) or canal wall down (CWD) mastoidectomy, depending on the disease extent. Cholesteatoma matrix removal from the fistula was performed carefully. Fistula closure involved layered grafts of temporalis fascia, temporalis muscle, and/or gelfoam. The postoperative follow-up included audiometry and vestibular assessments. Results: Nine patients with LSCFs were identified (one Type III, three Type IIb, and four Type I/IIa). Five patients were found to have additional disease complications intraoperatively, including facial nerve involvement and middle fossa dehiscence. Postoperatively, hearing outcomes varied, with some patients experiencing improvement, others demonstrating stable hearing, and some exhibiting further decline, particularly in cases with extensive disease. Vestibular symptoms, including vertigo, generally resolved postoperatively, although some patients required prolonged vestibular rehabilitation. Conclusions: LSCF management in cholesteatoma surgery requires a careful preoperative assessment, meticulous surgical technique, and individualized fistula closure based on the size and type. While hearing preservation remains a challenge, particularly in extensive cases, the “underwater technique” and layered grafting may contribute to minimizing further damage and promoting fistula closure. Vestibular rehabilitation plays a crucial role in managing postoperative balance issues. A long-term follow-up is essential to monitor for recurrence and assess both auditory and vestibular function. Full article

Background: Tinnitus has been increasingly reported during the COVID-19 pandemic, following both infection and vaccination. While these reports suggest that pandemic-related factors may influence the onset or worsening of tinnitus, the perceptual characteristics and functional consequences of such cases remain poorly understood. This study examined the nature, severity, and communication-related impact of self-reported tinnitus following COVID-19 vaccination. Methods: A total of 770 adults who self-reported new or worsened tinnitus after vaccination completed a structured online survey between August 2021 and May 2023. Standardized instruments included the Tinnitus Functional Index (TFI), the Speech, Spatial and Qualities of Hearing Scale (SSQ), and visual analog scales assessing loudness discomfort and hyperacusis-related symptoms. Analyses included descriptive statistics, chi-square tests, t-tests, and correlation matrices. Results: Respondents reported moderate to severe tinnitus-related distress, with the greatest impacts on emotional control, sleep, and relaxation. Many described communication difficulties in noisy or multi-talker environments, despite relatively preserved spatial hearing and sound quality. A substantial subset endorsed hyperacusis symptoms, including sound-induced annoyance, fear, and intolerance. Correlation analyses revealed strong associations between emotional, cognitive, and auditory domains, underscoring the multidimensional burden of tinnitus in this population. Conclusions: Self-reported tinnitus after COVID-19 vaccination was associated with distress, sleep disruption, and communication difficulties, mirroring patterns commonly observed in tinnitus more broadly. Although causality cannot be determined, these findings highlight the importance of comprehensive audiological and psychological assessment for individuals reporting auditory complaints after vaccination and support the inclusion of functional hearing outcomes in tinnitus evaluation protocols. Full article

Freezing of gait (FoG) is a common motor symptom in advanced Parkinson’s disease, leading to falls, disability, and reduced quality of life. Although cueing systems using visual or auditory stimuli can help patients resume walking, existing solutions are often expensive, uncomfortable, and conspicuous. ParCuR (Parkinson Cueing and Rehabilitation) is a compact, ankle-worn wearable integrating an inertial sensor, haptic stimulator, and AI-based software. It was developed to detect FoG episodes in real time and provides automatic sensory cues to assist patients with Parkinson’s Disease (PwP). A classifier was trained for FoG detection using the DAPHNet dataset, comparing patient-specific and patient-independent models. While a small-scale trial with PwP assessed usability and reliability. ParCuR is watch-sized (35 × 41 mm), discreet, and comfortable for daily use. The online detection algorithm triggers stimulation within 0.7 s of episode onset and achieves 94.9% sensitivity and 91.3% specificity using only 14 frequency-based features. Preliminary trials confirmed device feasibility and guided design refinements. This low-cost, wearable solution supports personalized, real-time FoG detection and responsive cueing, improving patient mobility while minimizing discomfort and continuous stimulation habituation. Full article

Objectives: Alexander disease (AxD) is a rare neurodegenerative disorder that represents a group of leukodystrophies with severe disability and premature death, mostly with an infancy/childhood onset. In rare cases of late-onset phenotypes, symptoms are often milder and difficult to diagnose. We present a diagnostic journey of a teenage male patient with a progressive gait disorder starting at the age of 13 years, with a final diagnosis of Alexander disease. Early in the course of the disease, the boy exhibited distinctive cognitive involvement and neuropsychological deterioration characterized by selective impairment of visual and long-term auditory memory, along with a decline in IQ but preserved reasoning abilities. Methods: The patient underwent an extensive neurological diagnostic workup, which included magnetic resonance imaging (MRI) of the brain, spine, and abdomen, as well as electrophysiological, metabolic, and biochemical tests. Numerous specialist consultations were conducted, including genetic, cardiology, ophthalmology, pulmonology, oncohematology, psychological, and speech–language pathology consultations. In addition, a focused literature review was performed using PubMed, Scopus, Web of Science, and Google Scholar with the search terms “Alexander disease,” “GFAP gene,” “late-onset,” “spastic paraplegia” and “GFAP variant p/Gly18Val”. Results: Whole exome sequencing revealed an extremely rare missense GFAP heterozygous variant NM_002055.5: c.54G>T (p/Gly18Val), confirming the diagnosis of AxD. Conclusions: The presented case highlights the importance of whole-exome sequencing in the diagnosis of unexplained otherwise neurological symptoms, such as progressive spastic paraplegia. Full article

Background/Objectives: The purpose of this study was to analyze changes in speech intelligibility, health-related quality of life, and the degree of comorbidities (depressive and anxiety symptoms and tinnitus-related distress) in a large cohort of 227 adults who underwent auditory rehabilitation with a cochlear implant (CI). The second goal was to identify the factors that influence the health-related quality of life in this cohort. Methods: Pre- and one-year post-CI data were collected on speech intelligibility (Freiburg Monosyllabic Test, FS), subjective hearing ability (Oldenburg Inventory, OI), health-related quality of life (Nijmegen Cochlear Implant Questionnaire, NCIQ), depressive symptoms (General Depression Scale, ADS-L), anxiety (Generalized Anxiety Disorder 7, GAD-7), perceived stress (Perceived Stress Questionnaire, PSQ), and tinnitus-related distress (Tinnitus Questionnaire, TQ). Results: The Wilcoxon matched-pairs signed-rank test showed significant improvements across the entire cohort in speech intelligibility, subjective hearing, and the quality of life. The scores indicating anxiety, depressiveness, perceived stress, and tinnitus-related distress decreased. The Spearman correlation showed that before implantation, quality of life positively related to subjective hearing, while depression, anxiety, stress, and tinnitus distress were negatively correlated. After a year, these links persisted but grew stronger. Regression analyses found subjective hearing (OI) as a positive predictor, and depression (ADS-L) and tinnitus distress (TQ) as negative predictors of life quality, especially in patients with low or median NCIQ scores. Conclusions: In a substantial cohort of adult patients with diverse CI indications, auditory rehabilitation enhances speech intelligibility and subjective hearing, improves health-related quality of life, and reduces the severity of depressive and anxiety symptoms, as well as tinnitus-related distress. Subjective hearing contributes positively to quality of life, whereas depressive symptoms and tinnitus distress negatively impact quality of life in patients with low NCIQ scores post-CI, highlighting the importance of monitoring and psychological intervention. Full article

Background/Objectives: Headache attributed to rhinosinusitis (HRS) is uncommon in children but often misdiagnosed as migraine or tension-type headache (TTH). Overlapping phenotypes, incidental sinus findings on neuroimaging, and limited communication in younger patients complicate diagnosis and lead to inappropriate treatment. Methods: We retrospectively analyzed 3065 pediatric patients (<19 years) presenting with headache at two tertiary neurology clinics (2014–2023) with ≥1 year follow-up. Headaches were classified by ICHD-3 criteria. HRS diagnosis required radiologic sinus pathology and ≥50% improvement within 72 h of antibiotic or decongestant therapy. Demographic, clinical, neuroimaging, and family history data were collected. Symptom profiling used principal component analysis (PCA) and k-means clustering; multivariate logistic regression identified independent predictors. Results: Of 3065 patients, 32.7% had migraines, 15.5% TTH, and 4.5% HRS. Nearly one-third of HRS cases were initially misclassified. Compared with migraine and TTH, HRS patients were younger (median 9 years), more often male, and enriched in preschool age. Independent predictors included shorter duration (<1 h; OR 0.62), higher intensity (OR 2.165), nasal symptoms (OR 9.836), hearing impairment (OR 22.52), allergic rhinitis (OR 8.468), and family history of HRS (OR 32.602) (all p < 0.001). PCA showed overlap but distinct clustering: HRS was characterized by sinonasal and otologic features, whereas migraine clustered around sensory hypersensitivity. Conclusions: Pediatric HRS shows distinct predictors—young age, acute severe headache, nasal and auditory symptoms, allergic history, and family history—despite overlap with migraine and TTH. Structured use of these predictors with otolaryngologic assessment may improve diagnostic accuracy, reduce misclassification, and avoid unnecessary neuroimaging or inappropriate therapy. Full article