Neuropsychological deficits in patients with persistent symptoms six months after mild head injury.

There is much debate on the nature and duration of cognitive deficits and postconcussive symptoms (PCS) after mild head injury. Most studies performed so far have compared head-injured patients with subjects who had not suffered a concussion, instead of directly comparing patients with and without persistent PCS. The present study examined whether patients with PCS (n = 9) about 6 months after an uncomplicated mild head injury performed less well on selected neuropsychological tests than patients with mild head injuries who did not have PCS (n = 9) and healthy controls (n = 9). Patients with PCS were individually matched with controls for the time elapsed after the injury, age, sex, and education. We found that patients with PCS performed less well on tests of divided and selective attention than both patients without PCS and healthy controls. It is concluded that cognitive deficits may be present up to 6 months after mild head injury when symptoms persist. The findings indicate that patients with mild head injury and subjective symptoms may manifest demonstrable cognitive deficits.     

Late neurobehavioural symptoms after mild head injury

The present study examined whether patients (n= 11) with post-concussional symptoms (PCS) 12-34 months after mild head injury (MHI) performed less well on selected neuropsychological tests than patients with MHI without PCS (n = 11) and healthy controls (n= 11). Patients with PCS were individually matched with controls for the time elapsed after the injury, age, sex, education and IQ. There were no overall gross differences between the groups in cognitive functioning, except for an isolated deficit on a sustained attention task. Post-hoc analysis of results obtained with two behavioural rating scales showed that patients with higher ratings on a post-concussive/cognitive complaints scale performed less well on a sustained attention task than subjects with lower ratings.     

Acute cerebral perfusion CT abnormalities associated with posttraumatic amnesia in mild head injury

Posttraumatic amnesia (PTA) is a common symptom following traumatic brain injury. Although this transient memory deficit implies specific impairment of higher brain function, the actual pathophysiology of PTA is not well understood. The aim of this study was to assess regional cerebral hemodynamics with perfusion computed tomography (CT) in patients during PTA following mild head injury compared to patients with resolved PTA. A total of 74 patients with mild head injury without structural abnormalities on a non-contrast CT scan were included and compared to 25 healthy controls. Two patient groups were defined: (1) a PTA group that was scanned during the episode of PTA (n?=?34), and (2) a post-PTA group scanned after resolution of PTA (n?=?40). The PTA group had significantly reduced cerebral blood flow (CBF) in the frontal grey matter (41.78 [SD 7.4] versus 44.44 [SD 6.2] mL ? 100?g?1 ? min?1, p?=?0.023), and caudate nucleus (44.59 [SD 6.2] versus 47.85 [SD 7.7] mL ? 100?g?1 ? min?1, p?=?0.021), compared to the post-PTA group. Thus in patients with mild head injury, PTA is associated with cerebral perfusion abnormalities in specific cortical and subcortical regions.     

Objective documentation of traumatic brain injury subsequent to mild head trauma: multimodal brain imaging with MEG, SPECT, and MRI

OBJECTIVE: To determine to what extent magnetic resonance imaging (MRI), single photon emission computed tomography (SPECT), and magnetoencephalography (MEG) can provide objective evidence of brain injury in adult patients with persistent (>1 year) postconcussive symptoms following mild blunt head trauma. DESIGN: A retrospective and blind review of imaging data with respect to the presence of specific somatic, psychiatric, and cognitive complaints. SETTING/PARTICIPANTS: Thirty complete data sets (with MRI, SPECT, MEG, and neuropsychological testing results) were collected between 1994 and 2000 from the MEG programs at the Albuquerque VAMC and the University of Utah. MAIN OUTCOME MEASURES: MRI data were evaluated for focal and diffuse structural abnormalities, SPECT data for regions of hypoperfusion, and resting MEG data for abnormal dipolar slow wave activity (DSWA) and epileptiform transients. RESULTS: Structural MRI was abnormal for 4 patients. SPECT showed regions of hypoperfusion in 12 patients, while MEG showed abnormal activity in 19 patients. None of the imaging methods produced findings statistically associated with postconcussive psychiatric symptoms. A significant association was found between basal ganglia hypoperfusion and postconcussive headaches. For patients with cognitive complaints, abnormalities were more likely to be detected by MEG (86%) than either SPECT (40%) or MRI (18%) (P<.01). MEG also revealed significant (P<.01) associations between temporal lobe DSWA and memory problems, parietal DSWA and attention problems, and frontal DSWA and problems in executive function. CONCLUSIONS: Functional brain imaging data collected in a resting state can provide objective evidence of brain injury in mild blunt head trauma patients with persistent postconcussive somatic and/or cognitive symptoms. MEG proved to be particularly informative for patients with cognitive symptoms.     

Disseminated intravascular coagulation after isolated mild head injury

A rare case is described of acute disseminated intravascular coagulation (DIC) following isolated mild head injury with acute subdural haematoma, coagulopathy onset preceding craniotomy. Surgical treatment of the cause followed by swift diagnosis and treatment soon after surgery enabled a good outcome. Post-operative recollection of subdural and extadural blood was treated by further surgery. DIC following isolated mild head injury without axonal damage is rare, but fatal if missed. Thrombocytopaenia in head injured patients should be investigated expediently. Post-operative interim imaging (if not standard practice) should also be considered to exclude haemorrhagic recollection requiring further surgery.     

Early seizures after mild closed head injury.

The authors review the seizure incidence in 4232 adult patients with mild closed head injury who did not receive prophylactic anticonvulsant agents. One hundred patients (2.36%) experienced seizures within 1 week after head injury; 43 of these (1.02% of the series) had seizures within 24 hours after trauma. Most of the seizures (84%) that developed during the 1st week after injury were of the generalized tonic-clonic type. The incidence of generalized tonic-clonic seizures was higher than that of partial seizures with motor symptoms both within 24 hours (91% vs. 9%) and during the Day 2 to 7 period (79% vs. 21%). No definite intracranial pathological findings were detected by computerized tomography (CT) in 53% of patients with early posttraumatic seizures; six patients had intracranial hemorrhage without intracranial parenchymal damage (three with epidural hematoma and three with subarachnoid hemorrhage). The most common positive CT findings in the early posttraumatic-seizure group were intracerebral hemorrhage (24%), followed by acute subdural hematoma with intracerebral hemorrhage (17%). Intracerebral parenchymal damage could be identified on CT scans in 41 (48.8%) of 84 patients with generalized tonic-clonic seizures and five (31%) of 16 patients with partial seizures with motor symptoms. The intracerebral parenchymal damage was most commonly detected in the frontal lobe (21%) and the temporal lobe (19%). Seven patients with early posttraumatic seizures received emergency craniotomy to remove an intracranial hematoma (epidural in three, subdural and intracerebral in four) because the mass effect resulted in significant midline shift as seen on CT scans. This review suggests that early posttraumatic seizures after mild closed head injury have a high incidence (53%) in patients with normal CT scan findings. Although the possibility of surgically correctable intracranial hemorrhage is low (7%), the condition may be devastating if not treated properly.     

Diagnosis of mild head injury and the postconcussion syndrome

Mild head injuries can cause acute transient cognitive inefficiency that typically resolves within 3 months. Postconcussion syndrome may initially be related to acute cerebral dysfunction but can also arise as a psychological consequence of head trauma. The syndrome persists beyond 3 months in a significant number of patients with mild head trauma as a psychological disorder. International Classification of Diseases diagnostic criteria for postconcussion syndrome are currently recommended for clinical purposes. These criteria are contrasted with research diagnostic criteria used in the Diagnostic and Statistical Manual of Mental Disorders. The differential diagnosis of persistent cognitive and postconcussive symptoms in forensic practice is reviewed.     

Necessity of monitoring after negative head CT in acute head injury

Objective

The main objective of this study was to evaluate the incidence of delayed complications in acute head injury (HI) patients with an initial normal head computed tomography (CT).

Materials and methods

This retrospective study included 3023 consecutive patients who underwent head CT due to an acute HI at the Emergency Department (ED) of Tampere University Hospital (August 2010–July 2012). Regardless of clinical injury severity, the patients with a normal head CT were selected (n = 2444, 80.9%). The medical records of these patients were reviewed to identify the individuals with a serious clinically significant complication related to the primary HI. The time window considered was the following 72 h after the primary head CT. A repeated head CT in the hospital ward, death, or return to the ED were indicative of a possible complication.

Results

The majority (n = 1811, 74.1%) of the patients with a negative head CT were discharged home and 1.1% (n = 27) of these patients returned to ED within 72 h post-CT. A repeated head CT was performed on 12 (44.4%) of the returned patients and none of the scans revealed an acute lesion. Of the 632 (25.9%) CT-negative patients admitted to the hospital ward from the ED, a head CT was repeated in 46 (7.3%) patients within 72 h as part of routine practice. In the repeated CT sample, only one (0.2%) patient had a traumatic intracranial lesion. This lesion did not need neurosurgical intervention. The overall complication rate was 0.04%.

Conclusion

In the present study, which includes head injuries of all severity, the probability of delayed life-threatening complications was negligible when the primary CT scan revealed no acute traumatic lesions.     

Relative risk of deterioration after mild closed head injury

Summary In this prospective study, a series of 1812 consecutive mild head injured adult patients who visited the hospital emergency department were assessed. Twenty-eight patients (1.5%) deteriorated after head injury; 23 of these (1.3% of the series) required surgical intervention. Five patients (0.3%) deteriorated due to non-surgical causes [post-traumatic seizure 2, syndrome of inapproapriate secretion of antidiuretic hormone (SIADH) 3]. Most of the deterioration occurred within the first 24 hours (57%). Post-traumatic headache was found in 280 patients (15.5%) and 84 patients (4.6%) suffered post-traumatic vomiting.The relative risk is calculated. Age over 60, presence of drowsiness, focal motor weakness, post-traumatic headache and vomiting has increased risk of deterioration (p < 0.001). This study suggests that post-traumatic headache and vomiting deserve more clinical attention rather than being considered as post-traumatic syndrome only.     

颅脑外伤后持续性植物状态的影像预测与对策

持续性植物状态(persistent vegetatitve state,PVS)是一种持续生存而无意识的状态,可发生在颅脑外伤后.本院自1996年10月至2002年10月,共收治颅脑外伤1547例,其中22例呈PVS.笔者对外伤后不同时期的影像学特点进行了分析,现报告如下.     

Neuropsychological function 23 years after mild traumatic brain injury: a comparison of outcome after paediatric and adult head injuries

Primary objective: To the authors' knowledge no study comparing very long-term neuropsychological outcome after mild paediatric and adult traumatic brain injury (TBI) has been published. The primary objective of this study was to compare neuropsychological outcome 23 years after mainly mild paediatric and adult TBI.

Research design: The study was a neuropsychological follow-up 23 years after a prospective head injury study conducted at a Norwegian public hospital.

Methods and procedures: One hundred and nineteen patients were assessed with a comprehensive neuropsychological test battery. Of these, 45 were paediatric TBI and 74 were adult TBI.

Main outcomes and results: Both the paediatric and adult groups obtained scores in the normal range. In the paediatric group significant relationships were found between head injury severity and current neuropsychological function. The most important predictors of poor outcome were length of post-traumatic amnesia (PTA) and a combination of PTA and EEG pathology within 24 hours of injury. No influence of pre- and post-injury risk factors on current neuropsychological function was evident.

Conclusions: The findings indicate that children sustaining complicated mild TBI may be more vulnerable to development of chronic mild neuropsychological dysfunction than adults sustaining similar head injuries.