Post-traumatic stress disorder following minor and severe closed head injury: 10 single cases

Post-traumatic stress disorder (PTSD) was found to occur after minor or severe closed head injury in 10 single cases which are reported in detail. They were drawn from 312 cases of closed head injury who were referred for neuropsychological assessment or neurorehabilitation. All cases which had been given both diagnoses are presented. Information was collected retrospectively from case notes and reports. It is argued that a continuum of experience, which represents the entirety of an event, is not necessary for PTSD to occur, but that a 'window' of real or imagined experience which results from loss of consciousness and post-traumatic amnesia after closed head injury need not prevent the symptoms of PTSD from arising, although they may make them less likely and the phenomenon of the dual diagnoses relatively rare. The issue of whether PTSD found following closed head injury is a sub-classification of PTSD is raised.     

Is early prediction of outcome in severe head injury possible?

To determine whether the outcome of patients with severe head injury could be predicted early after presentation to the hospital, the records of 306 trauma patients with head injury and Glasgow Coma Scale scores of 10 or less were reviewed. There was poor correlation between initial scores at patient arrival and eventual outcome, while scores 6 hours after presentation correlated better with eventual outcome. Many patients with scores as low as 3 had good neurologic recovery. Patient age, associated injuries, blood pressure, mechanism of injury, presence of spontaneous ventilation, and computed tomographic findings all affected survival. However, considering even these parameters, statistical analysis could not provide sensitive prediction of outcome, which we defined as identifying those patients who eventually had good recovery. We conclude that initial therapy should be aggressive for patients with severe head injury, regardless of initial neurologic status, because accurate prediction of outcome within 6 hours of presentation is impossible.     

Predictive value of an early Glasgow Outcome Scale score: 15-month score changes

OBJECT: Does an early Glasgow Outcome Scale (GOS) assessment provide a reliable indicator of later outcome in a patient with traumatic brain injury (TBI)? The authors examined the utility of the GOS during early treatment as a predictor of outcome score 15 months postinjury by analyzing outcome score change in a group of patients with closed head injuries. METHODS: Glasgow Outcome Scale scores assessed within 3 months of injury (baseline) were compared with scores obtained at 15 months postinjury in 121 patients, primarily young military personnel. Score changes between baseline and 8 months postinjury were also studied in a subgroup of 72 patients. The impact of initial injury severity (determined by the duration of unconsciousness) on score change was also explored. The GOS scores at three time points within the 15-month period-baseline (within 3 months of injury), 8, and 15 months postinjury-were examined to ascertain when the maximal GOS score had been reached. CONCLUSIONS: Baseline GOS score was a reliable predictor of outcome in patients with an initial score of 5 (no disability) or 4 (mild disability), but not in patients with an initial score of 3 (severe disability). Patients who remained unconscious for more than 24 hours did not have significantly lower outcome scores than those who experienced loss of consciousness for less than 24 hours at 15 months postinjury. Interestingly, the duration of unconsciousness did not affect the likelihood of an improved score during the study period in patients with a GOS score of 3 or 4 at baseline. An updated evaluation conducted after the early phases of treatment is needed to provide a realistic prognosis of severe TBI.     

The utility of head computed tomography after minimal head injury

OBJECTIVE: To determine if patients who present with a history of loss of consciousness who are neurologically intact (minimal head injury) should be managed with head computed tomography (CT), observation, or both. METHODS: We prospectively studied patients who presented to our urban Level I trauma center with a history of loss of consciousness after blunt trauma and a Glasgow Coma Scale score of 15. All patients underwent CT of the head and were subsequently admitted for 24 hours of observation. RESULTS: A total of 1,170 patients with minimal head injury were studied during a 35-month period. All patients had Glasgow Coma Scale scores of 15 on arrival and had a history of either loss of consciousness or amnesia to the event. Two hundred forty-seven patients (21.1%) were intoxicated with drugs or alcohol on admission; 39 patients (3.3%) had abnormalities detected by CT, including 18 intracranial bleeds; 21 patients (1.8%) had changes in therapy as a direct result of their CT results, including 4 operative procedures. No patient with negative CT results deteriorated during the subsequent observation period. CONCLUSION: CT is a useful test in patients with minimal head injury because it may lead to a change in therapy in a small but significant number of patients. Subsequent hospital observation adds nothing to the CT results and is not necessary in patients with isolated minimal head injury.     

Falling down and falling out: management and outcome analysis

BACKGROUND: This study compares young (< 65 years old) and elderly (> or = 65 years old) patients who fall secondary to syncope and seeks to determine whether syncope workups are being appropriately performed and whether they contribute new information that results in a change in management. METHODS: A retrospective review of patients who fell and were admitted to a Level I trauma center was performed. Data included mechanism of injury, comorbidities, and severity scores in addition to details regarding a syncope workup in patients who had unclear reasons for falling. Outcome variables were mortality, intensive care unit and hospital lengths of stay, and whether each test resulted in a change in management. RESULTS: The data set included 387 patients. Elderly patients who fell (n = 157) had significantly higher Injury Severity Scores and mortality, lower Glasgow Coma Scale scores, and longer intensive care unit and hospital lengths of stay than the younger cohort (n = 230). When a fall occurred secondary to syncope, however, there was no difference in injury severity or outcome. Patients who fell secondary to syncope (n = 61) had zero to six of the recommended tests ordered. Nineteen tests in the young group and 79 tests in the elderly patients had abnormal results. Overall, 37.8% of patients had specific interventions performed because of the abnormal test results CONCLUSION: Syncope workups were erratically performed in both young and older groups. These workups frequently resulted in abnormal findings that required intervention. Protocols are currently being developed at our institution to ensure complete assessment of trauma patients who fall for unknown reasons.     

Auditory brain stem responses in the prognosis of late postconcussional symptoms and neuropsychological dysfunction after minor head injury

Thirty patients suffering from minor head injury were examined with auditory brain stem responses (ABR), neuropsychological tests for assessment of higher nervous functions, and a questionnaire on postconcussional symptoms. Comparison of the 6 patients with altered ABR with the other 24 showed no statistical difference in either the number of long-lasting postconcussional symptoms or the scores on neuropsychological tests. Subclinical brain stem involvement as shown by ABR does not seem to correlated with impaired mental function or symptoms of the postconcussion syndrome. This greatly limits the use of ABR in forensic medicine.     

Elderly patients with severe head injury in coma from the outset--has anything changed?

Advancing age is known to be a determinant of outcome in head injury. We have sought to discover whether there has been any change in the outcome of elderly patients with severe head injury in Newcastle, where these patients have continued to be treated with maximum intervention. A review of prospectively collected data from the Newcastle Head Injury Database for the period 1990 to 2000 was carried out. All patients aged 70 years and above who had sustained a severe head injury (Glasgow Coma Score of 8 or less from the outset) were included. The Glasgow Outcome Score (GOS) was determined at 6 months. Seventy-one patients were identified. Fifty-seven (80%) died and 2 (3%) were in a vegetative state, 11 (16%) had severe disability, 1 (1%) had moderate disability and no patients made a good recovery. The natural history of this condition remains unchanged and due consideration should be given to this when evaluating interventions for elderly patients with a severe head injury.     

The long-term outcome of head injury: Implications for service planning

As most of those experiencing traumatic brain injury tend to be young, disabled survivors will be gradually accruing in each locality as each year passes. How many need continuing care a decade after injury? How many need day care, or need help with finding work, or continuing support for carers? 190 patients who had been admitted to two UK regional neurosurgical units on average some 7 years earlier were followed up. With an average age of 29 years these patients stayed in hospital for an average 33 days. At follow-up 23% were classified as having moderate disability or worse on the Glasgow Outcome Scale, including 7.4% who had died subsequent to discharge. Survivors were given a neuropsychological assessment and a socioeconomic interview. Of the survivors, 17% had failed to make a good recovery, but 36% were failing to occupy their time in a meaningful way. Age over 30 at time of injury, not occupied before injury, and above-average length of stay were some of the predictors for failing to occupy time. Quality of life was severely curtailed for those who could not occupy their time, as was the case for their carers. Appropriate counselling, vocational evaluation and family support in the early years following injury may help to improve quality of life for both the head-injured person and their carers.     

Head injury as a risk factor in Alzheimer's disease

Several case-control studies have reported head injury to be more common among patients with Alzheimer's disease (AD) than healthy elderly controls. The present study sought to determine whether milder head injury is also a risk factor for AD. Furthermore, it was hypothesized that head injury would be more common among AD patients without a genetic risk for the disease. History of head injury in 68 consecutive cases of probable or definite AD and 34 non-demented control subjects was ascertained from their spouses. Head injury was reported in 20 of the AD patients (29%), and in only one control subject (2.9%) (odds ratio = 13.75). Twenty per cent of the familial and 43.5% of the sporadic AD cases reportedly had a premorbid head injury (odds ratio = 3.08). Head injury had no effect on age of dementia onset. The results indicate that head trauma may be a predisposing factor to AD, particularly in the absence of a clear genetic contribution.     

Long-term neuropsychological outcome after severe head injury with good recovery

The quality of outcome after severe closed head injury has become of increasing concern to neurosurgeons. The assessment of residual deficits in patients who have recovered from closed head injury can be very difficult. Many patients are classified as having a good recovery according to the Glasgow Outcome Scale (GOS), but this may be insufficiently focused or sensitive to demonstrate mental deficits objectively. We investigated 33 patients with severe closed head injury who subsequently were diagnosed as having made a good recovery according to the GOS. The severity of the injury was determined by the Glasgow Coma Scale (GCS) and by the presence of a midline shift in the preoperative CT scans. There was a minimal interval of 15 months (x= 1080-5 days, SD = 491 days) between injury and time of neuropsychological testing. Their performance was compared with that of 15 orthopacdic cases. Residual neuropsychological deficits can be demonstrated on the majority of measures in a group of patients who have achieved good recovery on the GOS. Midline shift in preoperative CT scans is not of prognostic value for long-lasting neuropsychological deficits.     

Impact of skull fracture on neuropsychological functioning following closed head injury

The role of skull facture in affecting morbidity following closed head injury (CHI) has received a significant amount of attention from researchers. While there is fairly widespread agreement that skull fractures increase the risk of complications such as haematoma, it us unclear whether the presence of skull fracture has predictive value in terms of the neuropsychological sequelae of CHI. The purpose of the current study was to further investigate the role of skull fracture in predicting neuropsychological dysfunction following CHI. Subjects included patients admitted to the trauma service of a large teaching hospital who were suspected of having suffered CHI. All patients completed neuropsychological testing and had normal computerized tomography (CT) scans. Patients who had suffered skull fracture were compared to those who had not suffered skull fracture on selected neuropsychological measures. Groups did not differ in terms of CHI severity as assessed by the Glasgow Coma Scale (GCS). Multivariate analysis of variance revealed that the groups did differ in terms of neuropsychological functioning. Results are interpreted as suggesting that the presence of a skull fracture is predictive of additional neuropsychological dysfunction, even in the absence of intracranial pathology or more severe disturbance of consciousness on the GCS.     

Complications of preinjury warfarin use in the trauma patient

BACKGROUND: The frequency of use of warfarin anticoagulation increases significantly in the elderly population. It remains controversial whether this puts these patients at increased risk for hemorrhagic complications after trauma. METHODS: We prospectively evaluated consecutive trauma patients who were taking warfarin and compared their outcomes to a group of age-matched patients with head injuries but not taking warfarin. RESULTS: One hundred fifty-nine trauma patients on warfarin were evaluated, 94 (59%) with some type of head trauma; 25 of these 94 patients (27%) had documented intracranial trauma. Fifteen patients died (9.4%); they had an international normalized ratio of 3.3 +/- 1.6 versus 3.0 +/- 2.1 for survivors in the warfarin group (p = 0.585). Twelve deaths were in the group of 25 patients with intracranial injuries (48%). Three patients without head injury died (5%) of other causes not related to warfarin or hemorrhage at a mean of 13 days after admission. Ten of 12 patients on warfarin with intracranial injuries who died had documented loss of consciousness (LOC); two patients who died secondary to an isolated intracranial injury had no LOC. Of 70 age-matched patients with head trauma not taking warfarin, 47 (67%) had intracranial injury and 5 of these died (10%) (p < 0.001 for both values compared with study patients). There were no significant differences for patients with intracranial injury comparing those on warfarin and those who were not in terms of age, gender, mechanism of injury, Injury Severity Score, or Glasgow Come Scale score. CONCLUSION: We conclude that the preinjury use of warfarin does not place the trauma patient at increased risk for fatal hemorrhagic complications in the absence of head trauma. Furthermore, the presence of a head trauma alone is not predictive of mortality. However, the presence of intracranial injury is strongly associated with a mortality rate that is significantly higher than patients with head trauma who are not taking warfarin. LOC is also associated with mortality, but the absence of loss of consciousness does not reliably indicate the absence of intracranial injury or risk of death.     

Head injury mortality in a geriatric population: differentiating an "edge" age group with better potential for benefit than older poor-prognosis patients

A comparison of outcomes between different modes of head-injury treatment in the elderly has important bearing on questions of cost-effectiveness and medical ethics. Here, we have examined rates of mortality in elderly head-trauma victims to determine whether it is valid to differentiate an "edge" age group of younger elderly patients, 65-74 years of age, from older elderly patients, considering possible benefit from intensive treatment and surgical intervention. We collected data from 1926 cases of head trauma and separated them into three age groups: 14-64 years, 65-74 years, and 75 years or older. We then compared these groups with respect to cause of injury, severity of injury, and whether or not treatment included either admission to an Intensive Care Unit (ICU) or surgical intervention. We found that road traffic accidents were the major cause of head injury in the younger age group, whereas in the elderly falls predominated. Mortality was higher in the elderly in all the head injury severity subgroups. Young subjects with a Glasgow Coma Scale (GCS) score of less than or equal to 8 tended to benefit from ICU treatment whereas patients 75 and over did not, regardless of their severity of injury. For these patients who were in the 65-74 age group, the data suggested that some benefit was likely. Patients 75 and older were significantly less likely to survive surgical intervention than younger patients. We conclude that it is valid to treat patients in the age group 65-74 years as a separate group from those patients 75 and older. Patients in this younger subset of the elderly may benefit from ICU treatment or surgical intervention. However, the patients in our older subset of elderly patients clearly did not, and they had a significantly higher risk of surgical mortality.     

The mediating effects of effort upon the relationship between head injury severity and cognitive functioning

Primary objective : Given that poor effort may have a profound impact upon the results of neuropsychological assessment, it is of critical importance that assessment of effort is incorporated into the interpretation of a patient's neuropsychological profile. The current study examines the relationship between head injury severity (as measured by length of post-traumatic amnesia) and level of cognitive functioning in patients passing or failing a test of effort (Test of Malingered Memory).

Research design : A cross-sectional correlational design was employed in a consecutive cohort of 78 persons with ongoing compensation claims.

Methods and procedures : Head injury severity was assessed by duration of post-traumatic amnesia. All participants received a clinical interview followed by neuropsychological assessment.

Main outcomes and results : A systematic and interpretable negative correlation between head injury severity and intellectual and memory functioning was demonstrated in persons passing the test of effort. However, in persons failing the test of effort no such relationships were demonstrated.

Conclusions : The implications for the interpretation of neuropsychological test data are discussed. It is strongly recommend that valid interpretation of neuropsychological assessment data should include consideration of at least one test of effort.     

Effects of acute injury characteristics on neuropsychological status and vocational outcome following mild traumatic brain injury

Despite recent attempts to define acute injury characteristics of mild traumatic brain injury (MTBI), neuropsychological outcome is often unpredictable. One hundred MTBI cases were prospectively collected, which were consecutive referrals to a concussion clinic, and the roles of various acute neurologic variables were examined in relation to neuropsychological status and vocational outcome. Significant differences were found between subgroups of patients classified by (1) mechanism of injury (i.e. acceleration/deceleration trauma in which the head strikes an object (HSO) versus acceleration/ deceleration trauma in which the head does not strike an object (HNSO) versus trauma in which an object strikes the head (OSH), and (2) type of injury (i.e. motor vehicle collision, fall, assault, motor vehicle-pedestrian collision, falling object, sports/recreation). There was no difference, with respect to neuropsychological status or vocational outcome, between patients who had positive findings on computerized tomography (CT) versus those who were CT negative. Additionally, there was no difference between patients who had suffered brief loss of consciousness (LOC) and those without LOC. These findings suggest that selective acute injury characteristics may be used to classify subtypes of MTBI patients.     

Social, neuroradiologic, medical, and neuropsychologic correlates of sexually aberrant behavior after traumatic brain injury: a controlled study.

OBJECTIVE: To identify social, neuroradiological, medical, and neuropsychological correlates of sexually aberrant behavior (SAB) after traumatic brain injury (TBI). DESIGN: A controlled study using a retrospective file review. SETTING: A brain injury unit providing inpatient and outpatient rehabilitation services. PARTICIPANTS: A sample of males (n = 25) exhibiting SABs and a control group (n = 25) matched for gender, severity of injury, age at injury, and time after injury. MAIN OUTCOME MEASURES: A protocol that recorded data on demographic, injury, radiological, medical, and neuropsychological variables. RESULTS: The SAB group had a significantly higher incidence of postinjury psychosocial disturbance in areas of nonsexual crime and failure to return to work than the matched TBI group. There were no significant differences between the two groups in the incidence of premorbid psychosocial disturbance or postinjury radiological, medical, or neuropsychological variables. CONCLUSIONS: The study results caution against simplistic explanations of SAB as the product of damage to the frontal-lobe systems or premorbid psychosocial disturbance. Furthermore, the results suggest that a wide-ranging assessment of people with TBI who exhibit SABs is required, because results of neuropsychological examination alone cannot be considered conclusive. Future research into the etiology of SABs could examine additional factors such as lack of insight, lack of empathy, and premorbid history of family dysfunction.     

The applicability of a computer model for predicting head injury incurred during actual motor vehicle collisions

BACKGROUND: Head injury is a significant cause of both morbidity and mortality. Motor vehicle collisions (MVCs) are the most common source of head injury in the United States. No studies have conclusively determined the applicability of computer models for accurate prediction of head injuries sustained in actual MVCs. This study sought to determine the applicability of such models for predicting head injuries sustained by MVC occupants. METHODS: The Crash Injury Research and Engineering Network (CIREN) database was queried for restrained drivers who sustained a head injury. These collisions were modeled using occupant dynamic modeling (MADYMO) software, and head injury scores were generated. The computer-generated head injury scores then were evaluated with respect to the actual head injuries sustained by the occupants to determine the applicability of MADYMO computer modeling for predicting head injury. RESULTS: Five occupants meeting the selection criteria for the study were selected from the CIREN database. The head injury scores generated by MADYMO were lower than expected given the actual injuries sustained. In only one case did the computer analysis predict a head injury of a severity similar to that actually sustained by the occupant. CONCLUSION: Although computer modeling accurately simulates experimental crash tests, it may not be applicable for predicting head injury in actual MVCs. Many complicating factors surrounding actual MVCs make accurate computer modeling difficult. Future modeling efforts should consider variables such as age of the occupant and should account for a wider variety of crash scenarios.     

Usefulness of a cube-copying test in outpatients with dementia

Objective: To clarify whether a quantitatively scored cube-copying test could rapidly assess dementia patients, predicting thier performance in cognitive tests.

Methods: Subjects were 171 outpatients with amnesia who were including 92 with Alzheimer's disease (AD); 59 vascular dementia (VD); 17 frontotemporal dementia (FTD); and three lewy body disease (DLB) and 32 normal healthy subjects. Subjects asked to copy a perspective drawing of a cube. Points of connection and plane-orientation errors were scored using Maeshima's method. The Mini-Mental State Examination (MMSE), an auditory verbal learning test (AVLT), a word fluency test and Raven's Coloured Progressive Matrices (RCPM) were administered. Age, clinical disease severity, symptom duration, specific diagnosis and neuropsychological scores were evaluated for relationships with constructional ability.

Results: The cube-copying test showed errors in most dementia patients and 11 of 32 normal subjects. Only three patients each with AD and VD copied correctly, but 11 patients with 17 FTD drew the cube correctly. Numbers of connections completed and plane-orientation errors correlated significantly with MMSE, AVLT, word fluency and RCPM scores.

Conclusion: The cube-copying test is useful for routine clinical dementia screening, however the test examines only one aspect of cognitive function. While not an alternative to conventional neuropsychological examinations, quantitatively scored cube copying can provide a rough estimate of cognitive dysfunction in dementia patients.     

Cognitive deterioration due to GH deficiency in patients with traumatic brain injury: a preliminary report

PRIMARY OBJECTIVE: To determine whether cognitive and behavioural disorders observed in TBI patients are due to hormonal deficits or to the brain injury itself. Research design: Transversal, between-group design. METHODS AND PROCEDURES: Studied 22 severe TBI patients (GCS < 8): 11 had isolated GH deficiency and 11 did not. Prepared detailed clinical reports on patients and performed physical examinations, standard biochemical and full blood count analysis. Patients underwent neuropsychological assessment and hormonal evaluation 6 months after TBI diagnosis. RESULTS: TBI patients with GH deficiency show greater deficits in attention, executive functioning, memory and emotion than those without GH deficiency. CONCLUSIONS: Results show GH-related cognitive impairment in patients who develop GH deficiency after TBI and suggest that treatment of GH deficiency would improve cognition. The clinical importance of these findings should be established to better understand the nature, magnitude and meaning of GH-related cognitive impairment in patients who develop GH deficiency after TBI.     

Neuropsychological aspects of driving characteristics

Brain injury often causes impairments of cognitive functions, which may affect driving performance. The question of whether the brain-injured patient can resume car driving or not generally comes up during rehabilitation. The medical clinical examination, covering neurological status, screening of cognitive functions, and affective state, is insufficient in assessing relevant functions required for driving performance. A neuropsychological assessment and a driving test are additional parts of the driving assessment besides the medical examination. In this paper, neuropsychological test results and driving test results from four patients with brain injury are presented. The paper demonstrates the complementary value of neuropsychological assessment and a driving test: the relevance of cognitive factors for interpretation of driving problems, but also the relevance of a driving test to show compensatory capacity in some drivers with brain injury. Thus, collaboration between medical, neuropsychological and driving expertise can promote and deepen the total assessment of driving performance after brain injury.