Cognitive and psychosocial outcome following moderate or severe traumatic brain injury

The outcome of 96 consecutive adult patients with moderate to severe head injury was sequentially measured at 6, 12 and 24 months post-injury. In addition to global outcome using the Glasgow Outcome Scale (GOS) and a battery of neuropsychological tests of cognitive function, the Head Injury Symptom Checklist (HISC) and Relative's Questionnaire (RQ) were used. Although poorer GOS scores and severe cognitive impairments were typically associated with greater severity of initial injury, relatives reported similar functional problems irrespective of injury severity. This illustrates the legacy of moderate head injury in influencing many aspects of everyday life, supporting the argument that the needs of this group should not be overlooked.     

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.     

Clinical predictors and neuropsychological outcome in severe traumatic brain injury patients

Summary Background. The aim of the study was to evaluate the possible significant role of some clinical factors in predicting cognitive outcome in a group of severe traumatic brain injury (TBI) patients, with Glasgow Coma Scale (GCS) lower than 8 and duration of unconsciousness for at least 15 days (prolonged coma).Method. A consecutive sample of 25 survivors of severe TBI attending the Physical and Cognitive Rehabilitation program participated in this study. The neuropsychological test battery included: Word-list Learning, Prose recall, Rey Figure Delayed recall, Word fluency, Ravens Progressive Matrices 47. The clinical variables evaluated in correlation with the neuropsychological outcome were the following: age, duration of unconsciousness, duration of post-traumatic amnesia, interval from head trauma to neuropsychological evaluation, interval from head trauma to recovery of oral feeding, and finally interval from head trauma to first verbal communication.Findings. The clinical variable with a significant predictive value on most neuropsychological scores was the interval from head trauma to the recovery of oral feeding.Conclusions. If this result is confirmed in larger samples, time interval of oral feeding recovery from head trauma should be considered as a possible predictor of neuropsychological outcome in TBI patients with prolonged coma.     

Protein S-100 and neuropsychological functioning following severe traumatic brain injury

PRIMARY OBJECTIVE: To examine the relationship between serum concentrations of protein S-100beta and neuropsychological functioning following severe traumatic brain injury. DESIGN: Matched control group. METHODS: Blood samples were taken within 12 hours of injury and then daily up to 7 days post-injury (n=23). Within 2 weeks of emerging from post-traumatic amnesia (PTA), participants completed a battery of neuropsychological measures. These results were compared with a matched sample of healthy controls. RESULTS: Early measurement of S-100 not only reflected overall brain injury severity, but also related to neuropsychological deficits, with higher serum concentrations associated with poorer performance across most cognitive domains. PTA duration, measured by the Westmead PTA Scale, was found to be the strongest predictor of S-100 concentration (R2=0.59, p<0.001). CONCLUSIONS: These findings show that measurement of serum protein S-100 may further aid in the identification of individuals with severe TBI who are likely to experience cognitive difficulties.     

Outcome following moderate traumatic brain injury

BACKGROUND: Little is known about the outcome following moderate traumatic brain injury (TBI) (GCS 9-12). Most patients regain consciousness; however, the full magnitude of long-term cognitive and functional deficits is unknown. METHODS: We conducted a prospective observational study evaluating the outcome of patients suffering moderate TBI between October 1995 and March 1998. Long-term outcome was assessed by telephone interviews. RESULTS: A total of 79 consecutive patients were included. Average length of ICU and total hospital stay was 9.1 and 15.8 days respectively. The median GCS at 24 hours was 10 with 67% improving to GCS 15 by time of discharge. The presence of multisystem trauma did not affect outcome; however, age >/=45, initiation of enteral feeding after postinjury day 4 and the presence of pneumonia were all associated with longer lengths of stay and increased complication rates. Fifty-six (71%) patients were contacted for follow-up at an average of 27.5 months. GOS scores were 5 in 44%, 4 in 41%, 3 in 9%, 1 in 6%. Seventy-four percent of patients employed premorbidly returned to full-time work. Questions regarding cognitive and functional status revealed significant problems in the majority of patients. CONCLUSIONS: Pneumonia, age >/=45 years and a delay in initiation of enteral feeding all increased the duration of acute care hospital stay following moderate TBI. In addition, cognitive, emotional, and functional problems following such injuries are extensive and long lasting. Physicians must be knowledgeable of these long-term sequela so they can provide the appropriate support and treatment to these patients.     

Vocational outcome of aphasic patients following severe traumatic brain injury

The incidence and course of aphasia, and its impact on vocational outcome, were determined in a group of 351 patients with severe traumatic brain injury TBI . Aphasia was found in 111 , the common forms being amnestic 56 , 22 39 , expressive 10 3 , 4 39 and receptive 10 5 , 8 39 , as found on the first language assessment. No age difference was found between the aphasic and nonaphasic patients. Coma was more common in the aphasics than the non-aphasics 95 and 82 , respectively , although its mean duration was shorter. Aphasics had more severe locomotor deficits p 0 01, Fisher test and tended towards more severe cognitive disorders p 0 07, Fisher test . There was no difference between the groups in incidence of behavioural disturbances or occupational outcome. Most of the aphasic patients improved after therapy, and two recovered completely. The presence of aphasia did not have negative prognostic implications for occupational outcome.     

Prospective and declarative memory problems following moderate and severe traumatic brain injury

PRIMARY OBJECTIVE: To examine prospective and declarative memory problems following moderate and severe traumatic brain injury (TBI) and the relationship between prospective memory (PM) and declarative memory and PM and other cognitive functions. RESEARCH DESIGN: The performance of persons who suffered a TBI (n = 25) was compared with that of a demographically matched control group (n = 25). METHODS AND PROCEDURES: Measures of time- and event-based PM, visual and verbal declarative memory, attention and executive functioning were administered to both groups. MAIN OUTCOME AND RESULTS: The group with a TBI performed more poorly on event- and time-based PM, verbal declarative memory, certain aspects of attention and executive functioning. The correlations between the measures of PM, declarative memory and the other cognitive tests were all non-significant. CONCLUSIONS: Problems with declarative memory, attention, and executive functioning do not adequately account for poorer PM performance following a TBI, suggesting that PM should also be assessed following TBI.     

Long-term neuropsychological outcome after traumatic brain injury.

OBJECTIVE: To describe neuropsychological outcome 5 years after injury in persons with traumatic brain injury (TBI) who received inpatient medical rehabilitation. To determine the magnitude and pattern neuropsychological recovery from 1 year to 5 years after injury. DESIGN: Longitudinal cohort study with inclusion based on the availability of neuropsychological data at 1 year and 5 years after injury. SETTING: National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems of Care. PARTICIPANTS: One hundred eighty-two persons with complicated mild to severe traumatic brain injury. PRIMARY OUTCOME MEASURES: Digits Forward and Backward, Logical Memory I and II, Token Test, Controlled Oral Word Association Test, Symbol Digit Modalities Test, Trail Making Test, Rey Auditory Verbal Learning Test, Visual Form Discrimination, Block Design, Wisconsin Card Sorting Test, and Grooved Pegboard. RESULTS: Significant variability in outcome was found 5 years after TBI, ranging from no measurable impairment to severe impairment on neuropsychological tests. Improvement from 1 year after injury to 5 years was also variable. Using the Reliable Change Index, 22.2% improved, 15.2% declined, and 62.6% were unchanged on test measures. CONCLUSIONS: Neuropsychological recovery after TBI is not uniform across individuals and neuropsychological domains. For a subset of persons with moderate to severe TBI, neuropsychological recovery may continue several years after injury with substantial recovery. For other persons, measurable impairment remains 5 years after injury. Improvement was most apparent on measures of cognitive speed, visuoconstruction, and verbal memory.     

Influence of extraneurological insults on ventricular enlargement and neuropsychological functioning after moderate and severe traumatic brain injury

Extraneurological insults secondary to TBI such as hypotension or hypoxia have been associated with mortality and morbidity. The purpose of this study was to investigate the influence of systemic complications on both neuropsychological outcome and cerebral atrophy. Fifty-seven patients selected from 122 consecutive admissions were studied. Data on the type and severity of injury as well as other systemic insults were collected prior to and during the first 3 days of hospitalization. These data included the presence or absence of a hypoxic episode during the pre-hospital period, the presence and degree of hypoxia, hypercapnia, anemia, hypotension and intracranial hypertension, pupillary reactivity, Glasgow Coma Scale score and coma duration. From the last control CT scan image, performed 6 months post-injury, four different indexes of ventricular dilatation were calculated. Neuropsychological assessment at 6 months included tests of verbal and visual memory, visuoconstructive functions, fine motor speed, and frontal lobe functions. Our results showed that hypoxia and hypotension were related to neuropsychological outcome and long-term ventricular enlargement. Hypoxic episodes prior to hospitalization were related to third ventricle dilatation and to adverse neurological and cognitive outcomes, especially to attention, motor speed, mental flexibility, fluency and verbal memory impairments, suggesting fronto-striatal and hippocampal dysfunction. We conclude that the effect of extraneurological insults on brain structure and function may be as important as the severity of the primary injury.     

Supported employment and compensatory strategies for enhancing vocational outcome following traumatic brain injury

Epidemiological research clearly indicates that traumatic head injury has reached epidemic proportions. Incidence rates for head injury are greater than those for cerebral palsy, multiple sclerosis, and spinal cord injury combined. Many victims suffer from long-term impairments in functional, neurological, medical, neuropsychological and linguistic status. Emotional and behavioural problems are common as well. Additionally, family problems often ensue as a consequence of the victim's dependency and concomitant emotional changes. Investigations of post-injury vocational status indicate that unemployment rates within the first 7 years post-injury range as high as 70% for those with moderate and severe injuries. Researchers have demonstrated that the emotional and neuropsychological changes arising from injury are the greatest contributors to reduced employability. Relatively high unemployment rates strongly suggest that traditional approaches to physical and vocational rehabilitation have been entirely inadequate. To complement existing services and enhance employment outcome, two approaches have been developed and refined for use with victims of head injury. Supported employment is a unique approach which assists the client to select, obtain and maintain suitable employment on the basis of his/her interests and abilities. Compensatory strategies have been developed to help the individual offset intellectual problems which would otherwise interfere with learning job skills and maintaining production levels. Often, compensatory strategies are used in the context of a comprehensive supported employment programme. The greater use of supported employment and compensatory strategies is likely to enhance employment outcomes for those with traumatic head injury. Nevertheless, additional research is needed to more clearly identify the types of techniques which work best for each unique set of problems.     

The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injury

BACKGROUND: Although early intubation to prevent the mortality that accompanies hypoxia is considered the standard of care for severe traumatic brain injury (TBI), the efficacy of this approach remains unproven. METHODS: Patients with moderate to severe TBI (Head/Neck Abbreviated Injury Scale [AIS] score 3+) were identified from our county trauma registry. Logistic regression was used to explore the impact of prehospital intubation on outcome, controlling for age, gender, mechanism, Glasgow Coma Scale score, Head/Neck AIS score, Injury Severity Score, and hypotension. Neural network analysis was performed to identify patients predicted to benefit from prehospital intubation. RESULTS: A total of 13,625 patients from five trauma centers were included; overall mortality was 22.9%, and 19.3% underwent prehospital intubation. Logistic regression revealed an increase in mortality with prehospital intubation (odds ratio, 0.36; 95% confidence interval, 0.32-0.42; p < 0.001). This was true for all patients, for those with severe TBI (Head/Neck AIS score 4+ and/or Glasgow Coma Scale score of 3-8), and with exclusion of patients transported by aeromedical crews. Patients intubated in the field versus the emergency department had worse outcomes. Neural network analysis identified a subgroup of patients with more significant injuries as potentially benefiting from prehospital intubation. CONCLUSION: Prehospital intubation is associated with a decrease in survival among patients with moderate-to-severe TBI. More critically injured patients may benefit from prehospital intubation but may be difficult to identify prospectively.     

Age effects on long-term neuropsychological outcome in paediatric traumatic brain injury

In order to investigate the relationship between age at injury and long-term neuropsychological impairment, 29 children and adolescents who sustained traumatic brain injury (TBI) were studied at least 6 years post-trauma. Tests of intellectual, memory, visuospatial and frontal lobe functions were administered to patients and 29 normal matched control subjects. Correlations between performance on neuropsychological tests and age showed the following direction: the younger the child when TBI was sustained, the worse the cognitive outcome. After controlling for injury severity, visuospatial functions remained related to age. Patients' performance differed significantly from that of controls in half of the neuropsychological variables analysed. To further investigate the effects of age at injury, the sample was divided in two groups (TBI before and after age of 8) and then compared with their respective controls. Patients damaged earlier presented impaired intellectual and visuospatial functions. The results suggest that neuropsychological sequelae remain after at least 6 years of evolution, and that there is an age at injury effect.     

Psychiatric treatment outcome following traumatic brain injury

The relationship between self-reported history of traumatic brain injury (TBI) and psychiatric treatment outcome was investigated. TBI was hypothesized to be frequent, associated with cognitive deficits on neuropsychological testing, and less amenable to standard psychiatric treatment. Subjects were 42 psychiatric patients with a self-reported history of TBI and 25 psychiatricpatients with no TBI history. Subjects received approximately 2 weeks of inpatient psychiatric treatment. Subjects received neuropsychological testing and completed the Brief Symptom Inventory weekly. TBI was frequent (66% of subjects); multiple injuries were common. Neuropsychological performance was generally average in both groups with few group differences. Subjects, on average, reported significantly decreased psychiatric symtoms on discharge. However, the TBI group appeared to improve less than the control group; group status was a significant predictor of treatment outcome. Implications of results for assessment and treatment of psychiatric disorders in patients with a history of TBI are discussed.     

Association between elevated brain tissue glycerol levels and poor outcome following severe traumatic brain injury

OBJECT: Glycerol is considered to be a marker of cell membrane degradation and thus cellular lysis. Recently, it has become feasible to measure via microdialysis cerebral extracellular fluid (ECF) glycerol concentrations at the patient's bedside. Therefore the aim of this study was to investigate the ECF concentration and time course of glycerol after severe traumatic brain injury (TBI) and its relationship to patient outcome and other monitoring parameters. METHODS: As soon as possible after injury for up to 4 days, 76 severely head-injured patients were monitored using a microdialysis probe (cerebral glycerol) and a Neurotrend sensor (brain tissue PO2) in uninjured brain tissue confirmed by computerized tomography scanning. The mean brain tissue glycerol concentration in all monitored patients decreased significantly from 206 +/- 31 micromol/L on Day 1 to 9 +/- 3 micromol/L on Day 4 after injury (p < 0.0001). Note, however, that there was no significant difference in the time course between patients with a favorable outcome (Glasgow Outcome Scale [GOS] Scores 4 and 5) and those with an unfavorable outcome (GOS Scores 1-3). Significantly increased glycerol concentrations were observed when brain tissue PO2 was less than 10 mm Hg or when cerebral perfusion pressure was less than 70 mm Hg. CONCLUSIONS: Based on results in the present study one can infer that microdialysate glycerol is a marker of severe tissue damage, as seen immediately after brain injury or during profound tissue hypoxia. Given that brain tissue glycerol levels do not yet add new clinically significant information, however, routine monitoring of this parameter following traumatic brain injury needs further validation.     

Cognitive orientation in rehabilitation and neuropsychological outcome after traumatic brain injury

This study evaluated the ability of the Orientation Log (O-Log) to predict cognitive outcome at rehabilitation discharge, as well as future neuropsychological outcome. The hypothesis was that patients who demonstrated better orientation upon admission would achieve superior functional cognitive outcome at discharge and on subsequent neuropsychological assessment. Sixty individuals receiving inpatient rehabilitation following a new-onset TBI participated. Orientation data was collected using the O-Log during morning bedside rounds. Outcome data was collected at 6 and 12 months post-injury. Significant correlations were found between the O-log and measures of memory, executive functioning, basic verbal skills, and estimated intellectual ability. When compared to the other predictor variables, step-wise multiple regression analyses revealed that the minimum O-Log score was the primary significant predictor of performance on six neuropsychological and functional outcome measures. Results of this study suggest that evaluating orientation with the O-Log during acute rehabilitation may reflect level of injury severity and aid in predicting cognitive outcome.     

Abstract thinking following severe traumatic brain injury

abilities were studied in a sample of 34 individuals with severe TBI and a control group. The results indicate that TBI interferes with performance on tests requiring individuals to process information into new categories. There appears to be a dissociation between verbal abstract abilities and visual-perceptual abstract abilities. There is evidence that Goldstein and Sheerer's [1] postulate of a general 'abstract attitude' was at least partially correct. This attitude does not appear to be related to a general verbal ideational process, as dysphasic subjects were only deficient on a purely verbal abstract task.     

Rehabilitation and outcome following pediatric traumatic brain injury

The long-term outcome for a child who has sustained a traumatic brain injury must be viewed in the context of ongoing development and maturation. Although neuronal plasticity provides the potential for neuronal reorganization in a child's brain, it is the behavioral demands of the environment that allow the child to take advantage of this potential and to maximize recovery. Pediatric rehabilitation is the setting that provides the necessary experiences for stimulating neuronal reorganization following TBI. However, neuronal reorganization has a cost to long-term development. The ultimate long-term impact of a TBI sustained in childhood depends on the child's ability to achieve developmental milestones following injury. Although injury-related and treatment-related factors are critical during the early stages of recovery, patient-related factors such as age-at-injury, developmental achievement at time of injury, maturation, and family involvement and resources impact the later stages of recovery. The process of pediatric rehabilitation following TBI is to provide an enriched, stimulating environment tailored to the needs of the child and based on real-word experiences. Early in the recovery process, pediatric rehabilitation is the setting that maximizes the potential for neuronal reorganization. Early rehabilitation also prepares the family for the child's long-term recovery and developmental needs. Involvement and training of family members early in the recovery process is critical for successful long-term outcome. Family members are the individuals best equipped to ensure treatment compliance and follow through with treatment recommendations, in maintaining treatment gains, and in generalizing treatment effects beyond the medical settings. Despite the life-long ramifications of childhood TBI, pediatric rehabilitation is the necessary step in promoting recovery and successful long-term outcome.     

Cognitive indicators of vocational outcome after severe traumatic brain injury (TBI) in childhood

Recent studies suggest that plasticity does not benefit outcome when diffuse cerebral pathology of the young child's brain is concerned. Thirty-three patients with severe traumatic brain injury (TBI) at preschool age were followed-up until adulthood. After the age of 18 years, a thorough neurological, neuropsychological and social evaluation, including detailed patient history and assessment of identity, was made by the team. When the youngest patients were 21 years old, the study was completed, with a questionnaire assessing employment status and ability to live independently. Twenty-seven per cent of the patients worked full time, 21% had subsidised work, 37% lived independently at home and 15% needed help with every-day functions. Tests measuring speed, executive and memory functions were significantly associated with vocational outcome, as was the sense identity, which was independent of the test scores. The results support the recent reports on the vulnerability of a young child's brain to early trauma. The study also strongly suggests that the final assessment of outcome after childhood TBI should be done in adulthood.