Should we have a guard against therapeutic nihilism for patients with severe traumatic brain injury?

<正>Many clinicians would agree that a vegetative outcome is a fate worse than death after a severe traumatic brain injury(TBI).In an effort to avoid poor outcomes of this nature,neurotrauma practitioners draw from their training and experience to make     

Does memory of a traumatic event increase the risk for posttraumatic stress disorder in patients with traumatic brain injury? A prospective study

OBJECTIVE: The present study examined prospectively the relationship between memory of the traumatic event and subsequent development of posttraumatic stress disorder (PTSD). More specifically, the aims of this study were to 1) investigate the possibility that lack of memory of the traumatic event might be a protective factor; 2) assess whether memory of the traumatic event equally affects the three symptom clusters of PTSD: reexperiencing, avoidance, and hyperarousal; and 3) explore the predictive value of memory of the traumatic event for the development of subsequent PTSD in the immediate aftermath of the event. METHOD: One hundred twenty subjects with mild traumatic brain injury who were hospitalized for observation were assessed immediately after the trauma and followed up 1 week, 3 months, and 6 months later. All participants underwent psychiatric evaluation and self-assessment of their memory of the traumatic event. RESULTS: Overall, 17 (14%) of the participants met full criteria for PTSD at 6 months. Subjects with memory of the traumatic event were significantly more likely to develop PTSD than those without memory of the traumatic event; the difference between the groups resulted primarily from the reexperiencing cluster. Logistic regression analysis revealed that memory of the traumatic event within the first 24 hours is a strong predictor of PTSD 6 months after the event. CONCLUSIONS: Our study indicated that memory of a traumatic event is a strong predictor and a potential risk factor for subsequent development of PTSD. Future studies are needed to show whether these findings can be generalized to other traumatic conditions.     

What has inflammation to do with traumatic brain injury?

Introduction  

Inflammation is an stereotypical response to tissue damage and has been extensively documented in experimental and clinical traumatic brain injury (TBI), including children.     

Is progesterone a worthy candidate as a novel therapy for traumatic brain injury?

Although progesterone is critical to a healthy pregnancy, it is now known to have other important functions as well. Recent research demonstrates that this hormone is also a potent neurosteroid that can protect damaged cells in the central and peripheral nervous systems and has rapid actions that go well beyond its effects on the classical intranuclear progesterone receptor. Based on years of preclinical research demonstrating its safety and effectiveness in animal models of central nervous system injury the hormone was recently tested in two Phase II clinical trials for traumatic brain injury (TBI). A US National Institutes of Health-sponsored, nationwide Phase III clinical trial is now evaluating progesterone for moderate-to-severe TBI in 1200 patients. An industry-sponsored Phase III international trial is also under way, and planning for a trial using progesterone to treat pediatric brain injury has begun. Preclinical data suggest that progesterone may also be effective in stroke and some neurodegenerative disorders.     

Better together? Treating traumatic brain injury with minocycline plus N-acetylcysteine

Traumatic brain injury has a complex pathophysiology that produces both rapid and delayed brain damage. Rapid damage initiates immediately after injury. Treatment of traumatic brain injury is typically delayed many hours, thus only delayed damage can be targeted with drugs. Delayed traumatic brain injury includes neuroinflammation, oxidative damage, apoptosis, and glutamate toxicity. Both the speed and complexity of traumatic brain injury pathophysiology present large obstacles to drug developme...     

Pediatric traumatic brain injury: quo vadis?

In this review, five questions serve as the framework to discuss the importance of age-related differences in the pathophysiology and therapy of traumatic brain injury (TBI). The following questions are included: (1) Is diffuse cerebral swelling an important feature of pediatric TBI and what is its etiology? (2) Is the developing brain more vulnerable than the adult brain to apoptotic neuronal death after TBI and, if so, what are the clinical implications? (3) If the developing brain has enhanced plasticity versus the adult brain, why are outcomes so poor in infants and young children with severe TBI? (4) What contributes to the poor outcomes in the special case of inflicted childhood neurotrauma and how do we limit it? (5) Should both therapeutic targets and treatments of pediatric TBI be unique? Strong support is presented for the existence of unique biochemical, molecular, cellular and physiological facets of TBI in infants and children versus adults. Unique therapeutic targets and enhanced therapeutic opportunities, both in the acute phase after injury and in rehabilitation and regeneration, are suggested.     

Can traumatic brain injury cause psychiatric disorders?

Traumatic brain injury (TBI) may cause psychiatric illness. This article reviews the evidence on the basis of an established set of causation criteria. The evidence is convincing for a strong association between TBI and mood and anxiety disorders. Substance abuse and schizophrenia are not strongly associated with TBI, and there is little research into the rates of personality disorders after TBI. Evidence for a biologic gradient is lacking, but such a gradient may not be relevant to TBI. Evidence for the correct temporal sequence is present. Preliminary evidence suggests a biologic rationale for TBI causing psychiatric illness. Further and methodologically improved research is supported and required.     

Is Goshinjo therapy effective in cognitive impairment after severe traumatic brain injury?

We report a case of a 21-year-old man who had severe traumatic brain injury as a result of an accident at the age of 16 years. Two years and 4 months after the trauma, at the age of 19 years, he still had severe right hemiplegia and cognitive dysfunction including aphasia and attention and memory disturbance. Conventional rehabilitation programs could not resolve all of the neuropsychological problems. He started receiving Goshinjo therapy over a period of 22 months. Following the therapy, significant improvements in verbal intelligence quotient (assessed by the Wechsler Adult Intelligence Scale-Third Edition) and attention and concentration function (using the Wechsler Memory Scale-Revised), and remission of traumatic epilepsy were observed. Goshinjo therapy is suspected to be effective in the treatment of cognitive dysfunction in the chronic stage after severe traumatic brain injury.     

Can patients with severe traumatic brain injury be trained with cognitive telerehabilitation? An inpatient feasibility and usability study

Traumatic Brain Injury (TBI) is the most common cause of long-term disability and death among young adults. Innovation technology, with regard to telerehabilitation, may be of help in managing these frail patients. The aim of the study is to evaluate whether TBI patients and caregivers are able to properly use a Tele-rehabilitation device during hospitalization. Ten TBI subjects (5 males and 5 females; mean age of 45.7 ± 14.4 years), and their caregivers (6 males and 4 females; mean age of 43.7 ± 13.5 years) were consecutively recruited in this preliminary study. After 3 meetings with the telemedicine operators aimed to provide both patients and caregivers with the basic information for the proper use of the device, patients were submitted to 6 training sessions, provided 3 times per week for two weeks, each session lasting about one hour. The telerehabilitation simulation was carried out using the tele-cockpit station and the VRRS-Tablet, used either in the patient's room or in the institute's Family Room. The motivation during training was positive, as per the Intrinsic Motivation Inventory score: 202.6 for patients and 216 for caregivers. Participants also presented positive usability scores, as per the System Usability Scale score: 68 for patients and 69 for caregivers. Our feasibility and usability study supports the idea that in-patients with severe TBI could benefit from cognitive telerehabilitation performed in the pre-discharge phase, in order to get a higher level of adherence to the home tele-treatment and potentially better outcomes.     

Reversible dysfunction of receptors in traumatic brain injury?

In many brain disorders reduced binding of central benzodiazepine receptor ligands indicates irreversible neuronal damage. The data presented by Koizumi et al (2010) demonstrate that this is not the case in traumatic brain injury suggesting different pathogenetic mechanisms leading to tissue damage. The proof for this hypothesis requires further studies that should also consider thresholds of ligand binding as indicators of irreversible damage.     

Does feedback influence awareness following traumatic brain injury?

This study examined the relationship between the nature of feedback provided by close-others and self-awareness in individuals with traumatic brain injury (TBI). Using a cross-sectional design, 69 individuals with mild-to-severe TBI and their close-others completed the Awareness Questionnaire, Hospital Anxiety and Depression Scale, Trail Making Test–Part B and Feedback about Cognitive Difficulties Questionnaire, between 3?months and 20?years post-injury. Results showed cognitive and/or behavioural issues post-injury were identified in 97% of individuals with TBI and over 80% of these were provided with feedback by close-others at least sometimes after making errors. Close-others reported two main reasons for not providing feedback about problems: (1) not wanting to hurt the feelings of the injured individual and (2) pointing out errors would be detrimental to the injured individual's rehabilitation. Whilst nearly 60% of the individuals with TBI were reported to detect an error once they received feedback, they showed low levels of acceptance/acknowledgement in response to feedback. Analyses including injury-related and emotional variables failed to identify any mediated or moderated relations between frequency of feedback and self-awareness. The high rates of feedback by close-others but low acceptance/acknowledgement of that feedback by individuals with TBI suggests that clinicians may need to work in partnership with close-others to facilitate supportive relationships for effective delivery of feedback.     

Preinjury characteristics of children with mild traumatic brain injury: Is “other injury” an appropriate comparison group”?

Background: Mild traumatic brain injury (mTBI) has been associated with ongoing problems in children and young people. However, there remains to be considerable debate regarding whether outcomes are a result of brain impairment, or simply reflect preinjury characteristics of the child or family. To reliably assess outcomes, an appropriate control group is required. Aims: This study aimed to identify the preinjury characteristics of children with mTBI, and to examine whether an “other injury to the head” group is an appropriate comparison to control for preinjury characteristics of children with mTBI. Method: Parents of 290 children admitted to the emergency department with either a diagnosis of mTBI (n = 186, M = 6.44 years) or a superficial injury to the head (SIH) (n = 104, M = 5.40 years) were assessed. Parents completed three questionnaires examining behavioral problems (Clinical Assessment of Behavior), parental stress (Parenting Stress Index), and background variables (e.g., medical issues, socioeconomic factors). Results: A series of chi-square analyses and multivariate analysis of variance tests revealed no differences for behavior, parental stress, and other preexisting problems between children with mTBI and those with SIH. Conclusions: Children who experience a mTBI event present similarly to individuals with a SIH, and SIH is an appropriate comparison group to examine the outcomes of childhood mTBI, as it may help minimize any confounding effects of preexisting issues associated with mTBI.     

Quo vadis 2010? - carpe diem: challenges and opportunities in pediatric traumatic brain injury

Traumatic brain injury (TBI) in infants and children remains a public health problem of enormous magnitude. It is a complex and heterogeneous condition that presents many diagnostic, therapeutic and prognostic challenges. A number of investigative teams are studying pediatric TBI both in experimental models and in clinical studies at the bedside. This review builds on work presented in a prior supplement to Developmental Neuroscience that was published in 2006, and addresses several active areas of research on this topic, including (1) the application of novel imaging methods, (2) the use of serum and/or CSF biomarkers of injury, (3) advances in neuromonitoring, (4) the development and testing of novel therapies, (5) developments in modeling pediatric TBI, (6) the consideration of a new approach to classification of pediatric TBI, and (7) assessing the potential impact of the development of pediatric and neonatal neurocritical care services on the management and outcome of pediatric TBI.     

Is being plastic fantastic? Mechanisms of altered plasticity after developmental traumatic brain injury

Traumatic brain injury (TBI) is predominantly a clinical problem of young persons, resulting in chronic cognitive and behavioral deficits. Specifically, the physiological response to a diffuse biomechanical injury in a maturing brain can clearly alter normal neuroplasticity. To properly evaluate and investigate developmental TBI requires an understanding of normal principles of cerebral maturation, as well as a consideration of experience-dependent changes. Changes in neuroplasticity may occur through many age-specific processes, and our understanding of these responses at a basic neuroscience level is only beginning. In this article, we will particularly discuss mechanisms of TBI-induced altered developmental plasticity such as altered neurotransmission, distinct molecular responses, cell death, perturbations in neuronal connectivity, experience-dependent 'good plasticity' enhancements and chronic 'bad plasticity' sequelae. From this summary, we can conclude that 'young is not always better' and that the developing brain manifests several crucial vulnerabilities to TBI.     

Sleep disturbance after mild traumatic brain injury: indicator of injury?

Mild traumatic brain injury (mTBI) is a complex entity with no known objective diagnostic markers. To test the hypothesis that sleep disturbances in the acute mTBI period can serve as an indicator of brain injury, the authors compared sleep polysomnograms (PSG) and sleep EEG power spectra (PS) data in seven mTBI subjects with seven age- and race-matched healthy-control subjects. The two groups differed significantly on PS measures, suggesting that mTBI can result in a disruption of sleep microarchitecture and, in theory, could be of use as a marker for brain injury. These pilot findings need to be replicated on larger samples.