Predictors and indicators of quality of life in patients with closed-head injury

This study examined predictors and indicators of quality of life in 71 patients with closed-head injury (CHI), 2-4 years postinjury. Predictors included premorbid characteristics and acute injury-related data. Indicators included follow-up data, e.g., neuropsychological functioning. Exploratory canonical correlation analyses demonstrated that the combination of the predictor variable, initial Glasgow Coma Scale score, and indicator variables of neuropsychological data in the areas of motor functioning, memory, and constructional ability were related most strongly to quality of life as reported by the patients. Severity of head injury and motor disability also related strongly to quality of life, based on reports by relatives (n = 68) on the Katz Adjustment Scale (Relatives' Form). These findings suggest that quality of life is adversely affected by increased severity of head injury and greater residual motor deficits. Implications of these findings for treatment and recovery are discussed.     

Predictors of secondary attention-deficit/hyperactivity disorder in children and adolescents 6 to 24 months after traumatic brain injury

OBJECTIVE: To assess the phenomenology and predictive factors of attention-deficit/hyperactivity disorder (ADHD) after traumatic brain injury (TBI), also called secondary ADHD (SADHD). METHOD: Children without preinjury ADHD 5-14 years old with TBI from consecutive admissions (n = 143) to five trauma centers were observed prospectively from 6 to 12 months (12-month assessment) and from 12 to 24 months (24-month assessment) postinjury with semistructured psychiatric interviews. Injury and preinjury psychosocial variables were assessed. RESULTS: SADHD occurred in 15 of 103 (15%) of participants between 6 and 12 months after injury and 17 of 82 (21%) in the second year after injury. SADHD was significantly (p < .05) comorbid with personality change due to TBI and new-onset disruptive behavior disorders. Preinjury adaptive function was a consistent predictor of SADHD. Regression analyses revealed that preinjury psychosocial adversity was an independent predictor of SADHD in the second year after injury. Neither severity of injury nor lesion location predicted SADHD from 6 to 24 months postinjury. CONCLUSIONS: Determination of preinjury psychosocial adversity and the child's preinjury functioning during the index hospitalization would improve identification of children at highest risk of development of SADHD.     

Alterations in regional cerebral blood flow following brain injury in the rat

To elucidate the temporal changes in regional cerebral blood flow (rCBF) after experimental traumatic brain injury, serial rCBF measurements were made during a 24-h period following fluid-percussion (F-P) traumatic brain injury in the rat. Brain injury of 2.2 atm was induced over the left parietal cortex and serial measurements of rCBF were performed using the radiolabeled microsphere method. rCBF values were obtained prior to injury and at 15 and 30 min and 1, 2, 4, and 24 h postinjury. At 15 min postinjury, there was a profound, wide-spread reduction in rCBF in all brain regions studied (p less than 0.05). At 30 min and 1 h postinjury, all brain regions except pons-medulla and cerebellum showed significantly reduced rCBF compared to the preinjury values (p less than 0.05). By 2 h postinjury, however, a significant focal reduction of rCBF was observed only in the cerebral tissue surrounding the trauma site (p less than 0.05); rCBF in the remaining brain regions had recovered to the preinjury levels. By 4 h postinjury, rCBF had returned to normal in all brain regions studied. This recovery of rCBF was still evident at 24 h postinjury. The present study demonstrates that, following the experimental traumatic brain injury in the rat, (a) an initial global suppression of rCBF occurs up to 1 h postinjury; (b) at the trauma site, a more persistent focal reduction of rCBF occurs; and (c) these alterations in rCBF after trauma dissolve by 4 h postinjury.(ABSTRACT TRUNCATED AT 250 WORDS)     

Identifying factors contributing to child and family outcome 30 months after traumatic brain injury in children

OBJECTIVE: To examine the contributions of injury severity, physical and cognitive disability, child and family function to outcome 30 months after traumatic brain injury (TBI) in children. DESIGN: A prospective, longitudinal, between group design, comparing function before and after injury across three levels of injury severity. SUBJECTS: One hundred and fifty children, 3.0-12.11 years old, admitted to hospital with a diagnosis of TBI. The sample was divided according to injury severity: mild (n = 42), moderate (n = 70), severe (n = 38). Children with a history of neurological, developmental, and psychiatric disorders were excluded from participation. MAIN OUTCOME MEASURES: Post injury physical function, cognitive ability (incorporating intellect, memory, and attention), behavioural and family functioning, and level of family burden. RESULTS: A dose-response relation was identified for injury severity and physical and cognitive outcome, with significant recovery documented from acute to six months after TBI. Behavioural functioning was not related to injury severity, and where problems were identified, little recovery was noted over time. Family functioning remained unchanged from preinjury to post injury assessments. The level of family burden was high at both six and 30 months after injury, and was predicted by injury severity, functional impairment, and post injury child behavioural disturbance. CONCLUSIONS: These results suggest ongoing problems for the child and significant family burden 30 months after TBI. The nature and severity of the physical and cognitive problems are closely related to injury severity, with child and family function predicted by psychosocial and premorbid factors.     

Predictors and indicators of quality of life in patients with Closed-Head injury

Abstract

This study examined predictors and indicators of quality of life in 71 patients with closed-head injury (CHI), 2-4 years postinjury. Predictors included premorbid characteristics and acute injury-related data. Indicators included follow-up data, e.g., neuropsychological functioning. Exploratory canonical correlation analyses demonstrated that the combination of the predictor variable, initial Glasgow Coma Scale score, and indicator variables of neuropsychological data in the areas of motor functioning, memory, and constructional ability were related most strongly to quality of life as reported by the patients. Severity of head injury and motor disability also related strongly to quality of life, based on reports by relatives (n = 68) on the Katz Adjustment Scale (Relatives' Form). These findings suggest that quality of life is adversely affected by increased severity of head injury and greater residual motor deficits. Implications of these findings for treatment and recovery are discussed.     

Predicting premorbid neuropsychological functioning following pediatric traumatic brain injury

Abstract

This study examined the prediction of premorbid neuropsychological functioning using data from an ongoing prospective study of traumatic brain injuries (TBI) in children ages 6 to 12 years. Prediction equations were derived based on 80 children with orthopedic injuries (OI), who served as a comparison group for the children with TBI. Collectively, parent ratings of premorbid school performance, maternal ethnicity, family socioeconomic status, and children's word recognition skill predicted from 13% to 45% of the variance in three measures of neuropsychological functioning. The regression equations were used to compute predicted scores among 109 children with TBI. Actual scores fell significantly below predicted scores among children with TBI, and the magnitude of the deficits was correlated with injury severity. Premorbid neuropsychological functioning can be predicted in children with TBI, but with less precision than would be desirable for clinical purposes.     

The contributions of self-reported injury characteristics and psychiatric symptoms to cognitive functioning in OEF/OIF veterans with mild traumatic brain injury

Mild traumatic brain injury (mTBI) affects a significant number of combat veterans returning from Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF). Although resolution of mTBI symptoms is expected over time, some individuals continue to report lingering cognitive difficulties. This study examined the contributions of self-reported mTBI injury characteristics (e.g., loss of consciousness, post-traumatic amnesia) and psychiatric symptoms to both subjective and objective cognitive functioning in a sample of 167 OEF/OIF veterans seen in a TBI clinic. Injury characteristics were not associated with performance on neuropsychological tests but were variably related to subjective ratings of cognitive functioning. Psychiatric symptoms were highly prevalent and fully mediated most of the relationships between injury characteristics and cognitive ratings. This indicates that mTBI characteristics such as longer time since injury and loss of consciousness or post-traumatic amnesia can lead to increased perceived cognitive deficits despite having no objective effects on cognitive performance. Psychiatric symptoms were associated with both cognitive ratings and neuropsychological performance, illustrating the important role that psychiatric treatment can potentially play in optimizing functioning. Finally, subjective cognitive ratings were not predictive of neuropsychological performance once psychiatric functioning was statistically controlled, suggesting that neuropsychological assessment provides valuable information that cannot be gleaned from self-report alone.     

Factors moderating neuropsychological outcomes following mild traumatic brain injury: a meta-analysis.

There continues to be debate about the long-term neuropsychological impact of mild traumatic brain injury (MTBI). A meta-analysis of the relevant literature was conducted to determine the impact of MTBI across nine cognitive domains. The analysis was based on 39 studies involving 1463 cases of MTBI and 1191 control cases. The overall effect of MTBI on neuropsychological functioning was moderate (d = .54). However, findings were moderated by cognitive domain, time since injury, patient characteristics, and sampling methods. Acute effects (less than 3 months postinjury) of MTBI were greatest for delayed memory and fluency (d = 1.03 and .89, respectively). In unselected or prospective samples, the overall analysis revealed no residual neuropsychological impairment by 3 months postinjury (d = .04). In contrast, clinic-based samples and samples including participants in litigation were associated with greater cognitive sequelae of MTBI (d = .74 and .78, respectively at 3 months or greater). Indeed, litigation was associated with stable or worsening of cognitive functioning over time. The implications and limitations of these findings are discussed.     

Mood and anxiety disorders following pediatric traumatic brain injury: a prospective study

Studies utilizing standardized instruments for assessing mood and/or anxiety disorders following pediatric traumatic brain injury have seldom been reported in the literature. Previous reports have largely focused on cognitive impairment, behavioral dysfunction, or adaptive functioning, and have typically relied on parental informants. In this study, children hospitalized for mild (N = 42) and moderate/severe (N = 19) brain injury were assessed 6-months postinjury using the Anxiety disorders Module A and the Mood disorders Module C of the Diagnostic Interview Schedule for Children - IV Revision (DISC-IV). The data collected for the brain injury groups were compared to an orthopedic control group (N = 35). The relationship between a new onset mood and/or anxiety disorder (NOD) and injury severity indices was examined. Sequential logistical regression was also utilized to examine the impact of a brain injury, demographic variables, preinjury psychiatric disturbance, development disorders, litigation status and postinjury environmental stress on emotional outcome. Results indicated a relationship between brain injury and NOD. Multivariate analysis demonstrated that postinjury level of stress and severity of brain injury were the most robust predictors of NOD, accounting for 23% of the variance in the model. These results support the premise that the development of a mood and/or anxiety disorder following pediatric head injury is mediated by multiple determinants. The findings suggest that early psychosocial assessment and interventions aimed at increasing a child's coping may attenuate the emotional consequences of pediatric brain injury.     

Mood and Anxiety Disorders Following Pediatric Traumatic Brain Injury: A Prospective Study

Studies utilizing standardized instruments for assessing mood and/or anxiety disorders following pediatric traumatic brain injury have seldom been reported in the literature. Previous reports have largely focused on cognitive impairment, behavioral dysfunction, or adaptive functioning, and have typically relied on parental informants. In this study, children hospitalized for mild (N = 42) and moderate/severe (N = 19) brain injury were assessed 6-months postinjury using the Anxiety disorders Module A and the Mood disorders Module C of the Diagnostic Interview Schedule for Children – IV Revision (DISC-IV). The data collected for the brain injury groups were compared to an orthopedic control group (N = 35). The relationship between a new onset mood and/or anxiety disorder (NOD) and injury severity indices was examined. Sequential logistical regression was also utilized to examine the impact of a brain injury, demographic variables, preinjury psychiatric disturbance, development disorders, litigation status and postinjury environmental stress on emotional outcome. Results indicated a relationship between brain injury and NOD. Multivariate analysis demonstrated that postinjury level of stress and severity of brain injury were the most robust predictors of NOD, accounting for 23% of the variance in the model. These results support the premise that the development of a mood and/or anxiety disorder following pediatric head injury is mediated by multiple determinants. The findings suggest that early psychosocial assessment and interventions aimed at increasing a child's coping may attenuate the emotional consequences of pediatric brain injury.     

Randomized treatment trial in mild traumatic brain injury

OBJECTIVE: To determine whether multidisciplinary treatment of mild traumatic brain injury (MTBI) improves neurobehavioral outcome at 6 months postinjury. METHODS: Subjects with MTBI were randomly assigned to treatment (n=97) or nontreatment (control, n=94) groups. Treated patients were assessed within 1 week of injury and thereafter managed by a multidisciplinary team according to clinical need for a further 6 months. Control subjects were not offered treatment. Six-month outcome measures included: severity of postconcussive symptoms (Rivermead Post-Concussion Disorder Questionnaire), psychosocial functioning (Rivermead Follow-up Questionnaire), psychological distress (General Health Questionnaire), and cognition (neurocognitive battery). RESULTS: Treatment and control subjects were well-matched for demographic and MTBI severity data. In addition, the two groups did not differ on any outcome measure. However, in individuals with preinjury psychiatric difficulties (22.9% of the entire sample), subjects in the treatment group had significantly fewer depressive symptoms 6 months postinjury compared with untreated controls (P=.01). CONCLUSIONS: These findings suggest that routine treatment of all MTBI patients offers little benefit; rather, targeting individuals with preinjury psychiatric problems may prove a more rational and cost-effective approach.     

Personality change disorder in children and adolescents following traumatic brain injury.

The occurrence of personality change due to traumatic brain injury (PC), and its clinical and neuroimaging correlates were investigated. Ninety-four children, ages 5 through 14 at the time of hospitalization following traumatic brain injury (TBI; severe TBI N = 37; mild-moderate TBI N = 57), were assessed. Standardized psychiatric, adaptive functioning, cognitive functioning, family functioning, family psychiatric history, severity of injury, and neuroimaging assessments were conducted. The Neuropsychiatric Rating Schedule (NPRS) was used to establish a diagnosis of PC. Approximately 40% of consecutively hospitalized severe TBI participants had ongoing persistent PC an average of 2 years postinjury. An additional approximately 20% had a history of a remitted and more transient PC. PC occurred in 5% of mild-moderate TBI but was always transient. Interrater reliability for the diagnosis of PC was good (Kappa = .70). In severe TBI participants, persistent PC was significantly associated with severity of injury, particularly impaired consciousness over 100 hr, adaptive and intellectual functioning decrements, and concurrent diagnosis of secondary attention deficit hyperactivity disorder, but was not significantly related to any psychosocial adversity variables. These findings suggest that PC is a frequent diagnosis following severe TBI in children and adolescents, but is much less common following mild-moderate TBI.     

Significant other burden and factors related to it in traumatic brain injury

Feelings of burden and factors related to it were examined in a sample of 180 relatives of moderately to severely traumatically brain injured (TBI) subjects 6 months postinjury. Relatives were enrolled onto the study based on their family member's head injury and not on outcome. The results indicate that although both positive and negative experiences were common, the majority of the relatives reported an overall positive experience. The significant other's (SO's) experience was significantly and systematically related to many factors with overall negative experience associated with increased brain injury severity, worse neuropsychological functioning, increased dependency on others, SO's report of changes in the TBI subject, changes in the SO's life as a result of caregiving and SO depression.     

Cognitive complaints after mild traumatic brain injury: things are not always what they seem

OBJECTIVE: To compare nonreferred, emergency department (ED)-admitted mild traumatic brain injury (MTBI) patients with and without self-reported cognitive complaints on (1) demographic variables and injury characteristics; (2) neuropsychological test performance; (3) 12-day self-monitoring of perceived cognitive problems; and (4) emotional distress, physical functioning, and personality. METHODS: (Neuro)psychological assessment was carried out 6 months post-injury in 79 patients out of a cohort of 618 consecutive MTBI patients aged 18-60, who attended the ED of our level I trauma centre. Cognitive complaints were assessed with the Rivermead Postconcussional Symptoms Questionnaire (RPSQ). In addition, patients monitored concentration problems and forgetfulness during 12 consecutive days. RESULTS: Self-reported cognitive complaints were reported by 39% of the patients. These complaints were strongly related to lower educational levels, emotional distress, personality, and poorer physical functioning (especially fatigue) but not to injury characteristics. Severity of self-reported cognitive complaints was neither associated with the patients' daily observations of cognitive problems nor with outcome on a range of neuropsychological tests. CONCLUSION: Self-reported cognitive complaints were more strongly related to premorbid traits and physical and emotional state factors than to actual cognitive impairments. In line with previous work, this suggests that treatment of emotional distress and fatigue may also reduce cognitive complaints. Cognitive outcome assessment of symptomatic MTBI patients should not be restricted to checklist ratings only, but also include a (neuro)psychological screening. In addition, daily monitoring of complaints is a useful method to gather information about the frequency and pattern of cognitive problems in daily life.     

Social Support Moderates Caregiver Life Satisfaction Following Traumatic Brain Injury

Social support is an important determinant of adjustment following traumatic brain injury (TBI) sustained by a family member. The present study examined the extent to which social support moderates the influence of characteristics of the person with injury on caregiver subjective well-being. Sixty pairs of individuals who had sustained a moderate to severe TBI and their caregivers (N = 120) participated. Years postinjury ranged from 0.3 to 9.9 (M = 4.8, SD = 2.6). Cognitive, functional, and neurobehavioral functioning of participants with TBI were assessed using neuropsychological tests and rating scales. Caregiver life satisfaction and perceived social support were assessed using self-report questionnaires. Results indicated that time since injury was unrelated to life satisfaction. Neurobehavioral disturbances showed an inverse relation with life satisfaction. Social support emerged as an important moderator of life satisfaction. Only among caregivers with low social support was cognitive dysfunction adversely related to life satisfaction. Similarly, a trend suggested that patient unawareness of deficit was associated with caregiver life dissatisfaction only among caregivers with low social support. In contrast, these characteristics were unrelated to life satisfaction among caregivers with adequate social support.     

Differences in attention, executive functioning, and memory in children with and without ADHD after severe traumatic brain injury.

Although the development of Attention Deficit Hyperactivity Disorder (ADHD) after traumatic brain injury (TBI) has been described, it is unknown whether children with TBI and ADHD have greater neuropsychological impairments than children with TBI alone. This study examines attention, executive functioning, and memory in children with TBI-only and TBI + ADHD. Caregivers of 82 children with severe TBI completed structured psychiatric interviews at enrollment to diagnose premorbid ADHD and one-year after injury to diagnose post-injury ADHD. Children underwent neuropsychological testing one year after injury. One memory measure significantly differentiated children with TBI-only from children with newly developed ADHD [secondary ADHD (S-ADHD)] and those with premorbid ADHD that persisted after injury [persisting ADHD (P-ADHD)]. Compared with the TBI-only group, children with TBI + ADHD had worse performance on measures of attention, executive functioning, and memory. Results reveal that in children with severe TBI, the behavioral diagnosis of ADHD is associated with more difficulty in attention, executive functioning, and memory. Additionally, results suggest greater deficits in memory skills in the S-ADHD group compared with the P-ADHD group. Although findings provide preliminary support for distinguishing P-ADHD from S-ADHD, further research is needed to investigate neuropsychological differences between these subgroups of children with severe TBI.     

Predictors of personality change due to traumatic brain injury in children and adolescents six to twenty-four months after injury

Phenomenology and predictive factors of personality change due to traumatic brain injury (TBI) 6 to 24 months after injury was investigated in children, ages 5 to 14 years, enrolled from consecutive admissions and followed prospectively for 2 years. Injury and preinjury psychosocial variables were assessed. Personality change occurred in 13% of participants between 6 and 12 months after injury and 12% in the second year after injury. Severity of injury consistently predicted personality change, and preinjury adaptive function predicted personality change only in the second year postinjury. Lesions of the superior frontal gyrus were associated with personality change between 6 and 12 months following injury, after controlling for severity of injury and the presence of other brain lesions. Only lesions in the frontal lobe white matter were significantly related to personality change in the second year after injury. After childhood TBI, neural correlates of personality change evolve between 6 and 12 months and 12 to 24 months after injury. The data implicate the dorsal prefrontal cortex and frontal lobe white matter in the emergence of personality change involving the effortful or conscious regulation of affective states.     

Significant Other Burden and Factors Related to it in Traumatic Brain Injury

Feelings of burden and factors related to it were examined in a sample of 180 relatives of moderately to severely traumatically brain injured (TBI) subjects 6 months postinjury. Relatives were enrolled onto the study based on their family member's head injury and not on outcome. The results indicate that although both positive and negative experiences were common, the majority of the relatives reported an overall positive experience. The significant other's (SO's) experience was significantly and systematically related to many factors with overall negative experience associated with increased brain injury severity, worse neuropsychological functioning, increased dependency on others, SO's report of changes in the TBI subject, changes in the SO's life as a result of caregiving and SO depression.     

Early metabolic crisis-related brain atrophy and cognition in traumatic brain injury

Traumatic brain injury often results in acute metabolic crisis. We recently demonstrated that this is associated with chronic brain atrophy, which is most prominent in the frontal and temporal lobes. Interestingly, the neuropsychological profile of traumatic brain injury is often characterized as ‘frontal-temporal’ in nature, suggesting a possible link between acute metabolic crisis-related brain atrophy and neurocognitive impairment in this population. While focal lesions and diffuse axonal injury have a well-established role in the neuropsychological deficits observed following traumatic brain injury, no studies to date have examined the possible contribution of acute metabolic crisis-related atrophy in the neuropsychological sequelae of traumatic brain injury. In the current study we employed positron emission tomography, magnetic resonance imaging, and neuropsychological assessments to ascertain the relationship between acute metabolic crisis-related brain atrophy and neurocognitive outcome in a sample of 14 right-handed traumatic brain injury survivors. We found that acute metabolic crisis‐related atrophy in the frontal and temporal lobes was associated with poorer attention, executive functioning, and psychomotor abilities at 12 months post-injury. Furthermore, participants with gross frontal and/or temporal lobe atrophy exhibited numerous clinically significant neuropsychological deficits in contrast to participants with other patterns of brain atrophy. Our findings suggest that interventions that reduce acute metabolic crisis may lead to improved functional outcomes for traumatic brain injury survivors.     

Neuropsychological and neurobehavioral correlates of aggression following traumatic brain injury

This study aimed to establish the neuropsychological and neurobehavioral profile of individuals who develop aggression following traumatic brain injury. In a prospective cohort study, 134 brain-injured individuals who exhibited aggression were compared to 153 individuals who had sustained comparable injuries but were not aggressive. In the aggressive group, specific deficits were identified in verbal memory and visuo-perceptual skills. Compared to normative data, this group had impaired executive-attention function. It is tentatively suggested that significant impairment in verbal memory and visuospatial abilities against a background of diminished executive-attention functioning is associated with the development of aggression after brain injury, especially when other risk factors such as low premorbid IQ, low socioeconomic status, and male gender are present.