Balance abilities in individuals with moderate and severe traumatic brain injury

Balance characteristics, latency, amplitude, and symmetry were measured in 23 moderate and 23 severe traumatic brain-injured (TBI) patients. Patients received two graded forward and two graded backward linear perturbations. Although within normal limits, latency was high. Patients were able to appropriately grade force in relation to the size of the perturbation. Standing posture prior to and during perturbation was recorded by the amount of force generation through each lower extremity. Some individuals used an asymmetrical balance response following perturbations, whereas others shifted to a more symmetrical weight-bearing balance response. TBI patients may be prone to instability due to a combination of long latency of onset of the balance response coupled with asymmetrical stance patterns during recovery from an unexpected linear perturbation.     

The impact of anemia in moderate to severe traumatic brain injury

Purpose

The impact of anemia and restrictive transfusion strategies in traumatic brain injury (TBI) is unclear. The purpose of this study was to examine the outcome of varying degrees of anemia in patients who have sustained a TBI.

Methods

We performed a retrospective study of all adult patients with isolated blunt TBI admitted between January 2003 and June 2010. The impact of increasing severity of anemia (Hb ≤8, ≤9, or ≤10 g/dl measured on three consecutive draws within the first 7 days of admission) and transfusions on complications, length of stay, and mortality was examined using univariate and multivariate analysis.

Results

Of the 31,648 patients with blunt trauma admitted to the trauma service during the study period, 812 had an isolated TBI, among which 196 (24.1 %) met at least one of the anemia thresholds within the first 7 days [78 % male, mean age 47 ± 23 years, Injury Severity Score 16 ± 8, and head Abbreviated Injury Scale 3.3 ± 1.0]. Using a logistic regression model, anemia even as low as 8 g/dl was not associated with an increase in mortality [AOR₈ = 0.8 (0.2, 3.2), p = 0.771; AOR₉ = 0.8 (0.4, 1.6), p = 0.531; AOR₁₀ = 0.6 (0.3, 1.3), p = 0.233] or complications. However, for all patients, the transfusion of packed red blood cells was associated with a significant increase in septic complications [AOR = 3.2 (1.5, 13.7), p = 0.030].

Conclusion

The presence of anemia in patients with TBI as low as 8 g/dl was not associated with increased mortality or complications, while the transfusion of red blood cells was associated with a significant increase in septic complications. Prospective evaluation of an optimal transfusion trigger in head-injured patients is warranted.     

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.     

Mortality and morbidity from moderate to severe traumatic brain injury in Argentina

After adopting the Guidelines for the Management of Severe Head Injury, critical care physicians in Argentina reduced the mortality rate of patients with traumatic brain injury (TBI). However, there is no in-hospital or postdischarge rehabilitation services for persons with TBI in Argentina. Thus, severely disabled survivors were being discharged to home without follow-up or long-term care. OBJECTIVES: The objectives of this project were to establish a structure for conducting research about TBI in Argentina, and to conduct a prospective, observational study of outcomes from TBI in hospitals that had adopted the acute care guidelines. The goal was to document outcomes for people treated in a medical system that does not provide TBI rehabilitation. The focus of this report is mortality and morbidity during the acute care and hospital ward treatment of TBI in Argentina. METHODS: We established a data-collection system in 5 hospitals in Argentina, using instruments and protocols developed by the NIDRR-funded TBI Model System program. Data-collection intervals were established to be comparable with intervals used in the TBI Model System program. The Argentine team consists of 11 neurocritical care physicians and 1 project manager/translator. All patient evaluation, data collection and entry, quality control, and local administration were conducted by this group. RESULTS: Over 31 months, 278 patients were entered into the study. Approximately 61% were discharged from acute care directly to home. The in-hospital mortality rate was 31%. Seventy-six percent of expired patients died from secondary complications such as sepsis and pneumonia, and 93% while in the hospital. DISCUSSION: TBI is a major public health concern in Argentina. However, rehabilitation for TBI is not a part of this country's medical system. The greatest proportion of expired patients in the Argentine sample died of secondary complications such as pneumonia or sepsis, which may have been avoided employing basic medical rehabilitation. The next research questions to be addressed in this population should be designed to identify solutions to the immediate need for rehabilitation, including treatment efficacy questions as well as questions about systems for delivering treatments.     

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.     

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.     

Personality and neurocognitive correlates of impulsive aggression in long-term survivors of severe traumatic brain injury

This study addresses a common outcome of severe traumatic brain injury (TBI), disinhibited aggressive behaviour. This behaviour has been classified in aggression literature as 'impulsive aggression' (IA). The purpose was to: (1) characterize those TBI patients who are likely to be an aggression risk, and (2) determine if TBI patients with IA demonstrate personality style and neurocognitive performance similar to that seen in other IA groups. Participants were 45 survivors of severe TBI (26 of whom had persisting problems with IA), who were clients of a residential brain injury treatment facility. IA participants had a higher incidence of pre-morbid aggressive behaviour, were younger, had a shorter tenure in the programine, and were more impulsive, irritable, and antisocial than the non-aggressive control participants. Unlike past research, no neurocognitive differences were found. The results are discussed in terms of the conceptualization, identification, and treatment of persisting IA in severe TBI.     

Ethical considerations on consent procedures for emergency research in severe and moderate traumatic brain injury

Summary Therapeutic trials in TBI are subject to principles of Good Clinical Practice (GCP), to national legislation, and to international and European ethical concepts and regulations [e.g. 13]. The guiding principles underlying these investigations of treatment are respect for autonomy of research subjects, protection against discomfort, risk, harm and exploitation and the prospect of some benefit. Patients with significant TBI are mentally incapacitated, thus prohibiting obtaining consent directly from the subject. Various approaches to consent procedures are used as surrogate to subject consent: proxy consent, consent by an independent physician and waiver of consent. These approaches are reviewed. A questionnaire soliciting opinions was mailed to 148 EBIC (European Brain Injury Consortium) associated neuro-trauma centers in 19 European countries. 48% respondents believe that relatives were not able to make a balanced decision, 72% believed that consent procedures are a significant factor causing decrease in enrollment rate and 83% stated that consent procedures delay initiation of study treatment, resulting in possible harm if the agent has shown to be effective. 64% of the respondents considered TBI an emergency situation in which clinical research could be initiated under the emergency exception for consent. In new European legislation, emergency research under waiver of consent is not permitted. Nevertheless, we consider that randomising patients with TBI into carefully evaluated trial protocols without prior consent may be considered ethically justified.     

Management of severe traumatic brain injury

Severe brain injuries, most often occurring in young subjects, are a major source of lost work years. These injuries are medical and surgical emergencies. Prehospital management of severe brain injuries requires intubation and mechanical ventilation aimed at normal arterial carbon dioxide pressure. Signs of transtentorial herniation: Uni- or bilateral mydriasis requires immediate perfusion of 20% mannitol or hypertonic sodium chloride. Neurological disorders after head injury justify emergency cerebral computed tomography. The presence of a mass syndrome or signs of transtentorial herniation are in principle indications for surgery. Specialized hospital management is essential. In the case of refractory intracranial hypertension, the cerebral perfusion pressure and osmotherapy should be adapted to the volume of the cerebral contusion. The use of deep hypothermia and barbiturates should be minimized as much as possible. Magnetic resonance imaging makes it possible to identify the cerebral lesions.     

Effect of traumatic subarachnoid haemorrhage on neuropsychological profiles and vocational outcome following moderate or severe traumatic brain injury

OBJECTIVE: Traumatic subarachnoid haemorrhage (tSAH) frequently occurs in moderate or severe traumatic brain injury (TBI) and is related to worse outcome at time of discharge from the acute hospitalization. The current study compared neuropsychological impairment and vocational outcome at 1-year post-injury in patients with and without tSAH. DESIGN: Acute injury, neuroradiological, neuropsychological and vocational data were collected for 100 patients admitted for neurorehabilitation following TBI. RESULTS: Patients with tSAH had significantly worse vocational outcome than patients without tSAH. On neuropsychological measures, patients with tSAH generally performed worse than patients without tSAH across most neurocognitive domains. However, differences in neuropsychological test performance between patients with and without tSAH reached statistical significance on measures of visuospatial processing, verbal reasoning and mood only. CONCLUSION: The presence of tSAH appears to be associated with worse vocational outcome in survivors of moderate or severe TBI. As such, the presence of tSAH appears to have predictive value with respect to outcome following TBI.     

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.     

Metabolism and nutrition in patients with moderate and severe traumatic brain injury: A systematic review

Primary objective: To examine the evidence on the metabolic state and nutritional treatment of patients with moderate-to-severe traumatic brain injury (TBI). Research design: A systematic review of the literature. Methods and procedures: From 1547 citations, 232 articles were identified and retrieved for text screening. Thirty-six studies fulfilled the criteria and 30 were accepted for data extraction. Main outcomes and results: Variations in measurement methods and definitions of metabolic abnormalities hampered comparison of studies. However, consistent data demonstrated increased metabolic rate (96-160% of the predicted values), of hypercatabolism (-3 to -16 g N per day) and of upper gastrointestinal intolerance in the majority of the patients during the first 2 weeks after injury. Data also indicated a tendency towards less morbidity and mortality in early fed patients. Conclusions: The impact of timing, content and ways of administration of nutritional support on neurological outcome after TBI remains to be demonstrated.     

Frontal and temporal morphometric findings on MRI in children after moderate to severe traumatic brain injury

In vivo MRI volumetric analysis enables investigators to evaluate the extent of tissue loss following traumatic brain injury (TBI). However, volumetric studies of pediatric TBI are sparse, and there have been no volumetric studies to date in children examining specific subregions of the prefrontal and temporal lobes. In this study, MRI volumetry was used to evaluate brain volume differences in the whole brain, and prefrontal, temporal, and posterior regions of children following moderate to severe TBI as compared to uninjured children of similar age and demographic characteristics. The TBI group had significantly reduced whole brain, and prefrontal and temporal regional tissue volumes as well as increased cerebrospinal fluid (CSF). Confidence interval testing further revealed group differences on gray matter (GM) and white matter (WM) in the superior medial and ventromedial prefrontal regions, WM in the lateral frontal region, and GM, WM, and CSF in the temporal region. Whole brain volume and total brain GM were reduced, and total ventricular volume, total CSF volume, and ventricle-to-brain ratio (VBR) were increased in the TBI group. Additional analyses comparing volumetric data from typically developing children and subgroups of TBI patients with and without regional focal lesions suggested that GM loss in the frontal areas was primarily attributable to focal injury, while WM loss in the frontal and temporal lobes was related to both diffuse and focal injury. Finally, volumetric measures of preserved frontotemporal tissue were related to functional recovery as measured by the Glasgow Outcome Scale (adapted for children) with greater tissue preservation predicting better recovery.     

替代剂量的甲泼尼龙治疗急性中重型颅脑创伤后肾上腺皮质功能减低的应用

目的研究急性重型颅脑创伤病人中替代剂量地使用甲泼尼龙（methvlprednisn10ne）联合甘露醇能否改善患者预后状况。方法将74位：急性中重型颅脑外伤病人随机均分成A（GCS=7．57±2．97）、B（GCS=7．81±2,85）两组,然后按照GCS标准再将每组颅脑外伤病人按病情轻重分为中．重型两个亚组（即A1（中型颅脑损伤17人,GCS=10．35±1．13）、A2（重型颅脑损伤20人,GCS=5．20~1．75）、B1（中型颅脑损伤18人,GCS=i0．33-±1．11）、B2（重型颅脑损伤19人,GCS=5．42±1．70））,实验组A组病人在创伤后给予甲泼尼龙（1．0mg·kg。·d。）治疗。对照组B组病人给予同时间同样剂量的安慰剂治疗,疗程均为lO天,其余诊疗经过,如手术及手术方式、营养支持治疗、脱水治疗以及其他用药、护理等情况无明显差异。结果经过治疗,实验组A1亚组病人10天后8例GCS评分≥12分,5例GCS评分9～12分,3例GCS评分3～8分,1例死亡．死亡率5．82％,GCS=11．697±-3．40,与治疗前相比GCS评分未见明显统计学差异（P〉0．05）;实验组A2亚组病人10天后5例GCS评分≥12分,6例GCS评分9～12分,4例GCS评分3～8分,5例死亡,死亡率25．00％,GCS=10．46±3．30,与治疗前GCS相比具有统计学差异（P〈0．01）;对照组B1亚组病人10天后6例GCS评分≥12分,8例GCS评分9～12分。2例GCS评分3～8分,2例死亡,死亡率11．11％,GCS=11．06±2．56,与治疗前GCS相比无统计学差异（p〉0．05）;对照组B2亚组病人10天后2例GCS评分≥12分,5例GCS评分9～12分．6例GCS评分3-8分,7例死亡,死亡率36．84％,GCS=8．15±3．28,与治疗前GCS相比有统计学差异（P〈0．01）;治疗10天后A1组病人与B1组病人GCS评分比较不具有显著统计学差异（P〉0．05）．A2组病人与B2组病人GCS评分比较具有显著统计学差异（P〈0．05）。结论在中型颅脑创伤病人的治疗中使用替代剂量的甲泼尼龙不能显著改善预后,但也不会使病情恶化;而在重型颅脑创伤病人的治疗中使用替代剂量的甲泼尼龙与未使用者相比能显著改善患者预后状况。     

Diffusion tensor imaging in the corpus callosum in children after moderate to severe traumatic brain injury

Diffusion tensor imaging (DTI) is a recent imaging technique that assesses the microstructure of the cerebral white matter (WM) based on anisotropic diffusion (i.e., water molecules move faster in parallel to nerve fibers than perpendicular to them). Fractional anisotropy (FA), which ranges from 0 to 1.0, increases with myelination of WM tracts and is sensitive to diffuse axonal injury (DAI) in adults with traumatic brain injury (TBI). However, previous DTI studies of pediatric TBI were case reports without detailed outcome measures. Using mean FA derived from DTI fiber tractography, we compared DTI findings of the corpus callosum for 16 children who were at least 1 year (mean 3.1 years) post-severe TBI and individually matched, uninjured children. Interexaminer and intraexaminer reliability in measuring FA was satisfactory. FA was significantly lower in the patients for the genu, body, and splenium of the corpus callosum. Higher FA was related to increased cognitive processing speed and faster interference resolution on an inhibition task. In the TBI patients, higher FA was related to better functional outcome as measured by the dichotomized Glasgow Outcome Scale (GOS). FA also increased as a function of the area of specific regions of the corpus callosum such as the genu and splenium, and FA in the splenium was reduced with greater volume of lesions in this region. DTI may be useful in identifying biomarkers related to DAI and outcome of TBI in children.     

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.     

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.     

中重度颅脑损伤后血清三碘甲腺原氨酸水平变化与预后的关系

目的研究中重度颅脑损伤后血清三碘甲腺原氨酸水平变化与预后的关系。方法应用酶联免疫定量分析法多次检测164例中重度颅脑损伤患者游离三碘甲腺原氨酸(FT_3)、三碘甲腺原氨酸(T_3)水平的动态变化,同时记录GCS评分,观察分析血清FT_3及T_3水平变化与GCS变化的关系。结果不同程度的中重度颅脑损伤患者,其中恢复较好的患者在第7天和第14天检测的血清T_3和FT_3水平显著高于恢复较差的患者血清T_3和FT_3水平。结论中重度颅脑损伤T_3和FT_3的变化与预后密切相关,提高T_3和FT_3水平有望成为治疗中重度颅脑损伤的重要切入点。