Psychological distress and family burden following spinal cord injury: concurrent traumatic brain injury cannot be overlooked

Although concurrent spinal cord injury (SCI) and traumatic brain injury (TBI) are recognized, there is little acknowledgement of SCI/TBI as a contributor to psychological distress and family burden. By mail-out questionnaire, we evaluated psychological distress and family burden in a married group (n = 12) with traumatic SCI who had not been identified as having concurrent TBI on referral to the Canadian Paraplegic Association. Both the person with SCI and the partner completed the Brief Symptom Inventory (BSI), the Adjective Checklist, and a Likert strain scale to measure the perception of the partner's strain. The partner also completed the Zarit Burden Interview. Despite screening criteria designed to selectively recruit individuals without TBI, seven individuals described post-traumatic amnesia (PTA) > or = 3 days. Subsequently, participants' reports were divided into two groups--"longer PTA" and "shorter PTA". On the Brief Symptom Inventory, the two SCI groups did not differ, but the partners of individuals with "longer PTA" had significantly elevated Global Severity Index scores compared to the other partners. The "longer PTA" partner group demonstrated more strain and more burden (as measured by the Likert strain scale and the Zarit Burden Interview). Given the size of the groups (n = 7, n = 5), these findings are presented to illustrate trends and to stimulate further research.     

N200 latency and P300 amplitude in depressed mood post-traumatic brain injury patients

In order to examine the independent and combined effects of depressive symptoms and traumatic brain injury on event-related potential (ERP) components, we classified traumatic brain injury (TBI) patients as depressed and non-depressed mood according to their scores on the Zung Self-rating Depression Scale (SDS). Non-depressed mood post-traumatic brain injury patients (NondepTBI, n=9), depressed mood post-traumatic brain injury patients (DepTBI, n=26), and normal healthy control subjects (HC, n=10) were assessed for N100, N200, and P300 latencies and amplitudes by the auditory "oddball paradigm". DepTBI subjects had significantly prolonged N200 latency and low P300 amplitude compared with the NondepTBI and HC groups. A longer P300 latency in the NondepTBI and DepTBI than in the HC groups was found. A prolongation of N200 latency accompanied by low P300 amplitude may be a characteristic of post-traumatic brain injury patients with depressed mood. Prolonged P300 latency may be more closely associated with TBI than with depression, as it was significantly greater in both the DepTBI and NondepTBI, than in the HC group.     

Boomerang Sign on MRI

Introduction

Altered mental status and more subtle cognitive and personality changes after traumatic brain injury (TBI) are pervasive problems in patients who survive initial injury. MRI is not necessarily part of the diagnostic evaluation of these patients.

Methods

Case report with relevant image and review of the literature.

Results

Injury to the corpus callosum is commonly described in traumatic brain injury; however, extensive lesions in the splenium are not well described. This image shows an important pattern of brain injury and demonstrates a common clinical syndrome seen in patients with corpus callosum pathology.

Conclusion

Injury to the splenium of the corpus callosum due to trauma may be extensive and can cause significant neurologic deficits. MRI is important in the diagnostic evaluation of patients with cognitive changes after TBI.     

颅脑创伤后血清抗脑抗体变化及免疫抑制研究

目的 研究重型颅脑创伤患者血清抗脑抗体变化趋势;探讨免疫抑制治疗对于创伤后兔脑组织的保护作用.方法 ELISA法检测49例颅脑创伤患者和47例健康人的血清抗脑抗体浓度,时间点为伤后第3天、第7天、2周、3周、1、2、6、9个月;24只新西兰大白兔随机分为创伤组、免疫抑制组、假手术组;免疫抑制组伤后隔日口服环孢素A 50 mg,收集创伤前2 h及伤后3、7、14、21、28、35、42、49 d血清标本,检测血清抗脑抗体的浓度;50 d后处死,取创伤周围皮层组织,用免疫组化法测定谷氨酸表达,TUNEL法测定细胞凋亡.结果 颅腩创伤患者血清抗脑抗体明显高于健康人并持续较长时间;兔免疫抑制剂组血清抗脑抗体峰值较创伤组低;三组兔血清中抗腩抗体浓度两两比较差异有统计学意义(P<0.05);免疫抑制组兔创伤周围脑组织谷氨酸表达以及凋亡细胞明显低于颅脑创伤组(P<0.05).结论 健康人群血清中存在少量抗脑抗体;颅脑创伤后血清中抗腩抗体较正常状态明显升高;免疫抑制治疗通过降低组织免疫功能,降低自身抗脑抗体的产生,从而减轻继发性脑损害;免疫抑制治疗将可能是一种新的颅脑创伤治疗方法.     

rh—EPO对大鼠颅脑损伤模型脑红蛋白表达研究

目的观察重组人促红细胞生成素rh—EPO对大鼠脑损伤后皮层脑红蛋白NGB表达的影响,探讨其在脑损伤后的意义。方法78只大鼠随机分为3组：假手术组6只,单纯颅脑损伤组36只,rh—EPO干预组36只。单纯颅脑损伤组与rh—EPO干预组模型分别按照3h、6h、12h、24h、48h、72h 6个时间点随机分为6个亚组,每个亚组6只大鼠,通过免疫组化及图像分析方法,观察打击区周边皮层中脑红蛋白NGB的表达。结果单纯颅脑损伤组打击周边区NGB蛋白免疫反应阳性细胞表达较假手术组增多（P〈0．01）,在相应区域rh—EPO干预组明显高于前两组（P〈0．01）。结论rh—EPO可诱导增加大鼠脑损伤后脑红蛋白的表达。     

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.     

大鼠颅脑损伤后大脑中动脉形态结构的变化

目的探讨颅脑损伤后大鼠损伤侧和对侧大脑中动脉形态结构及管壁细胞Cx40、Cx43的改变。方法成年SD大鼠45只按随机数字表发随机分为正常组（9只）、假手术组（9只）及损伤组（27只）,损伤组又根据伤后时间分为伤后6 h、24 h、72 h三个亚组（每亚组9只）。利用液压冲击法建立大鼠颅脑损伤模型,通过显微镜和透射电镜观察损伤侧和对侧大脑中动脉形态学改变,免疫组化法检测管壁细胞Cx40、Cx43表达水平改变。结果颅脑损伤后,大鼠损伤侧大脑中动脉随时间进程出现不同程度的内皮细胞形态结构改变、内弹力膜皱缩、平滑肌细胞水肿变形,进而管腔出现不同程度的狭窄甚至闭塞;损伤对侧大脑中动脉也出现形态结构改变,但发生较晚,程度较轻。与对照组相比,损伤组大鼠损伤侧和对侧大脑中动脉血管壁细胞Cx40、Cx43表达均明显增加（P〈0.05）,伤后24 h达高峰。结论颅脑损伤后不仅损伤区域大血管受损,远隔区域大血管亦可见损伤性改变。     

Caregiver reports of common symptoms in children following a traumatic brain injury

This study describes the common symptoms in children and adolescents following a traumatic brain injury (TBI) as reported by their primary caregivers. Utilizing data from a large-scale state demonstration project, 681 children who had sustained a TBI were ascertained from both Hospital Emergency Departments (n = 409) and Pediatric Inpatient settings (n = 272). The sample ranged in age from infancy to 18 years, was largely male (59.7%), and had equal numbers of Caucasian and minority patients. Most of the participants experienced a mild TBI (83%), with about 5.1% being moderate and 12% severe. Caregivers described the presence of current symptoms (neurological, neurocognitive, behavioral, school problems) using a series of dichotomous questions regarding their child via a structured telephone interview at 1, 4, and 10 months post-injury. Inpatient children were described as manifesting more symptoms at each of the follow-up time points than their ED counterparts. At 1 month inpatients were described as having more symptoms across all 4 domains. At 4 and 10 months, the inpatients were described as having more neurocognitive symptoms and as not returning to school on a full-time basis, with behavior problems approaching significance at the 10-month point. A large number of individuals from both groups also reported persistent symptoms 10 months post-injury including headaches, attention and memory problems, low frustration tolerance, sleep problems, personality changes, and new school problems. Practical implications of these findings for the ongoing management of these children are discussed.     

颅脑创伤患者记忆障碍比较研究

目的探讨不同类型颅脑创伤患者记忆障碍的特征。方法根据患者入院时GCS评分,按创伤严重程度将42例颅脑创伤患者分为轻度创伤组(GCS13～15分,16例)、中度创伤组(GCS9～12分,14例)和重度创伤组(GCS3～8分,12例)。采用临床记忆量表进行短时记忆测量并与42名健康受试者(对照组)进行比较,观察冲击点伤、对冲伤、混合伤及加速伤、减速伤、混合伤、切线伤对颅脑创伤患者记忆力的影响。结果与对照组相比,不同程度颅脑创伤患者的记忆商(MQ)均显著下降,其中轻度创伤组与中、重度创伤组相比,差异具有显著性意义(P<0.05);冲击点伤、对冲伤以及混合伤患者之间MQ相比,差异具有显著性意义(P<0.01),冲击点伤患者的MQ值最高(P<0.05);加速伤、减速伤、混合伤和切线伤患者之间MQ相比,差异亦有显著性意义(P<0.01)。结论颅脑创伤后混合伤和切线伤对患者记忆的影响最为明显。     

Effect of methylphenidate on ICU and hospital length of stay in patients with severe and moderate traumatic brain injury

OBJECTIVE: Traumatic brain injury is one of the major causes of death and disability among young people. Methylphenidate, a neural stimulant and protective drug, which has been mainly used for childhood attention deficit/hyperactivity disorder, has shown some benefits in late psychosocial problems in patients with traumatic brain injury. Its effect on arousal and consciousness has been also revealed in the sub-acute phase of traumatic brain injury. We studied its effect on the acute phase of moderate and severe traumatic brain injury (TBI) in relation to the length of ICU and hospital admission. PATIENTS AND METHODS: Severely and moderately TBI patients (according to inclusion and exclusion criteria) were randomized to treatment and control groups. The treatment group received methylphenidate 0.3mg/kg per dose PO BID by the second day of admission until the time of discharge, and the control group received a placebo. Admission information and daily Glasgow Coma Scale (GCS) were recorded. Medical, surgical, and discharge plans for patients were determined by the attending physician, blinded to the study. RESULTS: Forty patients with severe TBI (GCS = 5-8) and 40 moderately TBI patients (GCS = 9-12) were randomly divided into treatment and control groups on the day of admission. In the severely TBI patients, both hospital and ICU length of stay, on average, were shorter in the treatment group compared with the control group. In the moderately TBI patients while ICU stay was shorter in the treatment group, there was no significant reduction of the period of hospitalization. CONCLUSION: There were no significant differences between the treatment and control groups in terms of age, sex, post resuscitation GCS, or brain CT scan findings, in either severely or moderately TBI patients. Methylphenidate was associated with reductions in ICU and hospital length of stay by 23% in severely TBI patients (P = 0.06 for ICU and P = 0.029 for hospital stay time). However, in the moderately TBI patients who received methylphenidate, there was 26% fall (P = 0.05) only in ICU length of stay.     

Post-traumatic amnesia

Of patients hospitalised for traumatic brain injury (TBI), most pass through a state of altered consciousness known as “post-traumatic amnesia” (PTA). Despite the lack of a consistent definition, PTA is widely used as a construct in neurosurgical practice to guide decision-making and prognosis. Accurate PTA assessment is important, because over-evaluation leads to excess social, financial and opportunity costs, whilst under-evaluation risks patient welfare. Whilst anterograde memory is certainly disrupted in PTA, PTA in fact involves a far more extensive memory disturbance. More instructively, the complete “post-TBI syndrome” also comprises an extensive cognitive deficit which includes a confusional state, as well as a behavioural disturbance characterised by acute agitation. Recently, impairments in attention and executive functioning have also been emphasised; indeed, some consider these the primary disturbance with PTA. Although all of these features were fully described (or implied) by the earliest pioneers, most current PTA scores do not assess the complete “post-TBI syndrome”. Currently, the Westmead PTA scale (WPTAS) directs most in-hospital TBI management throughout Australasia: however, in addition to general defects, specific limitations have been identified in the levels of evidence for WPTAS validity. We review the literature regarding PTA and, in particular, the continued role of the WPTAS in directing neurosurgical practice.     

脑损伤后脑细胞外液中糖代谢变化的微透析研究

目的探讨微透析技术监测脑损伤局部细胞外液(ECF)中糖代谢指标变化的意义。方法应用微透析技术动态收集大鼠轻、重度脑损伤局部的ECF透析液,观察其葡萄糖含量([Glu]d)和乳酸含量([Lac]d)的变化。结果透析管插入引起[Glu]d和[Lac]d的变化很小(P>0.05)。脑损伤后[Glu]d下降,与对照组及损伤前相比,相差显著(P<0.05),且损伤越重其变化越显著(P<0.05)。而脑损伤后[Lac]d则上升,与对照组及损伤前相比,相差显著(P<0.05),且损伤越重,其变化亦越显著(P<0.05)。脑损伤后[Glu]d和[Lac]d的变化分别与脑组织含水量呈显著负相关(P<0.05)和显著正相关性(P<0.05)。结论微透析技术是一种理想的动态监测脑损伤局部生化改变的方法;利用该技术监测损伤区ECF中糖代谢指标的异常变化,可以作为判定脑损伤程度的重要依据。     

A forensic peer group approach to bullying after traumatic brain injury

A forensic peer group programme adapted for bullying behaviour and antisocial attitudes in three young men with traumatic brain injury (TBI) is presented. Three TBI clients who had previously been resistant to an intensive neurobehavioural rehabilitation residential programme were enrolled into the EQUIP programme. EQUIP focused on teaching pro-social skills as they related to aggression, increasing moral development, and altering pro-aggressive attitudes. The group ran four days per week over six weeks, with each session lasting 30 minutes. Post-group assessment indicated that two of the three participants altered their beliefs regarding antisocial behaviour. At three-month follow up, of the two who demonstrated change one had returned to baseline while the other had maintained his progress. Aggression and bullying behaviour reduced in all three clients during the EQUIP programme and these improvements were maintained at three-month follow up. Self-esteem measures did not alter across the assessment period. Antisocial beliefs and their potential for change in clients with severe TBI are discussed.     

A forensic peer group approach to bullying after traumatic brain injury

A forensic peer group programme adapted for bullying behaviour and antisocial attitudes in three young men with traumatic brain injury (TBI) is presented. Three TBI clients who had previously been resistant to an intensive neurobehavioural rehabilitation residential programme were enrolled into the EQUIP programme. EQUIP focused on teaching pro-social skills as they related to aggression, increasing moral development, and altering pro-aggressive attitudes. The group ran four days per week over six weeks, with each session lasting 30 minutes. Post-group assessment indicated that two of the three participants altered their beliefs regarding antisocial behaviour. At three-month follow up, of the two who demonstrated change one had returned to baseline while the other had maintained his progress. Aggression and bullying behaviour reduced in all three clients during the EQUIP programme and these improvements were maintained at three-month follow up. Self-esteem measures did not alter across the assessment period. Antisocial beliefs and their potential for change in clients with severe TBI are discussed.     

Spinal Cord Injury and Traumatic Brain Injury: A Cost-of-Illness Study

Background: Among traumatic injuries, spinal cord injuries (SCI) and traumatic brain injuries (TBI) are of major importance because of their epidemiological and economic impact on society. The overall objective of this study was to estimate the economic cost associated with people with SCI and TBI in Spain in 2007. Methods: A cost-of-illness analysis was performed, considering the perspective of society, using a 1-year time horizon. Medical costs, adaptation costs, material costs, administrative costs, and costs of police, firefighters and roadside assistance, productivity losses due to institutionalization and sick leave, as well as an estimate of productivity losses of carers, and productivity losses due to death were included. Results: The economic cost associated with people with SCI is between EUR 92,087,080.97 and 212,496,196.41 (USD 131 million and 302 million) according to the injury mechanism, and between EUR 1,079,223,688.66 and 3,833,752,692.78 (USD 1,536 million and 5,458 million) for people with TBI. Conclusions: There is an urgent need to develop effective interventions known to prevent SCI and TBI, and to evaluate their effectiveness and efficiency.     

大鼠颅脑创伤后肝细胞生长因子表达变化的实验研究

目的 探讨肝细胞生长因子(HGF)在颅脑创伤后的表达趋势,为颅脑创伤治疗中的HGF干预策略提供前期研究基础. 方法 96只wistar大鼠按随机数字表法分为实验组和假手术组,实验组为液压冲击中度颅脑创伤大鼠,并分为伤后2h、6h、12h、24 h、72h、168 h、336 h组,假手术组不致伤,每组再分为两个亚组.每亚组6只,一组行HE及免疫组化染色,观察伤后病理变化及HGF的表达部位和表达量,另外一组用RT-PCR的方法 观察创伤后HGF mRNA表达情况.结果 在创伤后的大鼠大脑皮层组织中,HGF在蛋白水平以及基因水平都出现表达增高的情况.创伤边缘区HGF阳性细胞数从伤后24 h开始增多,168 h达高峰,336 h有所下降,但仍高于伤前水平,差异有统计学意义(P<0.05).HGF mRNA表达量从创伤后72 h开始增加,168 h达高峰,与假手术组比较差异有统计学意义(P<0.05). 结论 HGF作为神经营养因子和血管生长因子,可能参与了颅脑创伤后神经元的保护和组织的修复、再生.     

重组人促红细胞生成素对大鼠颅脑损伤后细胞间黏附分子-1及炎症因子表达变化的影响

目的 观察重组人促红细胞生成素(r-HuEPO)对大鼠颅脑损伤后细胞间黏附分子-1(ICAM-1)、IL-6和IL-10表达的影响,探讨其颅脑损伤后的抗炎症反应机制. 方法 75只雄性Wistar大鼠按随机数字表法分为假手术组(n=5)、颅脑损伤组(n=35)及r-HuEPO治疗组(n=35).采用改进Feeney法制作大鼠颅脑损伤模型,应用免疫组织化学法检测伤侧脑组织ICAM-1的表达.双抗体夹心酶联免疫(ELISA)法检测血清IL-6、IL-10表达水平. 结果 与假手术组相比.颅脑损伤组、r-HuEPO治疗组ICAM-1、IL-6和IL-10表达水平均明显增加;其中r-HuEPO治疗组与颅脑损伤组比较,ICAM-1和IL-6的表达相对降低,IL-10的表达相对增加. 结论 r-HuEPO可能通过促进IL-10的表达,抑制ICAM-1、IL-6的表达而减少颅脑损伤后细胞炎症反应.发挥脑保护作用     

Posttraumatic amnesia and recall of a traumatic event following traumatic brain injury

The relationship between posttraumatic amnesia (PTA) and symptoms of posttraumatic stress disorder (PTSD) was examined in 282 outpatients at a mean of 53 days after traumatic brain injury (TBI). Patients were assessed for TBI severity, intrusive and avoidant PTSD-type symptoms, and psychological distress, and were stratified into four comparison groups by duration of PTA. Levels of PTSD-type symptoms and psychological distress did not differ significantly between groups. Even patients with PTA >1 week reported intrusive and avoidant PTSD-type symptoms. However, when patients were stratified into those with PTA of <1 hour or >1 hour, the former were more likely to report such symptoms. TBI patients with brief PTA are more likely to experience PTSD-type reactions, but severe TBI with prolonged PTA is not incompatible with such reactions in a subset of patients. Possible mechanisms that could account for this finding are discussed.