3000 head injuries: a prospective study of patients admitted to Brisbane neurosurgical units

A prospective epidemiological study of 3095 patients with head injury admitted to Brisbane neurosurgical units is presented. Falls were the commonest cause of injury overall (42%) but traffic accidents were the leading cause of severe head injury Glasgow Coma Scale ([GCS] 8 or less) and had a higher mortality (5.6%). Outcome was closely related to GCS, presence or absence and type of skull fracture, computed tomography (CT) scan findings and age. Overall mortality was 4.4%. Mortality for mild head injury (GCS 13-15) was 0.4%, moderately severe head injury (GCS 9-12) 10.5% and severe head injury (GCS 3-8) 34.5%. The poor outcome in old patients who fall and sustain a mild head injury is highlighted. Low risk criteria are identified and recommendations regarding admission and management policies are made.     

Head injury in early adulthood and the lifetime risk of depression.

BACKGROUND: Depressive symptoms are common and can be debilitating in the months after head injury. Head injury can also have long-term cognitive effects, but little is known about the long-term risk of depression associated with head injury. We investigated the lifetime rates of depressive illness 50 years after closed head injury. METHODS: Participants were male World War II veterans who served during 1944-1945 and were hospitalized at that time for a head injury, pneumonia, or laceration, puncture, or incision wounds. We used military medical records to establish the presence and severity of closed head injuries. Veterans with (n = 520) and without (n = 1198) head injuries were interviewed in 1996-1997 for their lifetime history of depressive illness. Men with dementia were excluded. RESULTS: Veterans with head injury were more likely to report major depression in subsequent years and were more often currently depressed. Using logistic regression and controlling for age and education, the lifetime prevalence of major depression in the head injured group was 18.5% vs 13.4% in those with no head injury (odds ratio = 1.54, 95% confidence interval = 1.17-2.04). Current major depression was detected in 11.2% of the veterans with head injuries vs 8.5% of those without head injury (odds ratio = 1.63, 95% confidence interval = 1.07-2.50). This increase in depression could not be explained by a history of myocardial infarction, a history of cerebrovascular accident, or history of alcohol abuse. The lifetime risk of depression increased with severity of the head injury. CONCLUSION: The risk of depression remains elevated for decades following head injury and seems to be highest in those who have had a severe head injury.     

Motivation and Neuropsychological Test Performance Following Mild Head Injury

Effect of motivation on neuropsychological test performance in mild head injury was assessed. Motivation was measured using the Portland Digit Recognition Test. Three groups were compared: (a) mild head injury, financial incentives, good motivation; (b) mild head injury, financial incentives, poor motivation; (c) moderate/severe head injury, good motivation. The neuropsychological battery included measures of sensory function, motor function, attention, intelligence, reasoning, and memory. Mild head injury well motivated patients performed significantly better than the other two groups on some tests. Mild head injury poorly motivated individuals and moderate-severe head injury patients were indistinguishable on many tests. Consistent with previous reports, tactile sensory (finger recognition and Fingertip Number Writing Perception) and recognition memory (Rey Auditory Verbal Learning) tasks were identified as clinically useful measures of poor motivation. On these measures mild head injury well motivated examinees performed no better than moderate-severe patients, with both groups superior to mild head injury poorly motivated examinees. Sensitivity and specificity data are reported. Our measures of tactile sensation and verbal recognition memory were more affected by motivation than by the severity of head injury.     

颅脑损伤与胰岛素抵抗的相关性研究

目的分析颅脑损伤的严重性、血糖与胰岛素水平三者之间的关系。方法92例颅脑损伤患者按入院时GCS评分分为轻度、中度及重度颅脑损伤三组，分别于伤后24h、48h、72h测定空腹血糖、血清胰岛素值，并计算稳态模式中的胰岛素抵抗指数（HOMA—IR）。患者出院时按GOS标准评估预后。采用SPSS11．5统计软件对数据进行处理，分析GCS、空腹血糖、胰岛素水平的关系。结果出院时按GOS标准．良好72例，差12例，死亡8例．死亡率8．7％。92例颅脑损伤患者伤后连续3d空腹血糖及胰岛素水平在轻度、中度、重度颅脑损伤三组患者中有显著差异（P〈0．01或P〈0．05）。颅脑损伤程度越重．血糖和HOMA—IR越高。结论空腹血糖值和HOMA—IR值可作为评估颅脑损伤严重程度的参考指标。     

Motivation and neuropsychological test performance following mild head injury

Effect of motivation on neuropsychological test performance in mild head injury was assessed. Motivation was measured using the Portland Digit RecognitionTest. Three groups were compared: (a) mildhead injury, financial incentives, good motivation; (b) mild head injury, financial incentives, poor motivation; (c) moderate/severe head injury, good motivation. The neuropsychological battery included measures of sensory function, motor function, attention, intelligence, abstract reasoning, and memory. Mild head injury well motivated patients performed significantly better than the other two groups on some tests. Mild head injury poorly motivated individuals and moderate-severe head injury patients were indistinguishable on many tests. Consistent with previous reports, tactile sensory (finger recognition and Fingertip Number Writing Perception) and recognition memory (Rey Auditory Verbal Learning) tasks were identified as clinically useful measures of poor motivation. On these measures mild head injury well motivated examinees performed no better than moderate-severe patients, with both groups superior to mild head injury poorly motivated examinees. Sensitivity and specificity data are reported. Our measures of tactile sensation and verbal recognition memory were more affected by motivation than by the severity of head injury.     

Diffuse axonal injury due to nonmissile head injury in humans: An analysis of 45 cases

Forty-five cases of diffuse axonal injury (DAI) brought about by nonmissile head injury in humans are analyzed and compared with 132 cases of fatal head injury without DAI. All cases were subjected to a comprehensive neuropathological study. In the patients with DAI a statistically significant lower incidence of lucid interval, fracture of the skull, cerebral contusions, intracranial hematoma, and evidence of high intracranial pressure were found, with a higher incidence of head injury due to road traffic accident. Brain swelling and hypoxic brain damage were not statistically different in the two groups. The features of DAI in humans are compared with the DAI that has been produced in subhuman primates by pure inertial loading brought about by angular acceleration of the head. The available evidence indicates that DAI in human beings occurs at the time of head injury and is not due to complicating factors such as hypoxia, brain swelling, or raised intracranial pressure.     

Head injury and dementia

PURPOSE OF REVIEW: The link between head injury and dementia/Alzheimer's disease is controversial. This review discusses some recent epidemiological, human autopsy and experimental studies on the relationship between traumatic head injury and dementia. RECENT FINDINGS: Recent epidemiological studies have shown that head injury is a risk factor for the development of dementia/Alzheimer's disease, whereas others have not. After experimental brain trauma the long-term accumulation of amyloid beta peptide suggests that neurodegeneration is influenced by apolipoprotein E epsilon 4, and after human brain injury both amyloid beta peptide deposition and tau pathology are seen, even in younger patients. Amyloid beta peptide levels in the cerebrospinal fluid and the overproduction of beta amyloid precursor protein in humans and animals after traumatic brain injury are increased. Repeated mild head trauma in both animals and humans accelerates amyloid beta peptide accumulation and cognitive impairment. Retrospective autopsy data support clinical studies suggesting that severe traumatic brain injury with long-lasting morphological residuals are a risk factor for the development of dementia/Alzheimer's disease. The influence of the apolipoprotein E genotype on the prognosis of traumatic brain injury is under discussion. SUMMARY: Although epidemiological studies and retrospective autopsy data provide evidence that a later cognitive decline may occur after severe traumatic brain injury, the relationship between dementia after head/brain trauma and apolipoprotein E status is still ambiguous. Both human postmortem and experimental studies showing apolipoprotein beta deposition and tau pathology after head injury support the link between traumatic brain injury and dementia, and further studies are warranted to clarify this relationship.     

Posttraumatic visual agnosia and epilepsy as a consequence of gunshot injury to the head. Case report

Half million people in the world, each year have a gunshot injury to the head and eighty thousand of them are hospitalized. Gunshot injuries to the head have became in Poland second most frequent cause of death from head trauma, and in some countries during peace became the most frequent cause of death among patient with head injury. Glasgow Coma Scale (GCS) is a useful prognostic factor for patients with gunshot injury to the head. Injury to the eloquent regions of the brain, commotion and contusion of the brain, intracranial hematomas, subarachnoid hemorrhage, cerebro-vascular spasm, injuries to the major vessels, liquorrhea, infections, coagulopathies and epilepsy are the most important and influential factors in the clinical status of the patient with gunshot injury to the head. The operation is the preferred treatment to all patient, no matter of their clinical status at the moment of the admission. The report presents the history of treatment of a patient with gunshot injury to the head. During the treatment extremely infrequently occurring posttraumatic visual agnosia and posttraumatic epilepsy were observed. Twenty-two months after operation the patient is independent and professionally active.     

Features of pediatric head injury in Hong Kong

Head injury in children causes special concern in most communities. From 1989 to 1994, 2,785 children younger than 16 years old were admitted to our neurosurgical service because of head injury. Fall from a height was the major cause of head injury leading to admission in infants and children in preschool age groups, whereas traffic-related or bicycle-related accidents were more likely to be the cause of head injury for those aged 11–15 years. In all age groups there was a male preponderance. The overall mortality was 0.6%. Traffic-ralated accidents caused more severe injury and accounted for 67% of all fatalities. For patients under 6 years old, about 40% of head injuries occurred at home. Preventive measures for pediatric head injury in Hong Kong are suggested.     

Use of the ICECI and ICD-10 E-Coding structures to evaluate causes of head injury and concussion from sport and recreation participation in a school population

The purpose of this study was to identify the most common causes of head injury and associated symptoms of concussion in a population of school children (n=1,372,979). Using standardized injury report forms, we identified the mechanisms of head injury associated with various sports/recreation activities and assessed each injury for the presence of concussion symptoms. Head injury reports (n=7,765) were coded using the WHO's ICECI and ICD-10 E-codes. 1,338 Cases reported symptoms of concussion. The majority of head injuries occurred during School Free-Play/Recess (59.8%). Combative Sports and Wheeled Non-Motored Sports were the activities most often associated with concussion symptoms (rate of concussion (RC): 48.3% and 44.4%, respectively, p<0.001). School Free-Play/Recess and Physical Education Classes were significantly less likely to have head injuries associated with concussion (RC: 16.0%, p<0.001, and 12.4%, p=0.034, respectively). The most common causes of head injury were (1) Struck by an Object (24.9%) and (2) Falling on the Same Level (22.8%). Falling from a Transport was the only etiological code significantly associated with concussion symptoms after head injury (RC: 28.7%, p<.001). Results were similar when using the two coding structures in combination. Prevention efforts should focus on activities where children are moving at high speeds since these are more likely to cause a concussion when a head injury occurs.     

Impairment of memory functions after acute head injury

When memory functions are evaluated after head injury, two trends are apparent. Acute head injury patients with approximately normal intelligence demonstrate a reduced capacity to utilize structure in delayed recall relative to a control group. Furthermore, head injury patients with low intelligence demonstrate a wider memory deficit than the previous group, affecting perception and immediate recall as well. No relationship was found between severity of injury, recovery, and performance on the memory scale.     

Speech acts after mild or severe childhood head injury

Children with head injury have impairments in pragmatic language. We investigated speech acts, a form of pragmatic communication, after mild or severe childhood head injury in relation to two linguistic constituents of speech acts competence (lexical-semantic knowledge, pragmatic inference) and two cognitive resources (world knowledge, working memory). Children with head injury had difficulty producing speech acts, and the magnitude of this deficit varied with head injury severity. Within the head injury group, semantic reference and information were unimportant for speech acts, which were, however, significantly predicted by pragmatic inference and working memory. The results are discussed in relation to three general issues: the effect of severity of childhood head injury on linguistic and cognitive morbidity; the relation between semantic reference, pragmatic inference and more general cognitive resources in the production of speech acts; and why semantic competence at a lexical level may not be sufficient for the production of pragmatic utterances.     

盲管性颅脑火器伤119例分析

目的分析盲管性颅脑火器伤的临床特点。方法对１１９例盲管性颅脑火器伤病例进行回顾性分析总结。结果男１０５例，女１４例；平均年龄２１岁。入院时ＧＣＳ９～１５分４８例；６～８分５９例，３～５分１２例。早期合并症主要为脑挫裂伤、颅内血肿、感染等。晚期合并症主要为异物存留及癫痫。死亡１４例，死亡率１１．７％。结论火器伤能产生较大的瞬时伤道，对颅脑造成严重而广泛的损伤，不能用一般颅脑外伤的致伤原理和经验来诊治火器性颅脑伤。准确判断伤情及伤道，早期彻底清创，注意手术方法的选择和手术要点的掌握，以及尽量减少脑组织的继发损伤，防止各种并发症，是降低死亡及残废率的关键。     

Clinical evaluation of extracellular amino acids in severe head trauma by intracerebral in vivo microdialysis.

The underlying mechanisms of neuronal dysfunction in head injury are multifactorial and not fully understood. Recent experimental evidence indicates that excitatory amino acids--for example, glutamate--may play a key part in secondary neuronal damage after head injury. A patient with severe head trauma was monitored for extracellular amino acids by intracerebral in vivo microdialysis. Very high concentrations of glutamate, glycine, and gamma-aminobutyric acid were recorded in the microdialysate specimens collected over three hours. In vivo microdialysis in head injury may prove to be a useful tool in understanding the pathogenesis of cell death in head trauma.     

"Diagnosis Threat": the effect of negative expectations on cognitive performance in head injury

The present study examined the effect of negative expectations on neuropsychological test performance. It was hypothesized that having attention called to a history of prior head injury and the potential effects of head injury on cognition would result in diminished neuropsychological test performance relative to individuals with a similar head injury history but who did not have their attention called to their head injury history ('diagnosis threat'). Of 36 participants with a history of mild head injury, 17 were randomly assigned to diagnosis threat and 19 to neutral test directions. The diagnosis threat group performed significantly worse on tests measuring general intellect and memory, but were not different from the neutral group in basic attention or psychomotor speed. The diagnosis threat group rated themselves as putting forth less effort on the neuropsychological battery, and self-rated effort correlated with test performance in that group. Overall, results serve as a reminder that neuropsychological tests are measures of behavior, and thus can be influenced by nonneurological factors.     

Increased risk of dementia following mild head injury for carriers but not for non-carriers of the APOE epsilon4 allele

BACKGROUND: The epsilon4 allele of apolipoprotein E (APOE) and head injury are risk factors for dementia diseases, and may act synergistically to further increase the risk. The aim of this study was to examine the association between mild head injury, APOE and dementia. METHODS: Data were obtained from the Betula prospective population-based study of aging, memory, and health. The study included 543 participants in the age range 40-85 years, free of dementia at baseline, who were followed up within a 5-year interval. Dementia was classified using DSM-IV criteria. Information on previous head injury was obtained through screening of the participants' answers to health questionnaires at baseline and at follow-up. RESULTS: Subjects with head injury but without APOE epsilon4 had no increased risk of dementia. Subjects with APOE epsilon4 had an increased risk and those with both APOE epsilon4 and head injury had the highest risk of dementia (odds ratio = 5.2). CONCLUSIONS: APOE epsilon4 constitutes a risk factor for dementia, mild injury in isolation does not increase the risk, but head injury in combination with the APOE epsilon4 leads to increased risk of dementia.     

“Diagnosis Threat”: The Effect of Negative Expectations on Cognitive Performance in Head Injury

The present study examined the effect of negative expectations on neuropsychological test performance. It was hypothesized that having attention called to a history of prior head injury and the potential effects of head injury on cognition would result in diminished neuropsychological test performance relative to individuals with a similar head injury history but who did not have their attention called to their head injury history (‘diagnosis threat’). Of 36 participants with a history of mild head injury, 17 were randomly assigned to diagnosis threat and 19 to neutral test directions. The diagnosis threat group performed significantly worse on tests measuring general intellect and memory, but were not different from the neutral group in basic attention or psychomotor speed. The diagnosis threat group rated themselves as putting forth less effort on the neuropsychological battery, and self-rated effort correlated with test performance in that group. Overall, results serve as a reminder that neuropsychological tests are measures of behavior, and thus can be influenced by nonneurological factors.     

Documented head injury in early adulthood and risk of Alzheimer's disease and other dementias

BACKGROUND: The association between antecedent head injury and AD is inconsistent. OBJECTIVE: To examine the association between early adult head injury, as documented by military hospital records, and dementia in late life; and to evaluate the interaction between head injury and APOE epsilon4 as risk factors for dementia. METHODS: The study had a population-based prospective historical cohort design. It included men who were World War II Navy and Marine veterans, and were hospitalized during their military service with a diagnosis of either a nonpenetrating head injury or another unrelated condition. In 1996 to 1997, military medical records were abstracted to document the occurrence and details of closed head injury. The entire sample was then evaluated for dementia and AD using a multistage procedure. There were 548 veterans with head injury and 1228 without head injury who completed all assigned stages of the study. The authors estimated risk of dementia, specifically AD, using proportional hazards models. RESULTS: Both moderate head injury (hazard ratio [HR] = 2.32; CI = 1.04 to 5.17) and severe head injury (HR = 4.51; CI = 1.77 to 11.47) were associated with increased risk of AD. Results were similar for dementia in general. The results for mild head injury were inconclusive. When the authors stratified by the number of APOE epsilon4 alleles, they observed a nonsignificant trend toward a stronger association between AD and head injury in men with more epsilon4 alleles. CONCLUSIONS: Moderate and severe head injuries in young men may be associated with increased risk of AD and other dementias in late life. However, the authors cannot exclude the possibility that other unmeasured factors may be influencing this association.     

二次脑创伤的基础与临床研究

低血压或高热等是引起脑外伤病人二次脑创伤常见因素。本研究首先在大鼠弥漫性脑损伤模型基础上，造成大鼠低血压及高热，观察大鼠脑皮层脑血流（ＣｏＣＢＦ）变化。１６只ＳＤ大鼠随机分为假手术对照、脑损伤并二次脑创伤两组。结果表明，伤后４ｈ与假手术组对比，合并二次脑创伤组ＣｏＣＢＦ显著降低。随后对１６５例重型颅脑损伤病人进行回顾研究，探讨二次脑创伤因素如高热、低血压对颅脑损伤预后的影响。表明合并二次脑创伤因素者预后差。基础与临床研究提示，二次脑创伤者预后差的原因可能是其导致脑血管痉挛，脑血流下降，直接影响正常脑代谢     

The postconcussion syndrome and the sequelae of mild head injury.

The postconcussion syndrome refers to a large number of symptoms and signs that may occur alone or in combination following usually mild head injury. The most common complaints are headaches, dizziness, fatigue, irritability, anxiety, insomnia, loss of consciousness and memory, and noise sensitivity. Mild head injury is a major public health concern because the annual incidence is about 150 per 100,000 population, accounting for 75% or more of all head injuries. The postconcussion syndrome has been recognized for at least the last few hundred years and has been the subject of intense controversy for more than 100 years. The Hollywood head injury myth has been an important contributor to persisting skepticism and might be countered by educational efforts and counter-examples from boxing. The organicity of the postconcussion syndrome has now become well documented. Abnormalities following mild head injury have been reported in neuropathologic, neurophysiologic, neuroimaging, and neuropsychologic studies. There are multiple sequelae of mild head injury, including headaches of multiple types, cranial nerve symptoms and signs, psychologic and somatic complaints, and cognitive impairment. Rare sequelae include hematomas, seizures, transient global amnesia, tremor, and dystonia. Neuroimaging and physiologic and psychologic testing should be used judiciously based on the problems of the particular patient rather than in a cookbook fashion. Prognostic studies clearly substantiate the existence of a postconcussion syndrome. Manifestations of the postconcussion syndrome are common, with resolution in most patients by 3 to 6 months after the injury. Persistent symptoms and cognitive deficits are present in a distinct minority of patients for additional months or years. Risk factors for persisting sequelae include age over 40 years; lower educational, intellectual, and socioeconomic level; female gender; alcohol abuse; prior head injury; and multiple trauma. Although a small minority are malingerers, frauds, or have compensation neurosis, most patients have genuine complaints. Contrary to a popular perception, most patients with litigation or compensation claims are not cured by a verdict. Treatment is individualized depending on the specific complaints of the patient. Although a variety of medication and psychologic treatments are currently available, ongoing basic and clinical research of all aspects of mild head injury are crucial to provide more efficacious treatment in the future.