Rehabilitation outcome after traumatic brain injury

Rehabilitation goals after traumatic brain injury are improving function, increasing the level of independence as high as possible, preventing complications and providing an acceptable environment to the patient. Several complications can be encountered during the rehabilitation period which lead to physical, cognitive and neurobehavioral impairments that cause major delay in functional improvement. This prospective study was designed in order to investigate the complications and their relations with functional recovery in patients that were included in the acute phase of a rehabilitation program. Thirty traumatic brain injured patients admitted to the Intensive Care Units of Uludag University School of Medicine were included in the study. Rehabilitation program consisted in appropriate positioning, range of motion exercises, postural drainage and respiratory exercises. Complications that were encountered during intensive care rehabilitation program were recorded. All patients were evaluated by Functional Independence Measure, Disability Rating Scale and Ranchos Los Amigos Levels of Cognitive Function Scale at admission and discharge. Improvement was observed in patients in terms of functional outcome and disability levels. Pneumonia, athelectasis, anemia and meningitis were the most frequent complications. Deterioration in functional outcome and disability levels was noted as the number of these complications increased. In conclusion, rehabilitation has an important role in the management of traumatic brain injured patients. Reduction of frequency of complications and improvement in functional outcome and disability levels can be achieved through rehabilitation programs. Long-term controlled studies with large number of patients are needed in order to obtain accurate data on factors associated with rehabilitation outcomes.     

Catecholamines predict outcome in traumatic brain injury

Activation of the sympathetic nervous system attends traumatic brain injury, but the association of the severity of neurological impairment and recovery with the extent of sympathetic nervous system stimulation is poorly defined. In this study, plasma norepinephrine (NE), epinephrine (E), and dopamine (DA) levels were measured serially in 33 patients with traumatic brain injury and compared with the Glasgow Coma Score (GCS), which was obtained concurrently. A catecholamine gradient that reflected the extent of brain injury was demonstrated within 48 hours of the injury. In patients with a GCS of 3 to 4, NE and E levels increased four- to fivefold and the DA level increased threefold above normal (NE, 1686 +/- 416 pg/ml; E, 430 +/- 172 pg/ml; DA, 236 +/- 110 pg/ml), while patients with mild brain injury (GCS, greater than 11) had slightly elevated or normal levels. Patients with marked (GCS, 5 to 7) and moderate (GCS, 8 to 10) traumatic brain injuries had intermediate levels. The prognostic value of determining admission levels of NE was shown in patients with an admission GCS of 3 to 4 1 week after injury. Patients with severe and unchanging neurological impairment 1 week after injury had markedly elevated initial NE levels (2,176 +/- 531 pg/ml), whereas initial NE levels (544 +/- 89 pg/ml) were only mildly elevated in patients who improved to a GCS of greater than 11. These data indicate that markedly elevated NE levels predict outcome in patients with comparable neurological deficits. Thus levels of circulating catecholamines are excellent endogenous and readily quantifiable markers that appear to reflect the extent of brain injury and that may predict the likelihood of recovery.     

Rehabilitation and follow-up of children with severe traumatic brain injury

We studied the outcome of 25 patients [12 girls and 13 boys; mean age 13.7 (SD 3.9 years)] with severe traumatic brain injury (TBI). The Glasgow Coma Scale (GCS) score 6 h after the injury was (mean) 4.5 (SD 2.7), and the mean duration of unconsciousness was 15.8 (SD 10.6) days. Being the most severely brain-injured children in the health care region, they were all referred to its only regional pediatric rehabilitation center during 1986–1990. At discharge, 1 patient was healthy, 1 was in a vegetative state and 18 had multiple impairments. Motor problems were present in 22, epilepsy in 7 and speech impairment in 14. It was not possible to assess cognition in 3 of the children, and 15 of the remaining 22 fell in the normal range. At follow up 2–6 years after trauma, all 23 survivors reported at least one sequela, and 21 had multiple sequelae. As many as two-thirds had normal I.Q. and only 3 were non-ambulatory, but behavioral and personality disturbances were so disabling that none of the patients in this group had been able to readjust to a normal life in society after the trauma.     

神经干细胞移植对颅脑外伤神经组织的替代和修复作用

目的 神经干细胞具有自我更新及多向分化潜能的特性。本文将人类神经干细胞移植到大鼠颅脑损伤的模型中，观察是否有治疗效果。方法 人类神经干细胞取自3－4月胎儿海马，体重为300－370g的大鼠制成脑损伤模型，伤后24小时将神经干细胞用立体定向注射法注入双侧顶叶皮层，伤后1周动物运动功能评分后，处死取脑，行病理及免疫组化染色。结果 伤后1周接受干细胞移植的治疗组与损伤组相比呈现出明显的运动功能改善，一部分移植顶叶的干细胞呈Tubulin（＋）、GFAP（＋），表明它们分化成为神经元或胶质细胞。另外我们观察到治疗组伤区皮层的正常神经元增多，且坏死及凋亡的神经元减少。结论 社会干细胞是细胞移植治疗颅脑损伤的一种良好的细胞来源。     

Rehabilitation outcome evaluation after very severe brain injury

Few centres provide long-term therapy for survivors of very severe brain injury who continue in a minimally responsive state. We report on two outcome evaluation projects in association with one such centre in western Canada. In one project a functional scale to detect subtle changes after long-term therapy with the most severely compromised clients (Rancho levels II and III) is being tested. In the other project outcome indicators of change in quality of life after initiation of community-based rehabilitation have been generated by collecting over 400 critical incidents reported by family members, volunteers, staff and a few higher functioning clients. Our intention in this report is to highlight what can be done in terms of rehabilitation and outcome evaluation with clients who seem to be persisting in vegetative or minimally responsive states.     

Brain temperature and outcome after severe traumatic brain injury

Introduction  In humans, raised body temperature is linked to poor outcome after brain injury. Because deviations between brain and body temperature have been reported after severe traumatic brain injury (TBI), the aim of this study was to explore the relationship between initial and mean brain temperature and survival at 3 months. Methods  Intraparenchymal temperature was measured 3–4 cm within white matter. Logistic regression was used to explore linear and quadratic relationships between initial and average brain temperature and survival at 3 months. Results  In 36 patients, initial brain temperatures ranged from 33.5 to 39.2°C (median 37.4°C). There was no evidence of an association between initial brain temperature and risk of death, either linear (odds ratio [OR] 95% confidence interval [CI]=1.3 [0.68 to 2.5], p=0.42) or quadratic (p=0.26). Assuming a linear relationship, patients with higher mean brain temperatures were less likely to die: OR (95% CI) for death per 1°C was 0.31 (0.09 to 1.1), p=0.06. However, by fitting the quadratic relationship, there was a suggestion that both high and low temperatures were associated with increased risk of death: p=0.06. Conclusion  Initial brain temperature measured shortly after adminission did not predict outcome. There is a suggestion that patients with “middle range” temperatures were less likely to die.     

10 years outcome from childhood traumatic brain injury

Childhood traumatic brain injury (TBI) is a common, acquired disability, which has significant implications for subsequent development, and for later quality of life. To date few studies have documented outcomes in these children into adolescence, when academic, social and personal demands increase. The objective of this study was to document functional outcomes at 10 years post-injury, and to identify predictors of outcome including injury, socio-demographic and pre-injury characteristics. The study employed consecutive recruitment to a prospective, longitudinal study. Children with a diagnosis of TBI between 2 and 12 years were initially recruited and divided according to injury severity (mild, moderate, severe). The sample was reviewed at 10 years post-injury and intellectual, adaptive, executive and social domains were investigated. Results indicated that, at 10 years post child TBI, survivors' functional abilities fell overall within the low average to average range regardless of injury severity, suggesting no extreme impairments at a group level for any of the domains under investigation. Significant group differences were identified, though, for adaptive abilities and for speed of processing, with more severe injury associated with poorer performances in each instance. Further, a similar trend was identified for measures of intellectual ability and executive functions. Individual rates of impairment were considerably higher than population expectations across all severity groups for these domains. Although rates of social impairment were also elevated, they were less related to injury factors, suggesting that cognitive/adaptive outcomes and social consequences of TBI may have different bases.     

Fibrinolytic markers and neurologic outcome in traumatic brain injury

AIMS: To determine the usefulness of fibrinolytic markers as early prognostic indicators in patients with isolated head trauma. MATERIALS AND METHODS: Sixty-two consecutive patients (26 women and 36 men; mean age 61 years, range 2-76 years) with isolated head trauma seen within the first three hours of the trauma were included in the study. The Glasgow Coma score (GCS), platelet counts (Plt), prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen, fibrin degradation products (FDP) and D-dimer levels were measured. Head computerized tomography (CT) findings were categorized as brain edema, linear fracture, depressed fracture, contusion and bleeding. Plt counts, PT, PTT, fibrinogen, FDP, D-dimer levels and CT findings were compared with both GCS and mortality in the first week. Statistical significance was accepted at P 相似文献   

Functional outcome after diffuse axonal injury in childhood traumatic brain injury

We investigated the functional prognosis after traumatic diffuse axonal injury in children. We evaluated the status of the acute stage, as well as the functional independence measure (FIM) and intelligence quotient (IQ) at 4, 12, and 24 months after the injury. Physical disabilities persisted in all but 1 case, but 5 cases could walk by themselves after 1 year. IQ at 2 years after the injury was 64 in one case, but between 81 and 100 in others. Concerning the higher cortical function, all cases showed memory disturbance. None developed epilepsy. All cases showed abnormalities on cerebral MRI. Five of the 7 cases showed EEG abnormalities. As to the course of recovery scaled by FIM and IQ, marked improvement was seen in 4 cases during the first 4 months, 3 cases during the first 1 year. After 1 year, the degree of improvement became slower in all. All cases showed learning disability at school.     

Communication outcome in children and adolescents with traumatic brain injury

Abstract

This article gives a brief review of investigations of speech and language impairment after paediatric traumatic brain injury (TBI) and describes possible effects of frontal lobe injury on non-aphasic disorders of communication. The relation between age and outcome after brain injury in children is also considered. Procedures for overcoming chronic obstacles to effective supports and services for students returning to school after TBI are described briefly. Although most children with normal development of language at the time of their injury experience generally satisfactory recovery of speech and language skills, there is considerable variation within this population. The most likely communication challenges relate to the socially skilled application of available speech and language skills, not their possession.     

Medical and cognitive outcome in children with traumatic brain injury

BACKGROUND: Head injury is an important cause of morbidity and mortality in pediatrics. Comprehensive studies on outcome are scarce despite significant clinical concern that multiple areas of functioning may be impaired following moderate to severe head injury. The literature suggests that sequelae include not only medical problems but also impairments in cognitive functioning. METHODS: A retrospective medical and psychology chart review of patients, age 1-18 years, admitted to the Children's Hospital of Eastern Ontario with moderate (Glasgow Coma Scale [GCS] 9-12) or severe head injury (GCS < or = 8) from November 1, 1993 until December 31, 1998 was conducted. Correlations were performed between medical variables (i.e., GCS, Pediatric Risk of Mortality [PRISM] III score, duration of ICU and hospital stay) and measures of intelligence and memory functioning. RESULTS: Eighty-three children age 1 to 18 were included. Seventy percent of the children were classified as having a severe head injury. There was a mortality rate of thirteen percent. Younger age at injury, lower GCS, and higher PRISM III scores predicted higher mortality. Medical complications were documented systematically. Forty-four patients underwent at least one cognitive assessment and 17 of these children had intelligence testing at three points in time: baseline (< four months), early recovery (five to 15 months) and follow-up (16 to 38 months). The mean intelligence and memory scores fell within the average range at the latest point in follow-up. For those children who underwent three serial assessments, the mean verbal and performance IQ fell within the low average range at baseline improving significantly to fall within the average range by early recovery. Continued improvements were apparent in verbal memory beyond early recovery, with the mean obtained at follow-up falling within 1 SD of the normative mean. Despite the return to normal ranges for the group means the proportion of scores falling below 1.5 standard deviations from the mean was greater than population norms for verbal IQ, performance IQ and verbal memory. Lower GCS scores and longer duration of stay in ICU or hospital were predictive of lower nonverbal intelligence. Lower GCS was also predictive of lower visual memory scores. CONCLUSIONS: This study describes a population of Canadian children who suffered moderate or severe traumatic brain injury. Initial GCS was the best predictor of mortality and cognitive outcome. These children demonstrated a temporal improvement in intelligence and memory functioning, with their mean performance on these cognitive measures falling within the average range at 16 to 38 months postinjury, although there was considerable variability in the outcomes between individuals.     

Quantitative proton MRS predicts outcome after traumatic brain injury

OBJECTIVE: To determine whether proton MRS (1H-MRS) neurochemical measurements predict neuropsychological outcome of patients with traumatic brain injury (TBI). BACKGROUND: Although clinical indices and conventional imaging techniques provide critical information for TBI patient triage and acute care, none accurately predicts individual patient outcome. METHODS: The authors studied 14 patients with TBI soon after injury (45+/-21 days postinjury) and again at 6 months (172+/-43 days) and 14 age-, sex-, and education-matched control subjects. N-acetylaspartate (NAA), creatine, and choline were measured in normal-appearing occipitoparietal white and gray matter using quantitative 1H-MRS. Outcome was assessed with the Glasgow Outcome Scale (GOS) and a battery of neuropsychological tests. A composite measure of neuropsychological function was calculated from individual test z-scores probing the major functional domains commonly impaired after head trauma. RESULTS: Early NAA concentrations in gray matter predicted overall neuropsychological performance (r = 0.74, p = 0.01) and GOS (F = 11.93, p = 0.007). Other metabolite measures were not related to behavioral function at outcome. CONCLUSION: 1H-MRS provides a rapid, noninvasive tool to assess the extent of diffuse injury after head trauma, a component of injury that may be the most critical factor in evaluating resultant neuropsychological dysfunction. 1H-MRS can be added to conventional MR examinations with minimal additional time, and may prove useful in assessing injury severity, guiding patient care, and predicting patient outcome.     

Predicting neuropsychologic outcome after traumatic brain injury in children

The ability to predict long-term neurologic and neuropsychologic outcomes in 22 children, ages 1 week to 14 years at the time of traumatic brain injury, was investigated using proton magnetic resonance spectroscopy acquired post injury and compared with standardized neurologic, intellectual, and neuropsychologic testing done 1-7 years later. Clinical indicators of acute injury severity including age at injury, electroencephalography, spectroscopy metabolite ratio variables (N-acetyl aspartate/choline, choline/creatine) and lactate presence accurately classified children as functioning above or below the average range for most intellectual and neuropsychologic outcome measures. Combined clinical and spectroscopy variables accounted for approximately 50% of the variance in cognitive and neuropsychologic outcome confirming the validity of their predictive use. Of the injury severity indictors, presence of lactate is a particularly important prognostic marker of poor long-term intellectual and neuropsychologic functioning. Our findings indicate the potential for providing accurate estimates of long-term intellectual and neuropsychologic function after traumatic brain injury in infants and children using proton magnetic resonance spectroscopy in combination with clinical variables.     

Neuroimaging correlates of cognitive and functional outcome after traumatic brain injury

Magnetic resonance imaging (MRI) may provide an estimate of the severity of diffuse axonal injury by quantitative measurements of atrophy of white matter tracts (such as corpus callosum) and of ventricular enlargement (particularly the third ventricle). However, most MRI studies failed to reveal consistent relationships between the pattern of neuropsychological impairments and the site and extent of focal structural lesions after traumatic brain injury. Functional neuroimaging techniques, such as positron emission tomography or functional MRI, may reveal areas of cerebral dysfunction in regions that look structurally intact on MRI. Studies using these techniques have suggested that the cognitive and behavioural disturbances of traumatic brain injury could be related to a defective activation of a prefrontal-cingulate network.     

Normobaric oxygen worsens outcome after a moderate traumatic brain injury

Traumatic brain injury (TBI) is a multifaceted injury and a leading cause of death in children, young adults, and increasingly in Veterans. However, there are no neuroprotective agents clinically available to counteract damage or promote repair after brain trauma. This study investigated the neuroprotective effects of normobaric oxygen (NBO) after a controlled cortical impact in rats. The central hypothesis was that NBO treatment would reduce lesion volume and functional deficits compared with air-treated animals after TBI by increasing brain oxygenation thereby minimizing ischemic injury. In a randomized double-blinded design, animals received either NBO (n=8) or normal air (n=8) after TBI. Magnetic resonance imaging (MRI) was performed 0 to 3 hours, and 1, 2, 7, and 14 days after an impact to the primary forelimb somatosensory cortex. Behavioral assessments were performed before injury induction and before MRI scans on days 2, 7, and 14. Nissl staining was performed on day 14 to corroborate the lesion volume detected from MRI. Contrary to our hypothesis, we found that NBO treatment increased lesion volume in a rat model of moderate TBI and had no positive effect on behavioral measures. Our results do not promote the acute use of NBO in patients with moderate TBI.     

Heme regulation in traumatic brain injury: relevance to the adult and developing brain.

Intracranial bleeding is one of the most prominent aspects in the clinical diagnosis and prognosis of traumatic brain injury (TBI). Substantial amounts of blood products, such as heme, are released because of traumatic subarachnoid hemorrhages, intraparenchymal contusions, and hematomas. Despite this, surprisingly few studies have directly addressed the role of blood products, in particular heme, in the setting of TBI. Heme is degraded by heme oxygenase (HO) into three highly bioactive products: iron, bilirubin, and carbon monoxide. The HO isozymes, in particular HO-1 and HO-2, exhibit significantly different expression patterns and appear to have specific roles after injury. Developmentally, differences between the adult and immature brain have implications for endogenous protection from oxidative stress. The aim of this paper is to review recent advances in the understanding of heme regulation and metabolism after brain injury and its specific relevance to the developing brain. These findings suggest novel clinical therapeutic options for further translational study.