Suicide after traumatic brain injury: a population study

OBJECTIVES: To determine the rates of suicide among patients who have had a traumatic brain injury. METHODS: From a Danish population register of admissions to hospital covering the years 1979-93 patients were selected who had had either a concussion (n=126 114), a cranial fracture (n=7560), or a cerebral contusion or traumatic intracranial haemorrhage (n=11 766). All cases of deaths by the end of the study period were identified. RESULTS: In the three diagnostic groups there had been 750 (0.59%), 46 (0.61%), and 99 (0.84%) cases of suicide respectively. Standardised mortality ratios, stratified by sex and age, showed that the incidence of suicide among the three diagnostic groups was increased relative to the general population (3.0, 2.7, and 4.1 respectively). In all diagnosis groups the ratios were higher for females than for males, and lower for patients injured before the age of 21 or after the age of 60. The presence of a codiagnosis relating to substance misuse was associated with increased suicide rates in all diagnosis groups. There was a tendency, among patients with cerebral contusions or traumatic intracranial haemorrhages, for suicide risk to increase with duration of stay in hospital. Cox regression analyses for proportional hazards confirmed that there was a significantly greater risk of suicide among patients with cerebral contusions or traumatic intracranial haemorrhages than among patients with concussion or cranial fractures (hazard ratios=1.42 and 1.50 respectively). There was, however, no evidence of a specific risk period for suicide after injury. CONCLUSION: The increased risk of suicide among patients who had a mild traumatic brain injury may result from concomitant risk factors such as psychiatric conditions and psychosocial disadvantage. The greater risk among the more serious cases implicates additionally the physical, psychological, and social consequences of the injuries as directly contributing to the suicides.     

Psychosocial adjustment three years after traumatic brain injury

This study examined the relationship of social support and family cohesion to psychosocial outcome in a group of 25 individuals three years after they each sustained a severe brain injury (TBI). The subject group was initially recruited while they were inpatients in a community hospital rehabilitation unit. The subjects were assessed with the Portland Adaptability Inventory (PAI), the Family Environment Scale (FES), and a family interview at various intervals up to three years post-trauma. Findings suggested that family cohesion and available perceived social support for the injured person were related to the individual's psychosocial and vocational status three years after injury, with higher levels of cohesion and support being related to better outcomes. Implications for researching and applying techniques to improve social support variables in TBI rehabilitation are provided.     

Decision-making after traumatic brain injury in children: a preliminary study

Decision-making under conditions of uncertainty was studied in 11 children with moderate to severe post-acute traumatic brain injury (TBI) using a modification of the Iowa Gambling Task (Bechara et al., 1994). We hypothesized that decision-making would be compromised in children with TBI. The results revealed that when divided into subgroups by lesion location, children with lesions in the amygdala (AM) were impaired on modified gambling task performance, but children with ventromedial (VM) lesions did not appear to be impaired on the task. These results are in contrast to studies of decision-making in adults with focal lesions of vascular etiology.     

Recovery and predictors of intellectual ability two years following paediatric traumatic brain injury

While a number of research papers have reported findings on intellectual skills following traumatic brain injury (TBI), only limited studies have monitored the recovery of these skills over time. The present study examined intellectual skills in a group of 70 children who had sustained a mild, moderate, or severe traumatic brain injury (TBI). Results showed that, while the severe TBI group exhibited greatest recovery of intellectual ability over 24 months, they continued to perform more poorly than children who had sustained a mild and moderate injury. Further, domain-specific Index Scores, derived from intellectual measures, provided additional insight regarding the development and/or recovery of specific cognitive areas following TBI. Best predictor of intellectual outcome was socio-economic status.     

Age and sex-mediated differences in six-month outcomes after mild traumatic brain injury in young adults: a TRACK-TBI study

ABSTRACT

Introduction: Risk factors for young adults with mTBI are not well understood. Improved understanding of age and sex as risk factors for impaired six-month outcomes in young adults is needed.

Methods: Young adult mTBI subjects aged 18–39 years (18-29y; 30-39y) with six-month outcomes were extracted from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot (TRACK-TBI Pilot) study. Multivariable regressions were performed for outcomes with age, sex, and the interaction factor age-group*sex as variables of interest, controlling for demographic and injury variables. Mean-differences (B) and 95% CIs are reported.

Results: One hundred mTBI subjects (18-29y, 70%; 30-39y, 30%; male, 71%; female, 29%) met inclusion criteria. On multivariable analysis, age-group*sex was associated with six-month post-traumatic stress disorder (PTSD; PTSD Checklist-Civilian version); compared with female 30-39y, female 18-29y (B= ?19.55 [?26.54, ?4.45]), male 18-29y (B= ?19.70 [?30.07, ?9.33]), and male 30-39y (B= ?15.49 [?26.54, ?4.45]) were associated with decreased PTSD symptomatology. Female sex was associated with decreased six-month functional outcome (Glasgow Outcome Scale-Extended (GOSE): B= ?0.6 [1.0, ?0.1]). Comparatively, 30-39y scored higher on six-month nonverbal processing speed (Wechsler Adult Intelligence Scale-Processing Speed Index (WAIS-PSI); B= 11.88, 95% CI [1.66, 22.09]).

Conclusions: Following mTBI, young adults aged 18-29y and 30-39y may have different risks for impairment. Sex may interact with age for PTSD symptomatology, with females 30-39y at highest risk. These results may be attributable to cortical maturation, biological response, social modifiers, and/or differential self-report. Confirmation in larger samples is needed; however, prevention and rehabilitation/counseling strategies after mTBI should likely be tailored for age and sex.

Trial registration: ClinicalTrials.gov identifier: NCT01565551.     

A comparison of functional outcomes in hypoxia and traumatic brain injury: a pilot study

We present our experience with 30 patients on functional outcomes of patients with anoxic brain injury (ABI, n = 15) due to cardiac etiologies from freestanding inpatient rehabilitation hospital. A convenience sample of patient with traumatic brain injury (TBI, n = 15) with similar demographic characteristic to ABI was used for comparison on indices of activity of daily living, cognition, mobility as well as other indices of functional prognosis such as hospital length of stay, cost and discharge predisposition. No statistical significant differences were found between the two groups on the presently employed outcome measures. This investigation supports the positive impact of inpatient rehabilitation for individuals with hypoxia of cardiac etiology. Future research comparing outcomes of ABI to TBI with larger, controlled trials is warranted.     

Clock-drawing performance predicts inpatient rehabilitation outcomes after traumatic brain injury

The authors used clock-drawing performance to assess cognition and predict inpatient rehabilitation outcomes among persons with traumatic brain injury. Clock-drawing performance, as assessed with the Clock Drawing Interpretation Scale, predicts rehabilitation length of stay as well as Functional Independence Measure scores at the time of neurobehavioral assessment and rehabilitation discharge.     

Challenges in predicting traumatic brain injury outcomes

Journal of Neurology -     

Isolated medulla oblongata function after severe traumatic brain injury

The objective was to report the first pathologically confirmed case of partly functionally preserved medulla oblongata in a patient with catastrophic traumatic brain injury.A patient is described with epidural haematoma with normal breathing and blood pressure and a retained coughing reflex brought on only by catheter suctioning of the carina. Multiple contusions in the thalami and pons were found but the medulla oblongata was spared at necropsy. In conclusion, medulla oblongata function may persist despite rostrocaudal deterioration. This comatose state ("medulla man") closely mimics brain death.     

Neurogenic fever after traumatic brain injury: an epidemiological study

OBJECTIVES: To determine the incidence of neurogenic fever (NF) in a population of patients in the acute phase following severe traumatic brain injury (TBI); to identify factors associated with the development of NF following severe TBI in adults. METHODS: Charts of patients admitted from 1996 to 1999 with severe TBI at a large, urban mid-Atlantic teaching hospital were retrospectively evaluated based on diagnostic criteria for each episode of hyperthermia to determine the diagnosis of NF. Data were collected regarding mechanism and area of injury, severity of injury, and demographic factors to determine potential predictors of NF. RESULTS: Diffuse axonal injury (DAI) (OR 9.06, 95% CI 0.99 to 82.7) and frontal lobe injury of any type (OR 6.68, 95% CI 1.1 to 39.3) are independently predictive of an increased risk of development of NF following severe TBI. The presence of a skull fracture and lower initial Glasgow Coma Score (GCS) were individual predictors of development of NF, but did not contribute to the final model. CONCLUSIONS: These findings examine known and novel risk factors for this phenomenon in comparison to previously published literature on NF. A set of predictor variables was identified to help clinicians target patients at high risk for development of NF following severe TBI. It is hoped that earlier diagnosis and appropriate intervention for fever in the TBI patient will lead to improved outcomes.     

Self-esteem in children after traumatic brain injury: an exploratory study

Children with a traumatic brain injury (TBI) often have difficulties in adjusting to their injury and altered abilities, and may be at risk of low self-esteem and loss of confidence. However, few studies have examined self-esteem in this client group. The current study measured the self-esteem of a group of children who were, on average, two years post-TBI and compared this to their performance on other psychometric measures. Participants were 96 children with TBI and 31 peer controls, their parents and teachers. Self-esteem was measured using the Coopersmith Self-esteem Inventory (CSEI). CSEI scores were compared with performance on Wechsler Intelligence Scales (WISC-III), Hospital Anxiety and Depression Scale (HADS); Children's Memory Scale (CMS), Vineland Adaptive Behaviour Scales (VABS) and Parental Stress Index (PSI). Self-esteem was highly correlated with IQ; HADS anxiety and depression; and parental stress (p< 0.001). Children with TBI had significantly lower self-esteem than controls and population norms (p=0.015). Many children with TBI demonstrate low self-esteem and this is closely linked with anxiety and depression. This may hamper academic performance and could lead to further psychosocial problems. It is recommended that self-esteem is routinely assessed after brain injury and rehabilitation strategies implemented to promote a sense of self-worth.     

Robust detection of traumatic axonal injury in individual mild traumatic brain injury patients: Intersubject variation, change over time and bidirectional changes in anisotropy

To identify and characterize otherwise occult inter-individual spatial variation of white matter abnormalities across mild traumatic brain injury (mTBI) patients. After informed consent and in compliance with Health Insurance Portability and Accountability Act (HIPAA), Diffusion tensor imaging (DTI) was performed on a 3.0 T MR scanner in 34 mTBI patients (19 women; 19-64 years old) and 30 healthy control subjects. The patients were imaged within 2 weeks of injury, 3 months after injury, and 6 months after injury. Fractional anisotropy (FA) images were analyzed in each patient. To examine white matter diffusion abnormalities across the entire brain of individual patients, we applied Enhanced Z-score Microstructural Assessment for Pathology (EZ-MAP), a voxelwise analysis optimized for the assessment of individual subjects. Our analysis revealed areas of abnormally low or high FA (voxel-wise P-value < 0.05, cluster-wise P-value < 0.01(corrected for multiple comparisons)). The spatial pattern of white matter FA abnormalities varied among patients. Areas of low FA were consistent with known patterns of traumatic axonal injury. Areas of high FA were most frequently detected in the deep and subcortical white matter of the frontal, parietal, and temporal lobes, and in the anterior portions of the corpus callosum. The number of both abnormally low and high FA voxels changed during follow up. Individual subject assessments reveal unique spatial patterns of white matter abnormalities in each patient, attributable to inter-individual differences in anatomy, vulnerability to injury and mechanism of injury. Implications of high FA remain unclear, but may evidence a compensatory mechanism or plasticity in response to injury, rather than a direct manifestation of brain injury.     

Epidemiology and outcomes of pediatric traumatic brain injury

Traumatic brain injury is a leading cause of death and disability in the pediatric age group. Causes of injury vary with child developmental age, with more inflicted injuries in infants, fall-related injuries among toddlers, sports-related injuries among middle-school-aged children and motor vehicle crashes in older children. Prevention strategies exist for some pediatric traumatic brain injury; however, all suffer from lack of compliance and enforcement. Neuropsychological and behavioral outcomes for injured children vary with the severity of injury, child age at injury, premorbid child characteristics, family factors and the families' socioeconomic status. Each of these factors needs to be taken into account when designing rehabilitation strategies and assessing factors related to outcome.     

大鼠颅脑创伤后脑红蛋白表达变化的实验研究

目的研究弥漫性颅脑创伤后大鼠脑组织中脑红蛋白的核酸与蛋白表达变化情况，初探脑红蛋白与颅脑创伤的关系。方法选择Marmarou’s自由落体打击装置复制弥漫性颅脑创伤模型，采用实时定量PCR及Westernblotting分别检测伤后不同时间（30min、1h、2h、6h、12h、24h、48h、72h、5d）脑组织中脑红蛋白核酸及蛋白水平的表达情况，并对所得数据进行统计学分析。结果在伤后30min，脑组织中脑红蛋白的核酸表达m现首个高峰，相应地其蛋白表达于伤后1h增高，于伤后2h达峰值；伤后12h，脑红蛋白的核酸表达再次升高，于伤后48h达高峰，其蛋白表达亦于伤后24h增高，至72h达峰值。结论颅脑创伤后脑组织中脑红蛋白呈“双峰”样表达。提示脑红蛋白可拮抗对神经元的创伤应激及伤后继发缺血、缺氧性损害，对创伤后脑组织具有一定的保护作用。