Abnormal Neurological Exam Findings in Individuals with Mild Traumatic Brain Injury (mTBI) Versus Psychiatric and Healthy Controls

In those with a history of mild traumatic brain injury (mTBI), cognitive and emotional disturbances are often misattributed to that preexisting injury. However, causal determinations of current symptoms cannot be conclusively determined because symptoms are often nonspecific to etiology and offer virtually no differential diagnostic value in postacute or chronic phases. This population-based study examined whether the presence of abnormalities during neurological examination would distinguish between mTBI (in the chronic phase), healthy controls, and selected psychiatric conditions. Retrospective analysis of data from 4462 community-dwelling Army veterans was conducted. Diagnostically unique groups were compared on examination of cranial nerve function and other neurological signs. Results demonstrated that individuals with mTBI were no more likely than those with a major depressive disorder, generalized anxiety disorder, posttraumatic stress disorder, or somatoform disorder to show any abnormality. Thus, like self-reported cognitive and emotional symptoms, the presence of cranial nerve or other neurological abnormalities offers no differential diagnostic value. Clinical implications and study limitations are presented.     

Sleep and Psychiatric Disorders in Persons With Mild Traumatic Brain Injury

Mild traumatic brain injury (mTBI) frequently challenges the integrity of sleep function by affecting multiple brain areas implicated in controlling the switch between wakefulness and sleep and those involved in circadian and homeostatic processes; the malfunction of each causes a variety of disorders. In this review, we discuss recent data on the dynamics between disorders of sleep and mental/psychiatric disorders in persons with mTBI. This analysis sets the stage for understanding how a variety of physiological, emotional and environmental influences affect sleep and mental activities after injury to the brain. Consideration of the intricate links between sleep and mental functions in future research can increase understanding on the underlying mechanisms of sleep-related and psychiatric comorbidity in mTBI.     

Pediatric Traumatic Brain Injury : The Epidemiology in Korea

Traumatic brain injury (TBI) is one of the leading causes of death in the pediatric population in Korea. In addition, it can cause disability in children and adolescents, with physical and mental consequences. This causes a substantial burden on the health care system and occurs globally and not just in Korea. We searched and reviewed current data on the epidemiologic characteristics of pediatric TBI in Korea. Our review provides the recent epidemiological trend mainly focusing on incidence and mortality along with worldwide reported data. This review will be helpful to understand the global epidemiology of pediatric TBI and its differences between countries.     

Stress as a Diagnostic Challenge for Postconcussive Symptoms: Sequelae of Mild Traumatic Brain Injury or Physiological Stress Response

There is considerable controversy regarding whether persistent postconcussive symptoms (PCS) are injury-specific, in a subgroup of individuals after mild traumatic brain injury (TBI). The following findings have contributed to this controversy: (1) The base rate of PCS in mild TBI is comparable to uninjured controls; and (2) The severity of PCS covary with daily stress levels (Gouvier, Cubic, Jones, Brantley, Cutlip, 1992). We examined this relationship further by evaluating the effects of experimental conditions of stress or relaxation on individuals with TBI and uninjured control subjects, with low and high PCS endorsement. We evaluated psychophysiological parameters, neuropsychological performance, and changes in PCS and stress perception. In our study, subjects with TBI increased PCS after engaging in cognitively challenging tasks, and demonstrated significant autonomic changes in the stress condition. Symptomatic TBI subjects exposed to high stress had increases in PCS complaints, decreased speed of information processing, and subtle memory deficits. Our results suggest that PCS are injury-specific and that individuals with a history of TBI are susceptible to the effects of stress. Relaxation training including breathing retraining may be an effective means of decreasing PCS and cognitive complaints in subjects with mild TBI.     

The Relationship Between Suboptimal Effort and Post-Concussion Symptoms in Children and Adolescents With Mild Traumatic Brain Injury

This retrospective chart review study explored the relationship between suboptimal effort and post-concussion symptoms in pediatric mild traumatic brain injury (mTBI). Participants were 382 clinically referred children and adolescents between 8 and 16 years of age who sustained an mTBI. Suboptimal effort was identified using reliable digit span and age-corrected scaled scores from the Numbers subtest of the Children’s Memory Scale (CMS); 20% of the sample were classified as non-credible performers. Chi-square analyses and t-tests were used to examine differences in post-concussion symptoms and neuropsychological test performance between credible and non-credible performers. Linear regression was used to examine whether CMS Numbers performance predicted post-concussion symptoms after controlling for baseline symptoms and other relevant demographic- and injury-related factors. We found that non-credible performers presented with a greater number of post-concussion symptoms as compared with credible performers. Additionally, non-credible performers demonstrated comparatively poorer performance on neuropsychological tests of focused attention and processing speed. These results suggest that children and adolescents with mTBI who fail effort testing might have a greater tendency to exaggerate post-concussion symptoms and cognitive impairment. The clinical implications of these findings are discussed.     

Neurocognitive Function Differentiation from the Effect of Psychopathologic Symptoms in the Disability Evaluation of Patients with Mild Traumatic Brain Injury

Objective

We determined whether the relationship between the neuropsychological performance of patients with mild traumatic brain injury (TBI) and their psychopathological characteristics measured by disability evaluation are interrelated. In addition, we assessed which psychopathological variable was most influential on neuropsychological performance via statistical clustering of the same characteristics of mild TBI.

Methods

A total of 219 disability evaluation participants with mild brain injury were selected. All participants were classified into three groups, based on their psychopathological characteristics, via a two-step cluster analysis using validity and clinical scales from the Minnesota Multiphasic Personality Inventory (MMPI) and Symptom Checklist-90-revised (SCL-90-R). The Korean Wechsler Adult Intelligence Scale (K-WAIS), Korean Memory Assessment Scale (K-MAS) and the Korean Boston Naming Test (K-BNT) were used to evaluate the neurocognitive functions of mild TBI patients.

Results

Over a quarter (26.9%) experienced severe psychopathological symptoms and 43.4% experienced mild or moderate psychopathological symptoms, and all of the mild TBI patients showed a significant relationship between neurocognitive functions and subjective and/or objective psychopathic symptoms, but the degree of this relationship was moderate. Variances of neurocognitive function were explained by neurotic and psychotic symptoms, but the role of these factors were different to each other and participants did not show intelligence and other cognitive domain decrement except for global memory abilities compared to the non-psychopathology group.

Conclusion

Certain patients with mild TBI showed psychopathological symptoms, but these were not directly related to cognitive decrement. Psychopathology and cognitive decrement are discrete aspects in patients with mild TBI. Furthermore, the neurotic symptoms of mild TBI patients made positive complements to decrements or impairments of neurocognitive functions, but the psychotic symptoms had a negative effect on neurocognitive functions.     

Comorbid Psychiatric Disorders in Children with Autism: Interview Development and Rates of Disorders

The Kiddie Schedule for Affective Disorders and Schizophrenia was modified for use in children and adolescents with autism by developing additional screening questions and coding options that reflect the presentation of psychiatric disorders in autism spectrum disorders. The modified instrument, the Autism Comorbidity Interview-Present and Lifetime Version (ACI-PL), was piloted and frequently diagnosed disorders, depression, ADHD, and OCD, were tested for reliability and validity. The ACI-PL provides reliable DSM diagnoses that are valid based on clinical psychiatric diagnosis and treatment history. The sample demonstrated a high prevalence of specific phobia, obsessive compulsive disorder, and ADHD. The rates of psychiatric disorder in autism are high and are associated with functional impairment.     

Incidence of Post-Traumatic Stress Disorder after a Mild Traumatic Brain Injury: Preliminary Investigation Using the Brief Neuropsychological Screening Test

Objective

Post-traumatic stress disorder (PTSD) is a group of diseases that are observed in patients who had experienced a serious trauma or accident. However, some experienced it even after only a mild traumatic brain injury (TBI), and they are easily ignored due to the relatively favorable course of mild TBI. Herein, the authors investigated the incidence of PTSD in mild TBI using brief neuropsychological screening test (PTSD checklist, PCL).

Methods

This study was conducted on patients with mild TBI (Glasgow coma scale ≥13) who were admitted from January 2012 to December 2012. As for PCL, it was done on patients who showed no difficulties in communication upon admission and agreed to participate in this study. By using sum of PCL, the patients were divided into high-risk group and low-risk group. PTSD was diagnosed as the three major symptoms of PTSD according to the Diagnostic and Statistical Manual of Mental Disorders, fourth-edifion.

Results

A total of 314 TBI patients were admitted and 71 of them met the criteria and were included in this study. The mean age was 52.9 years-old (range: 15-94). The mean PCL score was 28.8 (range: 17-68), and 10 patients were classified as high-risk group. During follow-up, 2 patients (2.7%) of high risk group, were confirmed as PTSD and there was no patient who was suspected of PTSD in the low-risk group (p=0.017).

Conclusion

PTSD is observed 2.8% in mild TBI. Although PTSD after mild TBI is rare, PCL could be considered as a useful tool for screening of PTSD after mild TBI.     

Verbal Fluency Indicators of Malingering in Traumatic Brain Injury: Classification Accuracy in Known Groups

A known-groups design was used to determine the classification accuracy of verbal fluency variables in detecting Malingered Neurocognitive Dysfunction (MND) in traumatic brain injury (TBI). Participants were 204 TBI and 488 general clinical patients. The Slick et al. (1999 Slick, DJ, Sherman, EMS and Iverson, GL. 1999. Diagnostic criteria for malingered neurocognitive dysfunction: Proposed standards for clinical practice and research. The Clinical Neuropsychologist, 13: 545–561. [Taylor & Francis Online], [Web of Science ®] , [Google Scholar]) criteria were used to classify the TBI patients into non-MND and MND groups. An educationally corrected FAS Total Correct word T-score proved to be the most accurate of the several verbal fluency indicators examined. Classification accuracy of this variable at specific cutoffs is presented in a cumulative frequency table. This variable accurately differentiated non-MND from MND mild TBI patients but its accuracy was unacceptable in moderate/severe TBI. The clinical application of these findings is discussed.     

Management of a DBS System in Patients With Traumatic Brain Injury: Case Report

Introduction: The use of deep brain stimulation (DBS) is growing. While these patients may suffer from traumatic brain injuries, treatment guidelines for these patients have not yet been reported. This case report demonstrates a strategy for traumatic brain injury after DBS implantation. Clinical presentation: A 46‐year‐old man underwent bilateral DBS in the posterior subthalamic area for essential tremor, which improved both distal and proximal tremor. Two years later, he underwent emergent hematoma evacuation due to a motor vehicle associated injury. A 23‐year‐old male patient presented with severe Tourette's syndrome characterized by a vocal and self lip biting motor tic. There was a good effect of chronic bilateral thalamic DBS at CM‐Pf. Five months later, he had acute subdural hematoma after a motorcycle accident. Instead of removing stimulation electrodes immediately after traumatic brain injury, the patient was reassessed after recovery. Merged preoperative magnetic resonance images and brain computed tomography images, and clinical reassessments were used to plan future treatment. Conclusion: We recommend removing only the hematoma, leaving the electrodes in position, and then reassessing the electrode position using merged images. The clinical correlation with electrode migration also should be checked. If the patient can tolerate stimulation with a minor displacement, the electrodes should be left in position and the stimulation parameter needs to be adjusted. If not, the stimulation electrodes should be deactivated or repositioned appropriately, depending on the patient's conditions.     

Repetitive Transcranial Magnetic Stimulation for Depression and Posttraumatic Stress Disorder in Veterans With Mild Traumatic Brain Injury

ObjectivesMild traumatic brain injury (mTBI) is a signature injury of military conflicts and is prevalent in veterans with major depressive disorder (MDD) and posttraumatic stress disorder (PTSD). Although therapeutic transcranial magnetic stimulation (TMS) can reduce symptoms of depression and PTSD, whether traumatic brain injury (TBI) affects TMS responsiveness is not yet known. We hypothesized mTBI would be associated with higher pretreatment symptom burden and poorer TMS response.Materials and MethodsWe investigated a registry of veterans (N = 770) who received TMS for depression across the US Veterans Affairs system. Of these, 665 (86.4%) had data on TBI and lifetime number of head injuries while 658 had complete data related to depression outcomes. Depression symptoms were assessed using the nine-item Patient Health Questionnaire and PTSD symptoms using the PTSD Checklist for DSM-5. Linear mixed effects models and t-tests evaluated whether head injuries predicted symptom severity before treatment, and how TBI status affected clinical TMS outcomes.ResultsOf the 658 veterans included, 337 (50.7%) reported previous mTBI, with a mean of three head injuries (range 1–20). TBI status did not predict depressive symptom severity or TMS-associated changes in depression (all p’s > 0.1). TBI status was associated with a modest attenuation of TMS-associated improvement in PTSD (in patients with PTSD Checklist for DSM-5 scores > 33). There was no correlation between the number of head injuries and TMS response (p > 0.1).ConclusionsContrary to our hypothesis, presence of mTBI did not meaningfully change TMS outcomes. Veterans with mTBI had greater PTSD symptoms, yet neither TBI status nor cumulative head injuries reduced TMS effectiveness. Limitations include those inherent to retrospective registry studies and self-reporting. Although these findings are contrary to our hypotheses, they support the safety and effectiveness of TMS for MDD and PTSD in patients who have comorbid mTBI.     

Mediating Effects of Cognitive Effort and Depression on Intelligence,Memory, and Executive Functions in Individuals with Mild Traumatic Brain Injury

Objective

Mild traumatic brain injury (mTBI) is frequently associated with psychiatric symptoms and cognitive dysfunction, as well as with the receipt of workers'' compensation, as many mTBIs occur due to work-related accidents. We hypothesized that depression and insufficient cognitive effort mediate the relationship between sociodemographic variables and cognitive dysfunction in mTBI.

Methods

A retrospective chart review study was conducted using 115 records of patients with mTBI. Cognitive effort was measured based on scores on the Rey 15-Item Test. Multivariate linear regression analysis was performed to examine factors predictive of cognitive functions. Path analysis was subsequently performed to investigate the mediating effects of depression and cognitive effort in relation to receipt of workers'' compensation and demographic variables.

Results

Fifteen of the 115 participants (13.0%) received failing scores on the Rey 15-Item Test, which indicated insufficient cognitive effort. Path analysis indicated that cognitive effort mediated the effects of age and workers'' compensation on cognitive functions.

Conclusion

Given the significant mediating effects of cognitive effort on cognitive performance, it is important to address patient motivation and encourage mTBI patients covered by workers'' compensation to perform tests with authentic effort.     

Involvement of Activation of Dopamineraic Neuronal System in Learning and Memory Deficits Associated with Experimental Mild Traumatic Brain Injury

Much evidence has indicated that a disturbance in dopamine neurotransmission following mild to moderate traumatic brain injury is involved in the development of post traumatic memory deficits. In the present study we examined the effects of a dopamine receptor agonist and some antagonists on latent learning and memory deficits associated with a concussive traumatic brain injury in mice. Anaesthetized animals were subjected to mild traumatic brain injury by dropping a weight onto the head, and a single-dose injection of apomorphine (0.3–3.0 mg/kg) or haloperidol (0.3–3.0 mg/kg) was made i.p. 15 min after the trauma. One week later, a water-finding task consisting of an acquisition trial, a retention test and a retest was employed to assess learning and memory functions. Mice that had received a traumatic brain injury were impaired in task performance, with prolonged latencies for finding and drinking in the retention test and retest. Administration of haloperidol but not of apomorphine significantly shortened the prolonged latency in both of the tests, indicating that antagonism of dopamine receptors is beneficial for the recovery of post traumatic memory deficits. In order to evaluate which receptor subtype plays the major role in this model, we examined the effects of SCH-23390 (0.03–0.3 mg/kg), a D1 receptor antagonist, and sulpiride (3.0–30 mg/kg), a D2 receptor antagonist, in the same experimental paradigm. The results showed that administration of sulpiride but not of SCH-23390 significantly improved the deficits in task performance, indicating that D2 receptors are the major site of action. However, combined treatment with SCH-23390 (0.03–0.3 mg/kg) and sulpiride (3.0 mg/kg) at doses that had no effect when the antagonists were given alone exerted a significant additive effect in improving these deficits, indicating that interaction between D1 and D2 receptors is involved in these processes. The present results suggest that a dopaminergic mechanism contributes to the memory dysfunction associated with traumatic brain injury.     

Changes After EEG Biofeedback and Cognitive Retraining in Adults with Mild Traumatic Brain Injury and Attention Deficit Hyperactivity Disorder

Abstract

Introduction. Adults diagnosed with mild traumatic brain injury (mTBI) or Attention Deficit Hyperactivity Disorder (ADHD) were treated with EEG Biofeedback and cognitive retraining.

Methods. Psychological and neuropsychological tests were completed at pre-treatment and post-treatment and compared to a normal control group that did not receive training, but tested on two occasions.

Results. The results found significant improvement on full scale attention and full scale response accuracy of a continuous performance task in the mTBI and ADHD groups compared to the control group. A self report showed a significant decline in symptoms in the mTBI and ADHD groups compared to the control group. Errors on a problem solving task decreased only in the mTBI group.

Discussion. The treatment model used in this study showed significant improvement in the sustained attention of individuals diagnosed with mTBI and ADHD after twenty treatment sessions.     

Early-Onset Ventilator-Associated Pneumonia in Patients with Severe Traumatic Brain Injury: Incidence,Risk Factors,and Consequences in Cerebral Oxygenation and Outcome

Background

Early-onset ventilator-associated pneumonia (EOVAP) occurs frequently in severe traumatic brain-injured patients, but potential consequences on cerebral oxygenation and outcome have been poorly studied. The objective of this study was to describe the incidence, risk factors for, and consequences on cerebral oxygenation and outcome of EOVAP after severe traumatic brain injury (TBI).

Methods

We conducted a retrospective, observational study including all intubated TBI admitted in the trauma center. An EOVAP was defined as a clinical pulmonary infection score >6, and then confirmed by an invasive method. Patient characteristics, computed tomography (CT) scan results, and outcome were extracted from a prospective register of all intubated TBI admitted in the intensive care unit (ICU). Data concerning the cerebral oxygenation monitoring by PbtO₂ and characteristics of EOVAP were retrieved from patient files. Multivariate logistic regression models were developed to determine the risk factors of EOVAP and to describe the factors independently associated with poor outcome at 1-year follow-up.

Results

During 7 years, 175 patients with severe TBI were included. The overall incidence of EOVAP was 60.6% (47.4/1000 days of ventilation). Significant risk factors of EOVAP were: therapeutic hypothermia (OR 3.4; 95% CI [1.2–10.0]), thoracic AIS score ≥3 (OR 2.4; 95% CI [1.1–5.7]), and gastric aspiration (OR 5.2, 95% CI [1.7–15.9]). Prophylactic antibiotics administration was a protective factor against EOVAP (OR 0.3, 95% CI [0.1–0.8]). EOVAP had negative consequences on cerebral oxygenation. The PbtO₂ was lower during EOVAP: 23.5 versus 26.4 mmHg (p <0.0001), and there were more brain hypoxia episodes: 32 versus 27% (p = 0.03). Finally, after adjusting for confounders, an EOVAP was an independent factor associated with unfavorable neurologic functional outcome at the 1-year follow-up (OR 2.71; 95% CI [1.01–7.25]).

Conclusions

EOVAP is frequent after a severe TBI (overall rate: 61%), with therapeutic hypothermia, severe thoracic lesion, and gastric aspiration as main risk factors. EOVAP had a negative impact on cerebral oxygenation measured by PbtO₂ and was independently associated with unfavorable outcome at 1-year follow-up. This suggests that all precautions available should be taken to prevent EOVAP in this population.