Head-injured Adults Research Articles

Vestibular/ocular motor screening (VOMS) score for identification of concussion in cases of non-severe head injury: A systematic review

Background and importance Each year, 1.4 million patients attend a UK ED with a head injury. Mild traumatic brain injury affects up to 300/100 000 admitted patients/year and a greater number of non-admitted patients. Identifying those patients with a head injury that have concussion, and of those, which will have a prolonged recovery, is critical for discharge planning. The Vestibular/Ocular Motor Screening test (VOMS) has been reported as a useful “sideline tool” to evaluate for sports-related concussion (SRC). VOMS has been assessed for utility primarily for predicting in head-injured, which cases will have concussion, and secondarily in predicting in concussed patients, which will have prolonged recovery. Originally described in 2014, VOMS has not been subject to systematic review or meta-analysis, with regard to its predictive performance for concussion. Objective To assess the state of VOMS evidence for dichotomously classifying concussion status in patients with non-severe head injury Design Systematic review. Setting and participants Studies comprising the review enrolled ambulatory head-injured adults and children, usually from sports-related settings, in Europe or the USA. Exposure VOMS. Outcome measures Presence of concussion, presence of prolonged recovery in concussed patients Main results The review identified 17 studies, characterized by a wide variety of specific approaches to administering and scoring VOMS. While VOMS showed promise as a screening tool for concussion, marked study heterogeneity precluded generation of a pooled effect estimate for VOMS performance. Conclusion VOMS is potentially useful as a concussion screening tool. Available evidence from the SRC arena suggests sensitivity ranging from 58–96%, with specificity 46−92%. Directions for future VOMS research should include evaluation of standardized administration and scoring, potentially of a simpler VOMS (with fewer components), in a general head-injured population. Further analysis of precisely defined VOMS application may be useful to determine the proper place of VOMS screening for the head-injured.

How Well Do EMS Providers Predict Intracranial Hemorrhage in Head-Injured Older Adults?

Objective: To evaluate the accuracy of emergency medical services (EMS) provider judgment for traumatic intracranial hemorrhage (tICH) in older patients following head trauma in the field. We also compared EMS provider judgment with other sets of field triage criteria. Methods: This was a prospective observational cohort study conducted with five EMS agencies and 11 hospitals in Northern California. Patients 55 years and older who experienced blunt head trauma were transported by EMS between August 1, 2015 and September 30, 2016, and received an initial cranial computed tomography (CT) imaging, were eligible. EMS providers were asked, “What is your suspicion for the patient having intracranial hemorrhage (bleeding in the brain)?” Responses were recorded as ordinal categories (<1%, 1–5%, >5–10%, >10–50%, or >50%) and the incidences of tICH were recorded for each category. The accuracy of EMS provider judgment was compared to other sets of triage criteria, including current field triage criteria, current field triage criteria plus multivariate logistical regression risk factors, and actual transport. Results: Among the 673 patients enrolled, 319 (47.0%) were male and the median age was 75 years (interquartile range 64–85). Seventy-six (11.3%) patients had tICH on initial cranial CT imaging. The increase in EMS provider judgment correlated with an increase in the incidence of tICH. EMS provider judgment had a sensitivity of 77.6% (95% CI 67.1–85.5%) and a specificity of 41.5% (37.7–45.5%) when using a threshold of 1% or higher suspicion for tICH. Current field triage criteria (Steps 1–3) was poorly sensitive (26.3%, 95% CI 17.7–37.2%) in identifying tICH and current field trial criteria plus multivariate logistical regression risk factors was sensitive (97.4%, 95% CI 90.9–99.3%) but poorly specific (12.9%, 95% CI 10.4–15.8%). Actual transport was comparable to EMS provider judgment (sensitivity 71.1%, 95% CI 60.0–80.0%; specificity 35.3%, 95% CI 31.6–38.3%). Conclusions: As EMS provider judgment for tICH increased, the incidence for tICH also increased. EMS provider judgment, using a threshold of 1% or higher suspicion for tICH, was more accurate than current field triage criteria, with and without additional risk factors included.

Triage of Mild Head-Injured Intoxicated Patients Could Be Aided by Use of an Electroencephalogram-Based Biomarker.

Drug and alcohol (DA)-related emergency department (ED) visits represent an increasing fraction the head-injured population seen in the ED. Such patients present a challenge to the evaluation of head injury and determination of need for computed tomographic (CT) scan and further clinical path. This effort examined whether an electroencephalogram (EEG)-based biomarker could aid in reducing unnecessary CT scans in the intoxicated ED population. This is a retrospective secondary study of an independent prospective US Food and Drug Administration validation trial that demonstrated the efficacy of (1) an automatic Structural Injury Classifier for the likelihood of injury visible on a CT (CT+) and (2) an EEG-based Brain Function Index to assess functional impairment in minimally impaired, head-injured adults presenting within 3 days of injury. Impact on the biomarker performance in patients who presented with or without DA was studied. Structural Injury Classifier sensitivity was not significantly impacted by the presence of DA. Although specificity decreased, it remained several times higher than obtained using standard CT decision rules. Furthermore, the potential to reduce the number of unnecessary scans by approximately 30% was demonstrated when the Structural Injury Classifier was integrated into CT clinical triage. The Brain Function Index was demonstrated to be independent of the presence of DA. This EEG-based assessment technology used to identify the likelihood of structural or functional brain injury in mildly head-injured patients represents an objective way to aid in triage patients with DA on presentation, with the potential to decrease overscanning while not sacrificing sensitivity to injuries visible on CT.

From Interference to Factitious Disorder: Slippery Slope or Tip of the Iceberg? The Case of a Difficult Guardian of a Head-Injured Adult

Factitious disorder imposed on another is predominantly recognized in the pediatric population. It represents a diagnostic challenge and can have a profoundly negative influence on the illness and management of adult patients. This report describes a case of factitious disorder imposed on an adult with acquired brain injury and discusses the diagnostic and management challenges. Positive outcome followed appropriate limit-setting. J Med Cases. 2018;9(4):116-118 doi: https://doi.org/10.14740/jmc3030w

A comprehensive and integrated clinical rating for storytelling produced by individuals with traumatic brain injury: A preliminary report

A comprehensive and integrated clinical rating for storytelling produced by individuals with traumatic brain injury: A preliminary report

From Interference to Factitious Disorder: Slippery Slope or Tip of the Iceberg? The Case of a Difficult Guardian of a Head-Injured Adult

Factitious disorder imposed on another is predominantly recognized in the pediatric population. It represents a diagnostic challenge and can have a profoundly negative influence on the illness and management of adult patients. This report describes a case of factitious disorder imposed on an adult with acquired brain injury and discusses the diagnostic and management challenges. Positive outcome followed appropriate limit-setting. J Med Cases. 2018;9(4):116-118 doi: https://doi.org/10.14740/jmc3030w

Bypassing nearest hospital for more distant neuroscience care in head-injured adults with suspected traumatic brain injury: findings of the head injury transportation straight to neurosurgery (HITS-NS) pilot cluster randomised trial

ObjectiveReconfiguration of trauma services, with direct transport of patients with traumatic brain injury (TBI) to specialist neuroscience centres (SNCs)—bypassing non-specialist acute hospitals (NSAHs), could improve outcomes. However, delays in stabilisation...

Measuring sentence types and complexity of spontaneous discourse productions by Cantonese-speakers with traumatic brain injury in Guangzhou: A pilot study

Measuring sentence types and complexity of spontaneous discourse productions by Cantonese-speakers with traumatic brain injury in Guangzhou: A pilot study

Cohesion in oral discourse of Mandarin-speaking adults with traumatic brain injury: Report of pilot data on story telling

Cohesion in oral discourse of Mandarin-speaking adults with traumatic brain injury: Report of pilot data on story telling

Development of the MMPI-2 cognitive complaints scale as an embedded measure of symptom validity

Objective: To empirically-derive a new MMPI-2 sub-scale, the 13-item Cognitive Complaints Scale (CCS), as an embedded measure of symptom validity. This study hypothesized that mild traumatic brain injured subjects with financial incentives who failed performance validity tests (PVTs) would score significantly higher on the CCS compared to mild traumatic brain injured subjects with financial incentives who passed PVTs. Mild traumatic brain injured controls with no financial incentives were predicted to score lowest on the CCS.Research design: A known groups design was utilized as this design allows for the accurate classification of criterion groups.Methods: One hundred and fifty mild head-injured adults were assigned to one of three groups: the Failed Performance Validity (FPV) group, the Passed Performance Validity (PPV) group or a control group.Results: An ANOVA revealed that the FPV group scored significantly higher on the CCS compared to the PPV group. Controls with no financial incentives scored lowest. A CCS cut-score of ≥12 discriminated between the FPV and PPV groups at a high level of specificity (94%).Conclusions: A dissociation between ‘performance validity’ and ‘symptom validity’ supports recommendations for the differential application of these descriptive terms. The CCS may be helpful to assess credibility of clinical presentation in situations where PVTs are absent.

Risk factors indicating the need for cranial CT scans in elderly patients with head trauma: an Austrian trial and comparison with the Canadian CT Head Rule

This study presents newly defined risk factors for detecting clinically important brain injury requiring neurosurgical intervention and intensive care, and compares it with the Canadian CT Head Rule (CCHR). This prospective cohort study was conducted in a single Austrian Level-I trauma center and enrolled a consecutive sample of mildly head-injured adults who presented to the emergency department with witnessed loss of consciousness, disorientation, or amnesia, and a Glasgow Coma Scale (GCS) score of 13-15. The studied population consisted of a large number of elderly patients living in Vienna. The aim of the study was to investigate risk factors that help to predict the need for immediate cranial CT in patients with mild head trauma. Among the 12,786 enrolled patients, 1307 received a cranial CT scan. Four hundred eighty-nine patients (37.4%) with a mean age of 63.9 ± 22.8 years had evidence of an acute traumatic intracranial lesion on CT. Three patients (< 0.1%) were admitted to the intensive care unit for neurological observation and received oropharyngeal intubation. Seventeen patients (0.1%) underwent neurosurgical intervention. In 818 patients (62.6%), no evidence of an acute trauma-related lesion was found on CT. Data analysis showed that the presence of at least 1 of the following factors can predict the necessity of cranial CT: amnesia, GCS score, age > 65 years, loss of consciousness, nausea or vomiting, hypocoagulation, dementia or a history of ischemic stroke, anisocoria, skull fracture, and development of a focal neurological deficit. Patients requiring neurosurgical intervention were detected with a sensitivity of 90% and a specificity of 67% by using the authors' analysis. In contrast, the use of the CCHR in these patients detected the need for neurosurgical intervention with a sensitivity of only 80% and a specificity of 72%. The use of the suggested parameters proved to be superior in the detection of high-risk patients who sustained a mild head trauma compared with the CCHR rules. Further validation of these results in a multicenter setting is needed. Clinical trial registration no.: NCT00451789 ( ClinicalTrials.gov .).

Controlled Trials of Transport Modality in Trauma Are Feasible

I commend the excellent trauma registry–based study by Stewart et al.1 demonstrating reduced mortality risk associated with helicopter transfer compared with ground ambulance transport from the accident scene to a trauma center. However, contention by Stewart et al. that “... a randomized controlled trial [in prehospital mode of transport of injured persons] will likely never be conducted ...” does not take into account Careflight New South Wales’ Head Injury Retrieval Trial (HIRT) in Sydney, Australia, which commenced in May 2005 and was due for completion in October 2011.2 HIRT is a randomized prehospital study allocating severe head-injured adults (initial scene GCS 3 to 8) to standard road paramedic care or management by a critical care retrieval team led by a consultant anesthetist, emergency physician, or intensive care physician deployed by helicopter. The latter assignment could include rapid sequence intubation (RSI), blood transfusion, and surgical procedures provided by advanced-level prehospital providers.2 In a recent randomized comparison trial, prehospital RSI in head-injured patients was shown to significantly improve neurologic outcome at 6 months among survivors compared with intubation on arrival in the emergency department.3 As advanced airway and scene surgical procedures could be beneficial in severe trauma,2, 3 by not taking into account the competency and performance of time-critical medical procedures at the accident scene, Stewart et al.1 risk conflating the benefits of better prehospital trauma care provided by helicopter medical teams with mode of patient transport.

Performance of the Canadian CT Head Rule and the New Orleans Criteria for Predicting Any Traumatic Intracranial Injury on Computed Tomography in a United States Level I Trauma Center

This study compared the clinical performance of the Canadian CT Head Rule (CCHR) and the New Orleans Criteria (NOC) for detecting any traumatic intracranial lesion on computed tomography (CT) in patients with a Glasgow Coma Scale (GCS) score of 15. Also assessed were ability to detect patients with "clinically important" brain injury and patients requiring neurosurgical intervention. Additionally, the performance of the CCHR was assessed in a larger cohort of those presenting with GCS of 13 to 15. This prospective cohort study was conducted in a U.S. Level I trauma center and enrolled a consecutive sample of mildly head-injured adults who presented to the emergency department (ED) with witnessed loss of consciousness, disorientation or amnesia, and GCS 13 to 15. The rules were compared in the group of patients with GCS 15. The primary outcome was prediction of "any traumatic intracranial injury" on CT. Secondary outcomes included "clinically important brain injury" on CT and need for neurosurgical intervention. Among the 431 enrolled patients, 314 patients (73%) had a GCS of 15, and 22 of the 314 (7%) had evidence of a traumatic intracranial lesion on CT. There were 11 of 314 (3.5%) who had "clinically important" brain injury, and 3 of 314 (1.0%) required neurosurgical intervention. The NOC and CCHR both had 100% sensitivity (95% confidence interval [CI] = 82% to 100%), but the CCHR was more specific for detecting any traumatic intracranial lesion on CT, with a specificity of 36.3% (95% CI = 31% to 42%) versus 10.2% (95% CI = 7% to 14%) for NOC. For "clinically important" brain lesions, the CCHR and the NOC had similar sensitivity (both 100%; 95% CI = 68% to 100%), but the specificity was 35% (95% CI = 30% to 41%) for CCHR and 9.9% (95% CI = 7% to 14%) for NOC. When the rules were compared for predicting need for neurosurgical intervention, the sensitivity was equivalent at 100% (95% CI = 31% to 100%) but the CCHR had a higher specificity at 80.7% (95% CI = 76% to 85%) versus 9.6% (95% CI = 7% to 14%) for NOC. Among all 431 patients with a GCS score 13 to 15, the CCHR had sensitivities of 100% (95% CI = 84% to 100%) for 27 patients with clinically important brain injury and 100% (95% CI = 46% to 100%) for five patients requiring neurosurgical intervention. In a U.S. sample of mildly head-injured patients, the CCHR and the NOC had equivalently high sensitivities for detecting any traumatic intracranial lesion on CT, clinically important brain injury, and neurosurgical intervention, but the CCHR was more specific. A larger cohort will be needed to validate these findings.

Long-term effects of severe closed head injury on memory: evidence from a consecutive series of young adults.

Long-term cognitive sequelae of severe closed head injury were studied in a consecutive series of 39 young head-injury adults without gross intellectual deficits. Testing was carried out 2-5 years post-injury. Patients with a post-traumatic amnesia (PTA) greater than 3 weeks were impaired on a wide range of tests, particularly those requiring long-term retention of complex materials or where time constraints were a salient feature. Patients with a PTA of 1-3 weeks were unimpaired on all tasks. The results suggest that in young adults a threshold of brain damage related to long-term cognitive impairment operates at around a 2-3 week PTA duration.

The effects of head trauma on hypothalamic–pituitary function in children and adolescents

Endocrine dysfunctions have been increasingly recognized following traumatic brain injury. Ever more numerous studies on acute head-injured adults have also raised concern about this risk in children and adolescents who have experienced head injury. The current review of the pediatric literature summarizes recent findings on acute-phase dysfunction and traumatic brain injury-associated hypopituitarism. The pathophysiologic mechanisms underlying acute-phase hyponatremic and hypernatremic disorders have been elucidated. Prospective studies on traumatic brain injury-associated hypopituitarism in pediatric patients are ongoing and preliminary data are available. Traumatic brain injury, a 'silent epidemic' that carries a considerable burden of disabilities, leads to a variety of endocrine dysfunctions in 28-69% of adult acute head-injured patients. In the acute posttraumatic phase, adrenal insufficiency and electrolyte disorders are critical conditions. Neurosurgical patients, particularly those prone to neurological damage, require prompt diagnosis. Hypopituitarism may be diagnosed months or years after a traumatic brain injury event. Since growth hormone and gonadotropin secretion are most frequently compromised, careful follow-up of growth and pubertal development is mandatory in children hospitalized for traumatic brain injury.

Traumatic pediatric brain injury and intracranial pressure monitoring: does it really improve outcome?

Sir: We read with great interest the contribution by Morris et al. [1]. The authors and the United Kingdom Paediatric Traumatic Brain Injury (TBI) Study Group need to be congratulated on setting up this databank, providing useful information regarding severe traumatic brain injury in children. The objective of the study was to identify factors associated with the use of intracranial pressure (ICP) monitoring and to determine what ICP-targeted therapies are being used in children with severe TBI. The authors observed that ICP monitoring was undertaken in 45% of cases, and this increased to 59% in those with an emergency room Glasgow Coma Score of 8 or below. First-tier ICP targeted therapy was found to differ substantially between centers. Finally, the authors advocated the use of ICP monitoring and targeted therapy and concluded that less variation in management could have a beneficial effect on outcome. Despite widespread recommendation by experts in the field there is no sound evidence that monitoring of ICP and ICP-targeted therapy improve outcome [2]. Recently a retrospective cohort study in two level I trauma centers in The Netherlands from 1996 to 2001 determined the effect of ICP-targeted therapy on functional outcome in severely head-injured adults [3]. In center A therapeutic interventions were based on clinical observations and computed tomography findings, whereas in center B management was aimed at maintaining ICP below 20 mmHg and CPP above 70 mmHg. In-hospital mortality rate was 41 (34%) vs. 69 (33%, p = 0.87). The odds ratio for a more favorable functional outcome following ICP/CPP-targeted therapy was 0.95 (95% confidence interval 0.62–1.44). This result remained after adjustment for potential confounders. Sedatives, vasopressors, mannitol, and barbiturates were much more frequently used in center B (all p =< 0.01). In this respect it would have been very interesting if the authors had provided additional information on outcome between the groups, in particular for patients with an emergency room Glasgow Coma Score of 8 or below, for example, on whether was there a difference in death due to incarnation, in-hospital mortality, and neurological outcome. This additional information would provide at least some indication whether ICP-targeted therapy improves mortality and neurological outcome. References

Young men were at risk of becoming lost to follow-up in a cohort of head-injured adults

Objective This study is to identify predictors of loss to follow-up among adults with head injury. Study Design and Setting A prospective cohort of 1,857 adults enrolled in the Medical Research Council (MRC) CRASH trial known to be alive 2 weeks after head injury. Six-month follow-up was defined as “overdue” if over 6 months late. Patient information collected at enrollment and after 14 days was used to predict overdue follow-up. A random two-thirds of the cohort was analyzed using logistic regression and binary recursive partitioning. The regression model and decision rule derived by recursive partitioning were evaluated using the remaining third. Results Overdue follow-up was more likely in patients aged 25–34 years (odds ratio, 1.76; 95% confidence interval [CI] = 1.18–2.62), victims of assault (1.63; 1.09–2.45), patients independent after 2 weeks (1.79; 1.18–2.72) and patients for whom postcodes (2.36; 1.65–3.39), telephone numbers (1.82; 1.19–2.79) or general practitioners (1.67; 1.16–2.39) were unknown. Binary recursive partitioning specifically identified males aged younger than 43 years to be at risk. Conclusion Successful follow-up in head-injury studies requires patients' postcodes and telephone numbers to be available. Young men remain at risk of becoming lost to follow-up, presenting a challenge for researchers aiming for complete data.

Personality Disorder Symptomatology and Neuropsychological Functioning in Closed Head Injury

Personality Disorder Symptomatology and Neuropsychological Functioning in Closed Head Injury

Noninvasive Evaluation of Dynamic Cerebrovascular Autoregulation Using Finapres Plethysmograph and Transcranial Doppler

Mx is an index of cerebrovascular autoregulation. It is calculated as the correlation coefficient between slow spontaneous fluctuations of cerebral perfusion pressure (cerebral perfusion pressure=arterial blood pressure-intracranial pressure) and cerebral blood flow velocity. Mx can be estimated noninvasively (nMxa) with the use of a finger plethysmograph arterial blood pressure measurement instead of an invasive cerebral perfusion pressure measurement. We investigated the agreement between nMxa and the previously validated index Mx. The study included 10 head-injured adults. Intracranial pressure was monitored with a parenchymal probe. Arterial blood pressure was monitored simultaneously with an arterial catheter and with the Finapres plethysmograph. Flow velocity in the middle cerebral artery was measured bilaterally with transcranial Doppler. Mx and nMxa were computed in both hemispheres, and asymmetry of autoregulation was calculated. Ninety-six measures of Mx and nMxa were obtained (48 for each side) in 10 patients. Mx correlated with nMxa (R=0.755, P<0.001; 95% agreement=+/-0.36; bias=0.01). Asymmetry in autoregulation assessed with Mx correlated significantly with asymmetry estimated with nMxa (R=0.857, P<0.0001; 95% agreement=+/-0.26; bias=-0.03). The noninvasive index of autoregulation nMxa correlates with Mx and is sensitive enough to detect autoregulation asymmetry. nMxa is proposed as a practical tool to assess cerebral autoregulation in patients who do not require invasive monitoring.

Reports of Death with Use of Propofol (Diprivan) for Nonprocedural (Long-term) Sedation and Literature Review

Reports of Death with Use of Propofol (Diprivan) for Nonprocedural (Long-term) Sedation and Literature Review