King's Outcome Scale For Childhood Head Injury Research Articles

Postoperative magnetic resonance imaging may predict poor outcome in children with severe traumatic brain injuries who undergo cranial surgery.

Multiple studies have evaluated the use of MRI for prognostication in pediatric patients with severe traumatic brain injury (TBI) and have found a correlation between diffuse axonal injury (DAI)-type lesions and outcome. However, there remains a limited understanding about the use of MRI for prognostication after severe TBI in children who have undergone cranial surgery. Children with severe TBI who underwent craniectomy or craniotomy at Primary Children's Hospital in Salt Lake City, Utah, between 2010 and 2019 were identified retrospectively. Of these 92 patients, 43 underwent postoperative brain MRI within 4 months of surgery. Susceptibility-weighted imaging (SWI) and FLAIR sequences were used to designate areas of hemorrhagic and nonhemorrhagic cerebral lesions related to DAI. Patients were then stratified based on the location of the DAI as read by a neuroradiologist as superficial, deep, or brainstem. The location of the DAI and other variables associated with poor outcome, including Glasgow Coma Scale (GCS) score, pediatric trauma score, mechanism of injury, and time to surgery, were analyzed for correlation with poor outcome. Outcomes were reported using the King's Outcome Scale for Childhood Head Injury (KOSCHI). In the 43 children with severe TBI who underwent postoperative brain MRI, the median GCS score on arrival was 4. The most common cause of injury was falls (14 patients, 33%). The most common primary intracranial pathology was subdural hematoma in 26 patients (60%), followed by epidural hematoma in 9 (21%). Fifteen patients (35%) had cerebral herniation and 31 (72%) had evidence of contusion. Variables associated with poor outcome included cerebral herniation (r = 0.338, p = 0.027) and location of DAI (r = 0.319, p = 0.037). In a separate analysis, brainstem DAI was shown to predict poor outcome, whereas location (no, superficial, or deep DAI) did not. Logistic regression showed that brainstem DAI (OR 22.3, p = 0.020) had a higher odds ratio than cerebral herniation (OR 10.5, p = 0.044) for poor outcome. Thirty-six children (84%) had a satisfactory outcome at last follow-up; 3 (7%) children died. The majority of children in this series who presented with a severe TBI and underwent craniectomy or craniotomy made a satisfactory recovery. In patients in whom there is a concern for poor outcome, the location of DAI-type lesions with SWI and FLAIR may assist in prognostication. The authors' results revealed that DAI-type lesions in the brainstem and evidence of cerebral herniation may indicate a poorer prognosis; however, more studies with larger cohorts are needed to make definitive conclusions.

Validation of the pediatric stroke outcome measure for classifying overall neurological deficit.

The pediatric stroke outcome measure (PSOM) is a standardized, disease-specific outcome measure. We aimed to validate the overall classification of neurological deficit severity using PSOM. We identified 367 neonates/children with arterial ischemic stroke (AIS) (Derivation Cohort). We analyzed the PSOM subscales (scored as 0 [no deficit], 0.5 [minimal/mild deficit; normal function], 1 [moderate deficit; slowing function], or 2 [severe deficit; missing function]) to derive severity levels using latent class analysis (LCA). We validated a severity classification scheme (PSOM-SCS) in: (a) children who had Pediatric Evaluation of Disability Inventory (PEDI; n = 63) and/or the Pediatric Quality-of-Life Inventory (PedsQL; n = 97) scored; and (b) an external cohort (AIS; n = 102) with concurrently scored modified Rankin Scale (mRS), King's Outcome Scale for Childhood Head-Injury (KOSCHI) and PSOM. Within the Derivation Cohort, LCA identified three severity levels: "normal/mild," "moderate," and "severe" (83.7%, 13.3%, and 3%, respectively). We developed severity classification based on PSOM subscale scores: "normal/mild"-normal function in all domains or slowing in one domain, "moderate"-slowing in ≥2 domains or missing function in one domain, and "severe"-missing function in ≥2 domains or slowing in ≥1 plus missing in one domain. PEDI and PedsQL both differed significantly across the severity groups. PSOM-SCS displayed high concordance with mRS (agreement coefficient [AC2] = 0.88) and KOSCHI (AC2 = 0.79). The PSOM-SCS constitutes a valid tool for classifying overall neurological severity emphasizing function and encompassing the full range of severity in pediatric stroke. Arithmetic summing of the PSOM subscales scores to assess severity classification is inadequate.The prior severity classification using PSOM overestimates poor outcomes.Three distinct severity profiles using PSOM subscales are identified.The PSOM-SCS is in moderate to excellent agreement with other disability measures.PSOM-SCS offers a valid tool for classifying the overall neurological deficit severity.

Pediatric Extradural Hematoma: Clinical Assessment Using King's Outcome Scale for Childhood Head Injury.

Introduction:Epidural hematoma (EDH) is a traumatic accumulation of blood between the inner table of the skull and the stripped off dural membrane and predominantly consists of venous blood in infants. The study aims to assess the outcome of pediatric EDH using King's Outcome Scale for Childhood Head Injury (KOSCHI).Materials and Methods:A total of 72 patients’ files were reviewed retrospectively with a diagnosis of EDH from January 2012 to December 2014. Predesigned proforma was filled using data from patient records. In addition, KOSCHI was calculated using recent telephone interviews.Results:Among 72 patients, 65.3% were male and 34.7% were female. Overall, road traffic accident was the most common cause (52.8%) followed by fall, assault, and sports injury. The most common symptom was more than two episodes of vomiting which was present in 51.4% of patients followed by loss of consciousness in 37.5%, ENT bleed in 33.3%, headache in 16.7%, and fits in 11.1% of patients. The median follow-up of our patients was 19 (6–40) months. Most of our patients made good recovery with 76.4% of our patients scoring 5b on KOSCHI.Conclusion:EDH is not uncommon among children with head injury. It should be suspected in every child with posttraumatic skull fracture or scalp hematoma. Prompt surgical intervention can give good long-term outcome.

Delay in Arrival to Care in Perpetrator-Identified Nonaccidental Head Trauma: Observations and Outcomes

Children who sustained nonaccidental head trauma (NAHT) are at severe risk for mortality within the first 24 hours after presentation. Extent of delay in seeking medical attention may be related to patient outcome. A 10-year, single-institution, retrospective review of 48 cases treated at a large tertiary Children's Hospital reported to the New York State Central Registrar by the child protection team was conducted. The perpetrator was identified in 28 cases on the basis of confession or conviction. The medical and legal records allowed for identification of time of injury and the interval between injury and arrival to the hospital; this information was categorized as follows: <6 hours (without delay); 6-12 hours (moderate delay); and >12 hours (severe delay). The King's Outcome Scale for Childhood Head Injury (KOSCHI) score was recorded for each case. All children were 3 years of age or younger (2.1-34 months) and predominantly male (68%; 19/28). On arrival, 61% of patients (17/28) presented with moderate or severe delay. A low arrival Glasgow Coma Scale (GCS) score (P < 0.0001) and extracranial injuries (P < 0.0061) correlated with worse clinical patient outcomes. Patients with an arrival GCS score <7 predominantly arrived without delay or with moderate delay. Patients presenting without delay or with severe delay were more likely to have a higher KOSCHI outcome score on discharge (P < 0.0426). Four of the 6 patients who died presented after moderate delay. Patients presenting to medical care 6-12 hours after NAHT (moderate delay) appeared to have worse outcomes than those presenting earlier or later.

OP36 – 2640: King's Outcome Scale for Childhood Head Injury (KOSCHI) – Prospective and retrospective comparison of outcome, and level of agreement, within the neuro-rehabilitation cohort at Southampton Children's hospital

There is a need for standardised outcome assessment for survivors of paediatric traumatic brain injury (TBI). KOSCHI is associated with markers of injury severity. Inter-rater reliability is lacking comparing prospective (P) versus retrospective (R) categorisation. Objective To determine the inter-rater reliability between (P) and (R) KOSCHI scores at discharge. To utilise KOSCHI to evaluate outcome of Southampton (SCH) neuro-rehabilitation TBI cohort. Methods (P) scores were recorded on discharge of all patients 2–18 years with moderate/severe head injury requiring neurological rehabilitation (2005–2014) by specialist physiotherapists. A doctor identified all patients admitted with TBI aged 0–18 and retrospectively scored KOSCHI at discharge using casenotes (blind to (P) cohort). Once collated the agreement between (P) and (R) KOSCHI scores was calculated using Cohen's kappa coefficient (κ). Results 153 patients admitted: 10 died. Sixty-one (45 male, mean age 11 years (range 2–17 years) required neuro-rehabilitation; 15 classified as moderate (GCS 9–12), 46 as severe (GCS ≤8) TBI. κ scores between (P) and (R) showed moderate agreement (κ=0.41), with the agreement improving (moderate κ=0.5) when not utilising the sub-categories. (P) demonstrated the majority are discharged with “moderate disability” (28% KOSCHI 4a, 16% 4b). 32% have “good recovery” (11% documented complete recovery 5b). Poor outcomes less common: KOSCHI 2 “vegetative” (N=1), KOSCHI 3a (N=2), KOSCHI 3b (N=10, 16%). Of those ≤ 3b; the category 2 patient transferred locally to establish continuing care, 4 to another rehabilitation centre, 1 re-admitted for further rehabilitation. 13/61 completed their rehabilitation at Bursledon House (stand-alone rehabilitation unit within SCH). (R) also categorizes the majority of patients with moderate disability (21% 4a, 24% 4b). Conclusion To improve reliability and allow for changes to scores post discharge secondary to further rehabilitation or identification of emerging difficulties, KOSCHI scores should be completed at an agreed time frame post injury and completed prospectively.

Subclinical early posttraumatic seizures detected by continuous EEG monitoring in a consecutive pediatric cohort

Traumatic brain injury (TBI) is an important cause of morbidity and mortality in children, and early posttraumatic seizures (EPTS) are a contributing factor to ongoing acute damage. Continuous video-EEG monitoring (cEEG) was utilized to assess the burden of clinical and electrographic EPTS. Eighty-seven consecutive, unselected (mild - severe), acute TBI patients requiring pediatric intensive care unit (PICU) admission at two academic centers were monitored prospectively with cEEG per established clinical TBI protocols. Clinical and subclinical seizures and status epilepticus (SE, clinical and subclinical) were assessed for their relation to clinical risk factors and short-term outcome measures. Of all patients, 42.5% (37/87) had seizures. Younger age (p = 0.002) and injury mechanism (abusive head trauma - AHT, p < 0.001) were significant risk factors. Subclinical seizures occurred in 16.1% (14/87), while 6.9% (6/87) had only subclinical seizures. Risk factors for subclinical seizures included younger age (p < 0.001), AHT (p < 0.001), and intraaxial bleed (p < 0.001). SE occurred in 18.4% (16/87) with risk factors including younger age (p < 0.001), AHT (p < 0.001), and intraaxial bleed (p = 0.002). Subclinical SE was detected in 13.8% (12/87) with significant risk factors including younger age (p < 0.001), AHT (p = 0.001), and intraaxial bleed (p = 0.004). Subclinical seizures were associated with lower discharge King's Outcome Scale for Childhood Head Injury (KOSCHI) score (p = 0.002). SE and subclinical SE were associated with increased hospital length of stay (p = 0.017 and p = 0.041, respectively) and lower hospital discharge KOSCHI (p = 0.007 and p = 0.040, respectively). cEEG monitoring significantly improves detection of seizures/SE and is the only way to detect subclinical seizures/SE. cEEG may be indicated after pediatric TBI, particularly in younger children, AHT cases, and those with intraaxial blood on computerized tomography (CT).

The impact of attention deficit hyperactivity disorder on recovery from mild traumatic brain injury

Attention deficit hyperactivity disorder (ADHD) and traumatic brain injury (TBI) are significant independent public health concerns in the pediatric population. This study explores the impact of a premorbid diagnosis of ADHD on outcome following mild TBI. The charts of all patients with a diagnosis of mild closed head injury (CHI) and ADHD who were admitted to Children's Hospital of Pittsburgh between January 2003 and December 2010 were retrospectively reviewed after institutional review board approval was granted. Patient demographics, initial Glasgow Coma Scale (GCS) score, hospital course, and King's Outcome Scale for Childhood Head Injury (KOSCHI) score were recorded. The results were compared with a sample of age-matched controls admitted with a diagnosis of CHI without ADHD. Forty-eight patients with mild CHI and ADHD, and 45 patients with mild CHI without ADHD were included in the statistical analysis. Mild TBI due to CHI was defined as an initial GCS score of 13-15. The ADHD group had a mean age of 12.2 years (range 6-17 years), and the control group had a mean age of 11.14 years (range 5-16 years). For patients with mild TBI who had ADHD, 25% were moderately disabled (KOSCHI Score 4b), and 56% had completely recovered (KOSCHI Score 5b) at follow-up. For patients with mild TBI without ADHD, 2% were moderately disabled and 84% had completely recovered at follow-up (p < 0.01). Patients with ADHD were statistically significantly more disabled after mild TBI than were control patients without ADHD, even when controlling for age, sex, initial GCS score, hospital length of stay, length of follow-up, mechanism of injury, and presence of other (extracranial) injury. Patients who sustain mild TBIs in the setting of a premorbid diagnosis of ADHD are more likely to be moderately disabled by the injury than are patients without ADHD.

Outcome measurements in major trauma—Results of a consensus meeting

BackgroundThe NHS Outcomes Framework for England has identified recovery from major injury as an important clinical area. At present, there are no established outcome indicators. As more patients survive major trauma, outcomes will need to be measured in terms of morbidity and not mortality alone. ObjectiveTo make recommendations for a selection of outcome measures that could be integrated into National Clinical Audit data collection and form part of clinical governance requirements for Regional Trauma Networks (RTNs) and measures by which RTNs are held to account by government. Specific focus was given to acute care and rehabilitation for both adults and children. MethodA Multiprofessional, multidisciplinary expert group reviewed the current evidence on outcome measures for major trauma in the adult and children's populations, informed by a systematic review carried out jointly by the Trauma Audit and Research Network (TARN) and the Cochrane Injuries Group. A structured discussion covered functional and quality of life outcome measures as well as patient experience and indicators such as return to work, education and social dependency. ResultsFor the adult population the group agreed with the in-hospital performance and hospital discharge measures recommended in the TARN and Cochrane systematic review. Concerning longer-term outcome indicators, the group suggested the use of the Glasgow Outcome Scale – Extended (GOS-E) and European Quality of Life 5D (EQ-5D) with consideration to be given to the World Health Organisation Quality of Life survey (WHO-QoL). For patients who had ongoing inpatient rehabilitation needs the group thought the measurement of the Rehabilitation Complexity Scale (RCS) and Functional Independence Measure (FIM) were important in total brain injury and, the American Spinal Injury Association Impairment Scale (ASIA) and Spinal Cord Independence Measure (SCIM) in spinal cord injury. For children the group recommended the use of the King's Outcome Scale for Childhood Head Injury (KOSCHI) and Paediatric Quality of Life measure (Peds-QL) preferably at multiple intervals following injury to take into account effects on development. ConclusionSpecific recommendations were made for the use of outcome measures in adults and children with major trauma and those with complex rehabilitation needs following injury. More work on outcome measures in major trauma is needed especially for children. There are currently no robust measures of patient experience for use in major trauma. The importance of data linkage to allow measurement of non-clinical outcomes such as return to work, maintainence of education and societal dependency was emphasised by the group. A system for recording outcomes should be piloted post injury and at 6 and 12 months, with those still requiring inpatient rehabilitation after this time having longer follow up.

Use of the King's Outcome Scale for Childhood Head Injury in the evaluation of outcome in childhood traumatic brain injury

Objective: To examine the inter-rater reliability of The King's Outcome Scale for Childhood Head Injury (KOSCHI) with clinicians of varying experience in paediatric traumatic brain injury (TBI); and to examine change in outcome during long-term follow-up of children following traumatic brain injury (TBI) using KOSCHI.Method: Retrospective assessment of detailed clinic reports of 97 children followed-up by a tertiary specialist paediatric brain injury service. Investigators were blinded to each other's scores.Results: Inter-rater reliability was substantial (weighted kappa 0.71) and similar for investigators of varying experience. KOSCHI outcome was strongly associated with markers of injury severity (p = 0.028). In longitudinal follow-up, KOSCHI score worsened in 7 (23%) children who were injured under 8 years but in no older children (p = 0.02).Conclusion: KOSCHI has high inter-rater reliability for investigators of different experience. Long-term KOSCHI outcome is associated with injury severity. Some young children may develop worse disability over time.

Functional and Health-Related Quality of Life Outcomes After Pediatric Trauma

Pediatric trauma results in lower mortality than adults and a high potential for lifelong functional impairment and reduced health-related quality of life (HRQL). There is no consensus regarding the best approach to measuring outcomes in this group. One hundred and fifty injured children admitted to a pediatric trauma center participated in this study. The Pediatric Quality of Life Inventory (PedsQL), Child Health Questionnaire (CHQ-PF28), King's Outcome Scale for Childhood Head Injury (KOSCHI), modified Glasgow Outcome Scale (mGOS), and the Functional Independence Measure (FIM) were administered at 1 month, 6 months, and 12 months after injury by telephone. Change in instrument scores was assessed using multilevel mixed effects models. Mean HRQL scores were compared with population norms for the CHQ-PF28 and with healthy children for the PedsQL. Follow-up at all time points was completed for 144 (96%) cases. The median injury severity score was 10, and 65% of the patients enrolled were men. At 12 months, the percentage of cases with ongoing disability was 14% for the FIM, 61% using the mGOS, and 58% for the KOSCHI. CHQ-PF28 physical and PedsQL psychosocial health scores were below healthy child norms at 12 months. Improvement across all time points was demonstrated for the KOSCHI, mGOS, CHQ-PF28 physical, and PedsQL psychosocial summary scores. Seriously injured children showed ongoing disability and reduced HRQL 12 months after injury. The CHQ-PF28 and PedsQL, and the mGOS and KOSCHI, performed comparably. The FIM demonstrated considerable ceiling effects, and improvement over time was not shown. The results inform the methodology of pediatric outcomes studies and protocol development for the routine follow-up of pediatric trauma patients.

575 Intensive Care Management and Follow-Up of Severe Traumatic Brain Injury in Children

Introduction: Traumatic brain injury (TBI) is the leading cause of paediatric morbidity and mortality in developed countries. Acquired disability can be evaluated by King's Outcome Scale for Childhood Head Injury (KOSCHI).Objectives: Evaluate care and outcome in children with severe TBI.Methods: Analysis of clinical and demographic data of children admitted between January 2008 and December 2009 with the diagnosis of severe TBI. KOSCHI was used to assess recovery.Results: Of 92 admissions for trauma, 47 had severe TBI. The median age was 8 years, PRISM score was 13 and PTS was 6. The leading cause was road traffic accident (57%). Specialized medical teams provided pre-hospital care in 68% of cases. Raised intracranial pressure (ICP) signs were present in 34 cases. Neurosurgical intervention was necessary in 16 children and 10 had invasive ICP monitoring. All children were ventilated, 42 had hyperosmolar therapy (mannitol or NaCl 3%), 5 barbiturate-induced coma and 12 vasoactive drugs. Transcranial dopller (TCD) was performed in 27 children, 18 had raised pulsatility index. There was a good correlation between TCD information and ICP readings. Eight children (17%) died. In the follow-up period 8 children were in KOSCHI category 1, 2 in category 2, 5 in category 3, 11 in category 4 and 21 in category 5.Conclusions: KOSCHI provides a practical scale for paediatric head injury outcome. A high percentage of patients were discharged without any sequelae and mortality rate was low. Treatment in a PICU and early neurosurgical consultation were determinant for the good outcome.

Shaken baby syndrome in Switzerland: results of a prospective follow-up study, 2002–2007

Since the incidence of shaken baby syndrome in Switzerland was not known, we conducted a nationwide prospective follow-up study for a 5-year period (from 2002 to 2007). The data were collected through the Swiss Pediatric Surveillance Unit. Inclusion criteria were the presence, in a child <or=6 years of age, of 1) more than or equal to two clinical symptoms (altered consciousness, convulsions, respiratory irregularities, and bulging fontanel), 2) one eye finding (retinal hemorrhages, vitreous hemorrhages), 3) one MRI/CT finding (subdural hematoma, subarachnoid hematoma, and parenchymatous lesions), or 4) history of shaking. Exclusion criteria were age >6 years or documented accident/disease explaining symptoms/findings. To describe outcome, we used the King's Outcome Scale for Childhood Head Injury (KOSCHI). 56 cases were reported from 13 of 26 Swiss cantons, representing 80% of the Swiss population; 49 cases met the inclusion criteria. Preponderance of male infants was high (31 male and 18 female); median age at admission was 4 months (1-58). Clinical symptoms were present in 42 infants, retinal/vitreous hemorrhages in 39 infants, and pathological brain/head imaging in 46 infants. In 13 cases, the caregivers admitted shaking the child. Outcomes (KOSCHI 1-5; n = 47 patients) were death (KOSCHI 1) 8 (17.7%), vegetative state (KOSCHI 2) 0, severe disability (KOSCHI 3) 11 (22.2%), moderate disability (KOSCHI 4) 14 (31.1%), and good recovery (KOSCHI 5) 14 (28.8%). Based on these data, the incidence of shaken baby syndrome in Switzerland is 14 per 100 000 live births, which corresponds to the incidence in other Western countries. Demographic characteristics and outcomes of Swiss patients were comparable to published studies.

Comparison of accidental and nonaccidental traumatic brain injuries in infants and toddlers: demographics, neurosurgical interventions, and outcomes

Nonaccidental trauma has become a leading cause of death in infants and toddlers. Compared with children suffering from accidental trauma, many children with nonaccidental trauma present with injuries requiring neurosurgical management and operative interventions. A retrospective review was performed concerning the clinical and radiological findings, need for neurosurgical intervention, and outcomes in infants and toddlers with head injuries who presented to Albany Medical Center between 1999 and 2007. The Fisher exact probability test and ORs were computed for Glasgow Coma Scale (GCS) scores, hyperdense versus hypodense subdural collections, and discharge and follow-up King's Outcome Scale for Childhood Head Injury (KOSCHI) scores. There were 218 patients, among whom 164 had sustained accidental trauma, and 54 had sustained nonaccidental trauma (NAT). The patients with accidental traumatic injuries were more likely to present with GCS scores of 13-15 (OR 6.95), and the patients with NATs with of GCS scores 9-12 (OR 6.83) and 3-8 (OR 2.99). Skull fractures were present in 57.2% of accidentally injured patients at presentation, and 15% had subdural collections. Skull fractures were present in 30% of nonaccidentally injured patients, and subdural collections in 52%. Patients with evidence of hypodense subdural collections were significantly more likely to be in the NAT group (OR 20.56). Patients with NAT injuries were also much more likely to require neurosurgical operative intervention. Patients with accidental trauma were more likely to have a KOSCHI score of 5 at discharge and follow-up (ORs 6.48 and 4.58), while patients with NAT had KOSCHI scores of 3a, 3b, 4a, and 4b at discharge (ORs 6.48, 5.47, 2.44, and 3.62, respectively), and 3b and 4a at follow-up. Infant and toddler victims of NAT have significantly worse injuries and outcomes than those whose trauma was accidental. In the authors' experience, however, with aggressive intervention, many of these patients can make significant neurological improvements at subsequent follow-up visits.

The King's Outcome Scale for Childhood Head Injury and injury severity and outcome measures in children with traumatic brain injury

The aim of this study was to relate discharge King's Outcome Scale for Childhood Head Injury (KOSCHI) category to injury severity and detailed outcome measures obtained in the first year post-traumatic brain injury (TBI). We used a prospective cohort study. Eighty-one children with TBI were studied: 29 had severe, 15 moderate, and 37 mild TBI. The male:female ratio was 1.8:1. The mean age was 11 years 10 months (SD 3.6, range 5-16y). Discharge KOSCHI categories were good (n=34), moderate (n=39), severe (n=6), and unclassifiable (n=2). KOSCHI category correlated strongly with admission Glasgow Coma Score, length of hospital stay, and post-traumatic amnesia. It also correlated significantly with Verbal IQ and Performance IQ (Wechsler); measures of attention; health status (Health Utilities Index [HUI]); health-related quality of life (Pediatric Quality of Life Inventory [PedsQL]); depressive symptoms (Birleson Depression Scale) assessed within 3 months postTBI; and with Verbal IQ, selective attention (map mission), and HUI and PedsQL domains assessed at least 6 months post-TBI discharge. KOSCHI did not correlate with behaviour or executive function. We conclude that the KOSCHI scored at hospital discharge correlates with severity of injury and some cognitive, health status, and HRQL outcomes early after TBI. It is not helpful at predicting later difficulties, or behavioural and emotional problems.

A practical outcome scale for paediatric head injury

Traumatic brain injury (TBI) is the commonest cause of acquired disability in childhood. A major obstacle to the evaluation of acute and rehabilitative therapies after TBI is the lack of...