Post-traumatic Amnesia Research Articles

Comparing the Westmead Posttraumatic Amnesia Scale, Galveston Orientation and Amnesia Test, and Confusion Assessment Protocol as Measures of Acute Recovery Following Traumatic Brain Injury.

The duration of the acute period of recovery following traumatic brain injury (TBI) remains a widely used criterion for injury severity and clinical management. Consensus regarding its most appropriate definition and assessment method has yet to be established. The present study compared the trajectory of recovery using 3 measures: the Westmead Post-Traumatic Amnesia Scale (WPTAS), the Galveston Orientation and Amnesia Test (GOAT), and the Confusion Assessment Protocol (CAP). Patterns of symptom recovery using the CAP were explored. Eighty-two participants with moderate to severe TBI in posttraumatic amnesia (PTA) on admission to an inpatient rehabilitation hospital. Prospective longitudinal study. Length of PTA (days), agreement between measures (%, κ coefficient), and pattern of symptom recovery. Participants emerged from PTA earliest on the CAP followed the GOAT, and last on the WPTAS. There was good agreement between the CAP and the GOAT as to PTA status, but both tests had poor agreement with the WPTAS. Of patients considered out of PTA on the CAP, the majority exhibited signs of amnesia on the WPTAS and one-third had clinical levels of agitation. The WPTAS identifies a later stage of PTA recovery that requires specialized management due to ongoing amnesia and agitation. The CAP and the GOAT are less sensitive to this extended period of PTA.

The Use of Atypical Antipsychotics for Managing Agitation After Traumatic Brain Injury

This study examined the use of antipsychotics for managing agitation during posttraumatic amnesia (PTA) after traumatic brain injury (TBI) and its relationship with agitated behavior. Observational prospective study with correlational design. Inpatient rehabilitation hospital for TBI. A total of 125 consecutive admissions who were in PTA and had moderate-severe TBI. Antipsychotic use was compared with agitation levels as measured by the total scores on the Agitated Behavior Scale (ABS). Atypical antipsychotics were used in one-third of participants to manage agitation. Antipsychotic use was more common in participants with high levels of global agitation; however, there were many on antipsychotics who had mild or even no agitation according to the ABS. Uncontrolled observational data found no reduction in agitation after antipsychotic commencement or dose increase. Antipsychotics are commonly used to manage agitation after TBI despite limited evidence of efficacy. Agitation should be formally monitored in PTA to ensure antipsychotics are used to manage more severe agitation and for evaluating treatment response. Research is needed to understand why prescribers are using antipsychotics when agitation is mild or below clinical thresholds.

A-11 The Contribution of Psychological Stress to Adolescent Post-Concussive Symptoms Across Recovery

Abstract Objective The aim of this study was to explore whether less commonly explored injury factors account for variance in post-concussive symptoms across recovery. Method Participants aged 12–18 (n = 440) who reported to clinic within 14 days of concussion sustained in either sport injury, MVA, fall, or hit were selected from the ConTex registry. A PCS log, PHQ-8, and GAD-7 were completed at initial visit and 3-month follow-up. Separate hierarchical linear regressions determined predictors of PCS scores at both time points. Demographic, premorbid, injury, and psychological factors were entered in Step 1–4, respectively. A sample subset completed the PTSD Checklist (PCL-5) at initial (n = 58) and 3-month visits (n = 27). Exploratory analyses added the PCL-5 to determine whether post-traumatic stress symptoms contributed to the model. Results At initial visit, sex, post-traumatic amnesia (PTA), PHQ-8, and GAD-7 significantly predicted PCS total scores (p < .001), accounting for 43% of the variance. At 3-month follow-up, PTA dropped out of the model, and psychiatric history and mechanism of injury became significant, explaining an additional 15% of the variance in PCS scores (R2 = .58, p < .001). In exploratory analyses, when PCL-5 scores were added to the final models, demographic, premorbid, and injury factors did not remain significant, and the PCL-5 significantly contributed to the variance in PCS scores at both initial (p = .01) and 3-month follow-up (p < .001). Conclusions Psychological stress and context of injury may be strong predictors of PCS in addition to demographic and premorbid factors. These findings warrant continued investigation of less explored injury factors contribution to initial mTBI presentation and recovery.

A-114 Predicting Long-Term Cognitive Outcomes From Acute Orientation Performance After Traumatic Brain Injury

Abstract Objective To evaluate how initial orientation, rate of change in orientation, and duration of post-traumatic amnesia (PTA) during inpatient rehabilitation predict cognitive functioning (overall cognition, episodic verbal memory, and executive function) 1 year and 2 years after sustaining a moderate-to-severe traumatic brain injury (TBI). Methods Participants were 101 adults aged 18–81 years (M age = 39 years; 67% male) receiving inpatient rehabilitation following new-onset moderate–severe TBI at a level I trauma center, acute inpatient hospital. Orientation data (initial orientation, rate of change in orientation, and duration of PTA) were collected during inpatient rehabilitation where each participant received serial assessments of their orientation with the Orientation Log (O-Log) during bedside rounds. The Brief Test of Adult Cognition by Telephone (BTACT) was administered to participants over the telephone at 1 year and 2 years post-injury to assess cognitive outcomes. Results Initial orientation during acute inpatient rehabilitation was significantly associated with overall cognition (p < .01), episodic verbal memory (p < .01), and executive function abilities (p < .01) at 1 year post-injury. Duration of PTA and rate of change in orientation were not significant predictors, and none of the orientation factors predicted cognition at 2 years post-injury. Conclusion Initial level of orientation is important to consider in the prediction of cognitive impairments one year following moderate–severe TBI. This supports the need to assess orientation early in the recovery process, particularly upon admission to acute rehabilitation.

A-115 Predictors of Depressive Symptoms in Adolescent Patients Following Concussion

Abstract Objective The present study sought to examine specific predictors and factors associated with depressive symptoms at initial(V1) and subsequent(V2) visits following concussion in adolescents. Methods This study enrolled adolescents aged 10–18 (14.5 ± 2.2 years) within 30 days of a diagnosed concussion. Patients completed Mood and Feelings Questionnaire-Short-Child Report (MFQC), Postconcussion Symptom Scale (PCSS), neurocognitive testing(ImPACT), and Vestibular-Ocular Motor Screening. Logistic regression (LR) analyses evaluated risk factors and clinical presentation as predictors of post-injury MFQP scores above a cutpoint of 8. Results Participants included 113 adolescents (50.4% male; 77% sport-related) who presented for V1 8.9 ± 6.2 days post-injury and V2 18.43 ± 11.9 days after V1. Overall, 5.3% reported pre-injury depression and 15.8% reported post-injury depressive symptoms above clinical cutoff on the MFQC. The LR model predicting increased depressive symptoms at V1 was significant (R2 = 45.0%, p = .007), supporting post-traumatic amnesia(PTA; OR = 3.15, 1.01–9.88) as a predictor. The LR model predicting depressive symptoms at V2 was significant (R2 = 62.2%, p = .021), supporting history of depression(OR = 25.5, 3.86–168.2) as the only significant predictor. Those scoring above 8 on the MFQC at V1 were more likely to have a prolonged recovery(over 30 days; OR = 10.4, 1.29–83.6). Conclussions The primary findings indicated that PTA was associated with increased depressive symptoms earlier, whereas a history of depression was associated with increase depressive symptoms later following concussion. Patients scoring higher on depressive symptoms were 10 times more likely to have a prolonged recovery. Together, these findings highlight the importance of evaluating depressive symptoms and factors that are associated with these symptoms to inform prognosis and earlier treatment for depressive symptoms following concussion.

A-141 An Inclusive Recruitment Strategy Can Help to Improve mTBI Research

Abstract Objective Participant recruitment for mild traumatic brain injury (mTBI) research is challenging due to confounding factors and other documented selection biases. The strict application of typical inclusion and exclusion criteria has raised questions about the generalizability of mTBI research. This study explored the effect of applying commonly employed selection criteria on eligibility for mTBI research. Method Between July and October 2019, a trained research nurse performed a weekly review of a tertiary hospital emergency department treatment registry. Three hundred and eight cases coded as “minor head injury” were identified (Mage = 43.7, SDage = 25.6). The case records underwent formal data extraction. Extracted clinical and demographic data were mapped against commonly applied mTBI research selection parameters. The presence of persistent postconcussion symptoms (PPCS) was established via telephone administration of the Rivermead Postconcussion Symptom Questionnaire, 7–19 days post injury. Results Analysis revealed that 23% of patients met the World Health Organization operational definition of an mTBI. The failure to meet this criterion was primarily due to missing or incomplete information for post-traumatic amnesia. The application of exclusion criteria left just 5.5% of the initial pool eligible for mTBI research. Of these participants, ongoing PPCS could not be established in any individuals. Conclusion Participant recruitment for mTBI research could be improved by establishing a dedicated patient management system that streamlines and augments the quality of vital clinical data. An inclusive recruitment strategy that handles patient heterogeneity using statistical methods as opposed to exclusion from research could enhance the generalisability of mTBI research.

Improving communication with patients in post-traumatic amnesia: development and impact of a clinical protocol

ABSTRACT Objective To assess the impact of staff training focused on improved treatment and communication with patients in post-traumatic amnesia (PTA) or other disorders of explicit (declarative) memory. A major aim was to minimize questions demanding recall from explicit memory, e.g., orientation quizzing, and personal/medical history questions, which may produce unreliable information and exacerbate patient frustration and anxiety. Methods Mixed-methods design. Inpatients with impairments of explicit memory were observed before (n = 4) and after (n = 4) training, with staff interactions recorded verbatim. Records were coded for types of questions and patient responses. Clinicians who worked before and after training were surveyed regarding perceived changes in practice, team functioning, and patient behavior. Results Explicit memory questions decreased significantly, as did irrelevant or “don’t know” responses from patients, with large nonparametric effect sizes noted. The frequency of questions not relying on explicit memory remained stable. Most clinicians reported positive effects on their own and others’ practice with memory impaired patients, and one-quarter noted less patient frustration or agitation. Conclusions Although questioning patients is a natural part of medical care, targeted staff training can result in positive changes in communication practice and should be considered for facilities treating patients in PTA.

Brexpiprazole blocks post-traumatic stress disorder-like memory while promoting normal fear memory.

A cardinal feature of post-traumatic stress disorder (PTSD) is a long-lasting paradoxical alteration of memory with hypermnesia for salient traumatic cues and amnesia for peri-traumatic contextual cues. So far, pharmacological therapeutic approach of this stress-related disorder is poorly developed mainly because of the lack of animal model for this paradoxical memory alteration. Using a model that precisely recapitulates the two memory components of PTSD in mice, we tested if brexpiprazole, a new antipsychotic drug with pro-cognitive effects in rodents, may persistently prevent the expression of PTSD-like memory induced by injection of corticosterone immediately after fear conditioning. Acute administration of brexpiprazole (0.3 mg/kg) 7 days' post-trauma first blocks the expression of the maladaptive fear memory for a salient but irrelevant trauma-related cue. In addition, it enhances (with superior efficacy when compared to diazepam, prazosin, and escitalopram) memory for the traumatic context, correct predictor of the threat. This beneficial effect of brexpiprazole is overall maintained 1 week after treatment. In contrast brexpiprazole fully spares normal/adaptive cued fear memory, showing that the effect of this drug is specific to an abnormal/maladaptive (PTSD-like) fear memory of a salient cue. Finally, this treatment not only promotes the switch from PTSD-like to normal fear memory, but also normalizes most of the alterations in the hippocampal-amygdalar network activation associated with PTSD-like memory, as measured by C-Fos expression. Altogether, these preclinical data indicate that brexpiprazole could represent a new pharmacological treatment of PTSD promoting the normalization of traumatic memory.

Factors Affecting Participation in Physical Therapy During Posttraumatic Amnesia

ObjectivesTo examine the effect of agitation, cognitive impairment, fatigue, and pain on physical therapy participation and outcomes during posttraumatic amnesia (PTA) after traumatic brain injury (TBI). DesignProspective longitudinal study. SettingInpatient rehabilitation hospital. ParticipantsParticipants (N=77) with moderate-to-severe TBI who were deemed to be experiencing PTA using the Westmead Post-Traumatic Amnesia Scale. InterventionsNot applicable. Main Outcome MeasuresThe Pittsburgh Rehabilitation Participation Scale and time in therapy (min) were recorded twice daily after routine physical therapy sessions during PTA. The FIM-motor (select items related to physical therapy) score rated on admission and after emergence from PTA was used to calculate FIM-motor change. ResultsAgitation was associated with lower participation in therapy. The presence of agitation and pain both predicted lower FIM-motor change at emergence from PTA. Higher levels of cognitive impairment and fatigue were also associated with lower participation and less time in therapy. ConclusionsThe presence of agitation, fatigue, pain, and cognitive impairment impede rehabilitation success during PTA. This study strengthens the case for implementing environmental and behavioral recommendations, such as conducting therapy earlier in the day within a familiar space (ie, on the ward) and tailoring session duration to patient needs. This is with the aim of minimizing fatigue, agitation, and pain, while promoting cognitive recovery and arousal during PTA to maximize physical gains. Further research is warranted to examine the factors associated with rehabilitation success across other therapeutic disciplines.

Post-traumatic Confusional State: A Case Definition and Diagnostic Criteria

In response to the need to better define the natural history of emerging consciousness after traumatic brain injury and to better describe the characteristics of the condition commonly labeled posttraumatic amnesia, a case definition and diagnostic criteria for the posttraumatic confusional state (PTCS) were developed. This project was completed by the Confusion Workgroup of the American Congress of Rehabilitation Medicine Brain Injury Interdisciplinary Special Interest group. The case definition was informed by an exhaustive literature review and expert opinion of workgroup members from multiple disciplines. The workgroup reviewed 2466 abstracts and extracted evidence from 44 articles. Consensus was reached through teleconferences, face-to-face meetings, and 3 rounds of modified Delphi voting. The case definition provides detailed description of PTCS (1) core neurobehavioral features, (2) associated neurobehavioral features, (3) functional implications, (4) exclusion criteria, (5) lower boundary, and (6) criteria for emergence. Core neurobehavioral features include disturbances of attention, orientation, and memory as well as excessive fluctuation. Associated neurobehavioral features include emotional and behavioral disturbances, sleep-wake cycle disturbance, delusions, perceptual disturbances, and confabulation. The lower boundary distinguishes PTCS from the minimally conscious state, while upper boundary is marked by significant improvement in the 4 core and 5 associated features. Key research goals are establishment of cutoffs on assessment instruments and determination of levels of behavioral function that distinguish persons in PTCS from those who have emerged to the period of continued recovery.

Use of olanzapine to treat agitation in traumatic brain injury: study protocol for a randomised controlled trial

BackgroundAgitation is common in the early stages of recovery from traumatic brain injury (TBI), when patients are in post-traumatic amnesia (PTA). Agitation is associated with risk of harm to patients and caregivers. Recent guidelines recommend that agitation during PTA is managed using environmental modifications. Agitation is also frequently treated pharmacologically, with the use of atypical antipsychotics such as olanzapine among the most common. This is despite a lack of well-designed studies to support the use of antipsychotics within this context. This study will be a double-blind, placebo-controlled randomised controlled trial. We will examine the efficacy, safety, cost-effectiveness and outcomes associated with the use of olanzapine for reducing agitation in patients in PTA following TBI over and above recommended environmental management.MethodsFifty-eight TBI rehabilitation inpatients who are in PTA and are agitated will receive olanzapine or placebo for the duration of PTA. All participants will additionally receive optimal environmental management for agitation. Measures of agitation, PTA and health will be undertaken at baseline. Treatment administration will begin at a dose of 5 mg daily and may be escalated to a maximum dose of 20 mg per day. Throughout the treatment period, agitation and PTA will be measured daily, and adverse events monitored weekly. Efficacy will be assessed by treatment group comparison of average Agitated Behaviour Scale scores during PTA. Participants will cease treatment upon emergence from PTA. Agitation levels will continue to be monitored for a further 2 weeks, post-treatment measures of health will be undertaken and cognitive and functional status will be assessed. Level of agitation and functional health will be assessed at hospital discharge. At 3 months post-discharge, functional outcomes and health service utilisation will be measured.DiscussionThis trial will provide crucial evidence to inform the management of agitation in patients in PTA following TBI. It will provide guidance as to whether olanzapine reduces agitation over and above recommended environmental management or conversely whether it increases or prolongs agitation and PTA, increases length of inpatient hospitalisation and impacts longer term cognitive and functional outcomes. It will also speak to the safety and cost-effectiveness of olanzapine use in this population.Trial registrationANZCTR ACTRN12619000284167. Registered on 25 February 2019

Author response: Acute elevation of serum inflammatory markers predicts symptom recovery after concussion.

We thank Dr. Sethi for the comment and inquiry. In this sample,1 no concussed athletes reported loss of consciousness and only 2 athletes reported posttraumatic amnesia. Thus, we were unable to appropriately address the potential effects of these injury characteristics on the studied markers. Regarding the normalization of the inflammatory markers relative to symptom resolution, as seen in figure 2,1 the levels of interleukin-1 receptor agonist and interleukin-6 returned to the baseline levels by the 24–48-hour visit, whereas symptom severity scores remained elevated. That is, elevations in these inflammatory markers resolved before the symptoms did and the inflammatory markers only showed a prognostic promise when collected within 6 hours postinjury.

Reader response: Acute elevation of serum inflammatory markers predicts symptom recovery after concussion.

I read with interest the article by Nitta et al.1 A validated biofluid (blood or CSF) or imaging biomarker for sports-related concussion (SRC) remains elusive, but the search continues. Different grades of SRC are encountered, ranging from a football player getting his bell rung, but with no accompanying loss of consciousness, to an athlete getting knocked out in the field with accompanying loss of consciousness and posttraumatic amnesia of varying duration. Did the levels of the serum inflammatory markers measured correlate with the severity of the concussion, and did normalization of the inflammatory markers correlate with resolution of postconcussion symptoms? An ideal SRC biomarker would be able to accurately identify a concussed athlete and help guide medical decision-making about return to play.

Editors' note: Acute elevation of serum inflammatory markers predicts symptom recovery after concussion

In the article “Acute elevation of serum inflammatory markers predicts symptom recovery after concussion,” Drs. Nitta et al. studied serum inflammatory markers in 41 high school and collegiate football players with sports-related concussion (SRC) and 43 matched control athletes, and they collected symptom severity scores at a preinjury baseline and at several time points up to 45 days postconcussion. They found that interleukin-6 (IL-6) and IL-1RA were significantly elevated in SRC at 6 hours vs preinjury and other postinjury visits. These inflammatory markers discriminated concussed from control athletes at that time point, with IL-6 levels at 6 hours also being significantly associated with symptom duration. In response, Dr. Sethi asks whether the levels of serum inflammatory markers correlated with the severity of the concussion and whether the normalization of such markers correlated with symptom resolution. He notes that an ideal SRC marker would not only accurately identify a concussed athlete but also help guide return-to-play decisions. Responding to these comments, Drs. Meier and Nitta note that no concussed athletes reported loss of consciousness in their sample and only 2 reported posttraumatic amnesia; therefore, they could not relate the markers to such gradations of severity. They indicate that levels of IL-1RA and IL-6 returned to baseline levels by the 24–48 hours visit despite symptom severity scores remaining elevated and thus appeared to show prognostic promise only when collected within 6 hours postinjury. This discussion highlights enduring challenges in the search for clinically relevant biomarkers for SRC, and it is likely that a panel of markers will be needed to make various predictions following SRC. In the article “Acute elevation of serum inflammatory markers predicts symptom recovery after concussion,” Drs. Nitta et al. studied serum inflammatory markers in 41 high school and collegiate football players with sports-related concussion (SRC) and 43 matched control athletes, and they collected symptom severity scores at a preinjury baseline and at several time points up to 45 days postconcussion. They found that interleukin-6 (IL-6) and IL-1RA were significantly elevated in SRC at 6 hours vs preinjury and other postinjury visits. These inflammatory markers discriminated concussed from control athletes at that time point, with IL-6 levels at 6 hours also being significantly associated with symptom duration. In response, Dr. Sethi asks whether the levels of serum inflammatory markers correlated with the severity of the concussion and whether the normalization of such markers correlated with symptom resolution. He notes that an ideal SRC marker would not only accurately identify a concussed athlete but also help guide return-to-play decisions. Responding to these comments, Drs. Meier and Nitta note that no concussed athletes reported loss of consciousness in their sample and only 2 reported posttraumatic amnesia; therefore, they could not relate the markers to such gradations of severity. They indicate that levels of IL-1RA and IL-6 returned to baseline levels by the 24–48 hours visit despite symptom severity scores remaining elevated and thus appeared to show prognostic promise only when collected within 6 hours postinjury. This discussion highlights enduring challenges in the search for clinically relevant biomarkers for SRC, and it is likely that a panel of markers will be needed to make various predictions following SRC.

Epilepsy after severe traumatic brain injury: frequency and injury severity

ABSTRACT Objective: To estimate national frequency of posttraumatic epilepsy (PTE) after severe traumatic brain injury (TBI) and assess injury severity (Glasgow Coma Scale (GCS) and posttraumatic amnesia (PTA)) as prognostic factors for PTE. Methods Data on patients ≥18 years surviving severe TBI 2004–2016 were retrieved from the Danish Head Trauma Database (n = 1010). The cumulative incidence proportion (CIP) was estimated using death as competing event. The association between injury severity and PTE was assessed using multivariable competing risk regressions. Results CIP of PTE 28 days and one year post-TBI was 6.8% (95% confidence interval (CI) 5.4–8.5) and 18.5% (95% CI 16.1–21.1%), respectively. Injury severity was not associated with PTE within 28 days post-TBI but indicated higher PTE-rates in less severely injured patients. PTA-duration >70 days was associated with PTE 29–365 days post-TBI (Adjusted sub-hazard ratio 4.23 (95% CI 1.79–9.99)). GCS was not associated with PTE 29–365 days post-TBI. Conclusion The PTE frequency was higher compared to previous estimates. Increasing injury severity was associated with PTE 29–365 days post-TBI when measured with PTA, but not with GCS. Though nonsignificant, the increased PTE-risk within 28 days in lower severity suggests an underdiagnosing of PTE.

Opiate analgesics and testing of post traumatic amnesia in school-aged children

ABSTRACT Objective To assess the validity of the Westmead PTA scale in school-aged children treated with opiate analgesics. Method Twenty-eight hospitalized children without brain injury, aged between 8 and 16 years treated with opiate analgesics for pain relief following surgery were tested on the Westmead PTA scale. Pain and stress levels were also self-reported each day. Results Only 29% (n = 7) of children assessed over four days obtained a maximum score of 12/12 on three consecutive days, thus 71% would have been deemed to have been in PTA when they were not. The percentage of children who obtained a maximum score significantly decreased over consecutive days of assessment, due to an increase in error rate on picture memory items. Self-reported pain and stress ratings were not correlated with PTA scores. Conclusions Opiate analgesia can disrupt performance on the Westmead PTA scale in school-aged children resulting in a high false-positive error rate. It is therefore important to record pain medication schedules and interpret results cautiously when opiate analgesia is used following a TBI. Alteration of the method of administration of the memory items should be researched as this may increase the validity of the scale for children with TBI treated with opiate analgesics.

Predictors of involuntary and voluntary emotional episodic memories of virtual reality scenarios in Veterans with and without PTSD

ABSTRACT This study investigated predictors of involuntary and voluntary memories of stressful virtual reality scenarios. Thirty-two veterans of the two Persian Gulf Wars completed verbal memory tests and diagnostic assessments. They were randomly assigned to a Recounting (16) or a Suppression (16) condition. After immersion in the VR scenarios, the Recounting group described the scenarios and the Suppression group suppressed thoughts of the scenarios. One week later, participants completed surprise voluntary memory tests and another thought suppression task. The best predictors of voluntary memory were verbal memory ability, dissociation, and to a lesser extent, physiological arousal before and after scenarios. Dissociation and physiological stress responses selectively affected memory for neutral elements. Higher distress during scenarios impaired voluntary memory but increased the frequency of involuntary memories. Physiological stress responses promoted more frequent involuntary memories immediately after the scenarios. More frequent initial involuntary memories, tonic physiological arousal, and stronger emotional responses to dangerous events predicted difficulty inhibiting involuntary memories at follow-up. The effects of thought suppression were transient and weaker than those of other variables. The findings suggest that posttraumatic amnesia and involuntary memories of adverse events are more related to memory ability and emotional and physiological stress responses than to post-exposure suppression.

0606 Comparative Effectiveness of Sleep Apnea Screening Tools During Inpatient Rehabilitation for Moderate to Severe TBI

Abstract Introduction Recent studies highlight prevalent obstructive sleep apnea after moderate to severe TBI during a time of critical neural repair. The purpose of this study is to determine the diagnostic sensitivity, specificity and comparative effectiveness of traditional sleep apnea screening tools in TBI neurorehabilitation admissions. Methods This is a prospective diagnostic comparative effectiveness trial of sleep apnea screening tools (STOPBANG, Berlin, MAPI [Multi-Apnea Prediction Index]) relative Level 1 polysomnography at six TBI Model System Inpatient Rehabilitation Centers. Between 05/2017 and 02/2019, 449 of 896 screened were eligible for the trial with 345 consented (77% consented). Additional screening left 263 eligible for and completing polysomnography with final analyses completed on 248. The primary outcome was the Area Under the Curve (AUC) of screening tools relative to total apnea hypopnea index ≥15 (AHI, moderate to severe apnea) measured at a median of 47 days post-TBI (IQR 29-47). Results Participants were primarily young to middle age (AGE IQR 28,40,59), male (81%), white (74%), and had primarily severe TBI (IQR GCS 3,6,14). A subset (26%) had a history of military service. Results revealed that the Berlin high risk score (ROC-AUC=0.63) was inferior to the MAPI (ROC-AUC = 0.7802) (p=.0211, CI: 0.0181, 0.2233) and STOPBANG (ROCAUC = 0.7852) (p=.0006, CI: 0.0629, 0.2302); both of which had comparable AUC (p=.7245, CI: -0.0472, 0.0678). Findings were similar for AHI≥30 (severe apnea); however, no differences across scales was observed at AHI>5. The pattern was similar across TBI severity subgroups except for delirium or post-traumatic amnesia status wherein the MAPI outperformed the Berlin and STOPBANG. Youden’s Index to determine risk yielded lower sensitivities but higher specificities relative to non-TBI samples. Conclusion This study is the first to provide clinicians with data to support a choice for which sleep apnea screening tools are more effective during inpatient rehabilitation for moderate to severe TBI (STOPBANG, MAPI vs Berlin) to help reduce comorbidity and possibly improve neurologic outcome. Support PCORI (CER-1511-33005), GDHS (W91YTZ-13-C-0015; HT0014-19-C-0004)) for DVBIC, NIDILRR (NSDC Grant # 90DPTB00070, #90DP0084, 90DPTB0013-01-00, 90DPTB0008, 90DPT80004-02).

Post traumatic amnesia as a predictor for development and recovery of visual field defects following mild traumatic brain injury (mTBI)

Mild traumatic brain injury can trigger long term visual dysfunction in the form of visual field defects which can disrupt the normal lifestyle of any individual and other rehabilitation efforts resulting in social and professional distress. Post traumatic amnesia is one of the predictors of severity in mTBI.The purpose of this study was two fold (i)To find out the association between post traumatic amnesia and visual field defects following mild traumatic brain injury. (ii) The implication of post traumatic amnesia on the development and recovery of visual field defects post mTBI. Hospital based prospective, analytical, observational study. A total of 260 patients with the diagnosis of mTBI were studied. Diagnosis of mTBI was based on the WHO Operational criteria for clinical identification of mTBI.Visual field index (VFI) was taken to estimate the extent of visual field damage because it is a global index which expresses the amount of visual field loss as a percentage relative to the sensitivity of a reference group of healthy observers.The Galveston orientation and amnesia test (GOAT) was applied to assess post traumatic amnesia. The study period was from July 2017 to March 2019. Each patient with mTBI was examined for Visual field defects at 1 month, 6 months and 1 year post injury. The main observation of this study were (i) It is important to look for visual field defects even in mild traumatic brain injury for atleast 6 months post injury because during this period the appearance of visual field defect peaked. (ii) There is a strong possibility of developing visual field defects among the group of patients who presented with the history of post traumatic amnesia following mild traumatic brain injury (P=0.0001) (iii) If a patient with mild traumatic brain injury suffers from visual field defects, possibility of his/her symptoms persisting beyond 12 months increases significantly if there is history of post traumatic amnesia (P=0.0001).Mild traumatic brain injury can trigger long term visual dysfunction in the form of Visual field defects. Our results will help in providing information regarding development, progress and outcome of visual field defects following mild traumatic brain injury.

Admission Levels of Total Tau and β-Amyloid Isoforms 1-40 and 1-42 in Predicting the Outcome of Mild Traumatic Brain Injury.

Background: The purpose of this study was to investigate if admission levels of total tau (T-tau) and β-amyloid isoforms 1-40 (Aβ40) and 1-42 (Aβ42) could predict clinical outcome in patients with mild traumatic brain injury (mTBI).Methods: A total of 105 patients with mTBI [Glasgow Coma Scale (GCS) ≥ 13] recruited in Turku University Hospital, Turku, Finland were included in this study. Blood samples were drawn within 24 h of admission for analysis of plasma T-tau, Aβ40, and Aβ42. Patients were divided into computed tomography (CT)-positive and CT-negative groups. The outcome was assessed 6–12 months after the injury using the Extended Glasgow Outcome Scale (GOSE). Outcomes were defined as complete (GOSE 8) or incomplete (GOSE < 8) recovery. The Rivermead Post Concussion Symptoms Questionnaire (RPCSQ) was also used to assess mTBI-related symptoms. Predictive values of the biomarkers were analyzed independently, in panels and together with clinical parameters.Results: The admission levels of plasma T-tau, Aβ40, and Aβ42 were not significantly different between patients with complete and incomplete recovery. The levels of T-tau, Aβ40, and Aβ42 could poorly predict complete recovery, with areas under the receiver operating characteristic curve 0.56, 0.52, and 0.54, respectively. For the whole cohort, there was a significant negative correlation between the levels of T-tau and ordinal GOSE score (Spearman ρ = −0.231, p = 0.018). In a multivariate logistic regression model including age, GCS, duration of posttraumatic amnesia, Injury Severity Score (ISS), time from injury to sampling, and CT findings, none of the biomarkers could predict complete recovery independently or together with the other two biomarkers. Plasma levels of T-tau, Aβ40, and Aβ42 did not significantly differ between the outcome groups either within the CT-positive or CT-negative subgroups. Levels of Aβ40 and Aβ42 did not significantly correlate with outcome, but in the CT-positive subgroup, the levels of T-tau significantly correlated with ordinal GOSE score (Spearman ρ = −0.288, p = 0.035). The levels of T-tau, Aβ40, and Aβ42 were not correlated with the RPCSQ scores.Conclusions: The early levels of T-tau are correlated with the outcome in patients with mTBI, but none of the biomarkers either alone or in any combinations could predict complete recovery in patients with mTBI.