Severe Closed Head Injury Research Articles

Working Memory and Metacognition in Sentence Comprehension by Severely Head-Injured Children: A Preliminary Study

We studied the effects of working memory (WM) load on a sentence anomaly task in 12 children (mean age at study = 10.3 years) who had sustained a severe closed-head injury (CHI) at least 10 months previously and 12 healthy children (mean age = 8.92 years). Children were asked to judge whether each sentence (32 anomalous and 32 correct under high and low WM load conditions) was good or not good, and to identify and repair the anomaly. Group and age effects were significant, and both variables interacted with sentence type, reflecting greater sensitivity of anomalous than sensible sentences to CHI and age. A Group × WM load interaction was found. WM deficit contributes to impaired language processing after severe CHI and a metacognitive problem is dissociable from generalized cognitive dysfunction.

Head Trauma and Intellectual Status: Relation to Quantitative Magnetic Resonance Imaging Findings

This article contrasts 2 groups that sustained somewhat similar moderate to severe closed-head traumatic brain injury (TBI), but were deliberately selected to be different with regard to postinjury intellectual status--one group average or above, the other below. The purpose of this comparison was to describe any morphological characteristics of the 2 groups ascertained from quantitative magnetic resonance (QMR) imaging. Thirty-five TBI participants with Full Scale IQ (FSIQ) less than or equal to 90 were compared to 33 TBI participants whose FSIQ was above 90. A group of normal volunteer participants, age and gender matched, constituted a third magnetic resonance comparison group. All participants received uniform MRI from which QMR analysis was performed, including total cranial volume, subarachnoid cerebral spinal fluid ventricular volume, and hippocampal volume. Both TBI groups received neuropsychological testing in the course of clinical follow-up. Morphological comparisons between groups were made using multivariate analysis of variance. The TBI group with an IQ less than or equal to 90 had significantly enlarged third and temporal horn compartments. Total intracranial volume was smaller in this group as well. Lower psychometric intelligence postinjury may be associated with more temporal lobe atrophy and subcortical pathology. Smaller premorbid brain size may be another risk factor.

Cooling therapy for acute stroke.

Recent studies in acute stroke patients have shown an association between body temperature and prognosis. Our objective was to assess the effects of cooling when applied to patients with acute ischaemic stroke or primary intracerebral haemorrhage. We searched the Cochrane Stroke Group's trial register (last searched in March 1999), plus MEDLINE searched up to November 1998 and EMBASE searched from January 1980 to November 1998. We contacted investigators, pharmaceutical companies and manufacturers of cooling equipment in this field. All completed randomised controlled trials or controlled clinical trials, published or unpublished, where cooling therapy (therapy given by physical devices or antipyretic drugs primarily to lower body temperature independently of basal temperature at the beginning of treatment) was applied up to two weeks of an acute ischaemic stroke or primary intracerebral haemorrhage. Two reviewers independently searched for relevant trials. No randomised trials or controlled trials were identified; one placebo-controlled trial of metamizol is currently underway. There is currently no evidence from randomised trials to support the routine use of physical or chemical cooling therapy in acute stroke. Since experimental studies showed a neuroprotective effect of hypothermia in cerebral ischaemia, and hypothermia appears to improve the outcome in patients with severe closed head injury, trials with cooling therapy in acute stroke are warranted.

Prognostic value of early computerized tomography scanning following craniotomy for traumatic hematoma.

Patients with head injuries traditionally were categorized on the basis of whether their lesions appeared to be diffuse, focal, or mass lesions on admission computerized tomography (CT) scanning. In the classification of Marshall, et al., the presence of a hematoma (evacuated or not evacuated) is more significant than any diffuse injury (DI). The CT scan appearance after evacuation of a mass lesion has not been analyzed previously in relation to outcome. The authors have investigated the importance of: 1) neurological assessment at hospital admission; 2) the status of the basal cisterns and associated intracranial lesions on the admission CT scan; and 3) the degree of DI on the early CT scan obtained after craniotomy to identify patients at risk for development of raised intracranial pressure (ICP) and lowered cerebral perfusion pressure (CPP) and to discover the influence of the postoperative CT appearance of the lesion on patient outcome. The authors prospectively studied 82 patients with isolated, severe closed head injury (Glasgow Coma Scale [GCS] score < or = 8), all of whom had intracranial hematoma. Both ICP and CPP were continuously monitored, and a CT scan was obtained within 2 to 12 hours after craniotomy. The CT images were categorized according to the classification of Marshall, et al. The mortality rate during the hospital stay was 37%, and 50% of the patients achieved a favorable outcome. Compression of the basal cistern on the admission (preoperative) CT scan was associated with raised ICP and a CPP of less than 70 mm Hg but not with any other features or with poor patient outcome. In 53 patients the postoperative CT scan revealed DIs III or IV and 29 patients had DIs I or II. The percentages of time during the hospital stay in which ICP was higher than 20 mm Hg and CPP was lower than 70 mm Hg as well as unfavorable outcome were higher in the group of patients in whom DI III or IV was present (p < 0.001). Raised ICP, CPP lower than 70 mm Hg, DI III or IV, and unfavorable outcome were more frequently observed in patients who presented with a motor (m)GCS score of 3 or less, bilateral unreactive pupils, associated intracranial injuries, and hypotension (p < 0.001). When logistic regression analysis was performed, an mGCS score of 3 or less (p = 0.0013, odds ratio [OR] 10.8), bilateral unreactive pupils (p = 0.0047, OR 31.8), and DI III or IV observed on CT scanning after surgery (p = 0.015, OR 8.9) were independently associated with poor outcome. Features on CT scans obtained shortly after craniotomy constitute an independent predictor of outcome in patients with traumatic hematoma. Patients in whom DI III or IV appears on postoperative CT scanning, who often present with an mGCS score of 3 or less and nonreactive pupils, are at high risk for the development of raised ICP and lowered CPP.

Sports-Related Concussion

Sports-Related Concussion. Julian E. Bailes, Mark R. Lovell, Joseph C. Maroon (Editors). St. Louis, Quality Medical Publishing, Inc., 1999. Pages: 261. Price: $30. ISBN: 1-57626-050-X. Neurosurgical training, research, and practice have traditionally involved the assessment and management of severe closed head injury. An often neglected area has been the assessment of head injuries that are not initially considered life-threatening. Many of these injuries occur in patients participating in both organized and casual athletic endeavors. These injuries may be classified as minor, but they are far from trivial in terms of morbidity and disability. Physicians from a variety of specialities may be involved in management. A significant part of management includes prevention of further injury and the difficult question of when athletic activities may resume. There are significant issues concerning both safety and liability. The classifications of concussion and the concept of postconcussive syndrome have evolved over the past decade, and...

Posttraumatic cerebral vasospasm: clinical and morphological presentations.

Head injury is one of the leading causes of morbidity and mortality in the young population. Many factors complicate head injury and worsen an outcome. One of these factors is posttraumatic cerebral vasospasm. We studied 75 patients admitted to the University of Mississippi Medical Center with head injury. Their ages ranged from 14 to 67 years (mean 30 years, SD 11.63). Eighty percent of the patients were men, and 20% were women. Of these patients, 53 (70.6%) suffered severe blunt trauma, and 4 patients suffered gunshot wounds to the head. Four patients had mild head injury, and 14 had moderate head injury. Posttraumatic vasospasm was detected in 24 (32%) patients. Among these patients, 19 (79.2%) had severe closed head injury, 3 patients had moderate head injury, and 2 suffered gunshot wounds. The severity of the patient's respective condition was correlated with the development of posttraumatic cerebral vasospasm: 50% of the patients with Glasgow Coma Scale (GCS) 3-4 developed PTV, and only 30% with GCS 9-11, and none of the patients with GCS > 12 developed PTV. Overall, posttraumatic vasospasm started earlier and had a shorter course than did aneurysmal vasospasm. Morphologically, posttraumatic vasospasm resembled the features of aneurysmal vasospasm. We found increased corrugation of the internal elastic lamina and increased amounts of connective tissue in the subendothelial layer. These findings show that posttraumatic vasospasm, although clinically more mild, demonstrates the same morphological changes as aneurysmal vasospasm.

Recovery of written language production in children with traumatic brain injury: outcomes at one year

The purpose of this study is to determine if the pattern of deficits in written language production persists at one year after resolution post traumatic amnesia. Seventy-one children, aged 8 to 15 years, with mild, moderate and severe closed head injury were compared with controls who were individually matched on the premorbid characteristics of age, gender, school grade, behaviour and academic performance. For children with severe injury, deficits in written language persist at 1 year. Although the extent of the deficits lessens somewhat, the pattern of deficit at 1 month and 1 year are similar.

Abdominal Closure Using Nonabsorbable Mesh after Massive Resuscitation Prevents Abdominal Compartment Syndrome and Gastrointestinal Fistula

Patients who receive high-volume resuscitation after massive abdominopelvic trauma, or emergent repair of a ruptured abdominal aortic aneurysm (RAAA), are at a significant risk for postoperative abdominal compartment syndrome (ACS). Absorbable prosthetic closure of the abdominal wall has been recommended as a means of managing ACS. However, use of absorbable prosthetic has been associated with very high rates of intestinal fistula formation and ventral hernia formation. The purpose of this study was to retrospectively review our experience with the use of nonabsorbable prosthetic abdominal closures in patients with documented ACS or at high risk for ACS. All patients managed by this technique from July 1995 through July 1997 after repair of ruptured abdominal aortic aneurysm or massive abdominopelvic trauma were evaluated. A total of 18 patients were identified: 15 primary prosthetic placements (Gore-Tex patch, 12; Marlex mesh, 2; and silastic mesh, 1) and 3 delayed prosthetic placements for ACS (Gore-Tex, 1 and Marlex, 2). The mortality rate was 22 percent (4 of 18) and resulted from multisystem organ failure (2 patients), cardiac arrest 1 hour postoperatively (1 patient), and severe closed head injury (1 patient). Secondary closure and prosthetic removal was possible in 16 of 18 patients, including the 2 patients who died of multisystem organ failure within the same hospitalization. Delayed abdominal closure at a subsequent admission was performed in two cases. This same patient developed an enterocutaneous fistula 2 months after discharge. Importantly, only 1 of 18 closed in this manner developed ACS requiring reoperation. The results indicate that use of a nonabsorbable prosthetic, particularly with Gore-Tex, is efficacious in the prevention of postoperative ACS in high-risk patients, while it enhances the possibility for delayed abdominal closure and minimizes the risk of gastrointestinal fistulization associated with other techniques.

Fluid Resuscitation Of Multiply Injured Patients With Severe Closed Head Injury

Fluid Resuscitation Of Multiply Injured Patients With Severe Closed Head Injury

Traumatic disruption of the thoracic aorta in children.

This study was undertaken to identify mechanisms of injury, diagnostic modalities, surgical management, and outcome in children with traumatic aortic disruptions. Retrospective study. University-affiliated private hospital. All patients younger than 17 years listed in the trauma registry. Operative repair of thoracic aortic injuries. There were 8 boys and 3 girls ranging in age from 12 to 17 years (mean, 14.8 years). Seven children were motor vehicle passengers; 3 were pedestrians struck by vehicles; and 1 was thrown from a bull. Aortic injuries were suspected on the basis of the mechanism of injury and abnormal chest x-ray films (mediastinal widening). Aortic injuries were confirmed in 9 patients by arch aortography and in 2 patients by computed tomography. The injuries involved the isthmus of the aorta in 9 patients (complete transections) and the aortic arch in 2 patients (avulsions of the great vessels). Isthmus injuries were repaired by means of left heart bypass with direct cannulation of the distal thoracic aorta in 8 patients and femoral venous to femoral arterial bypass in 1 patient. Arch injuries were repaired during hypothermic circulatory arrest. The injured aortic segments were replaced with interposition grafts. There were no direct complications of anticoagulation. Ten patients (91%) survived. The only death was caused by a severe closed head injury. There were no instances of paraplegia related to aortic repairs. Good outcomes resulted from early diagnosis based on mechanism of injury, prompt aortography, and computed tomography and operative management that included distal aortic perfusion with left heart bypass.

Assessment of dysarthric speech: a case for a combined perceptual and physiological approach

Traditionally, the assessment of dysarthric speech has mainly involved the use of perceptual evaluation measures. The inherent inadequacies of this method of assessment have resulted in the development of a range of instrumental assessment techniques to provide more objective analyses of the underlying physiological impairments of the speech apparatus in individuals with a dysarthric speech disturbance. The aim of the current study was to highlight the importance of a combined approach to the assessment of dysarthria with reference to two case studies of individuals with dysarthric speech: a 32-year-old adult who suffered a severe closed head injury and a nine-year-old child who experienced a cerebrovascular accident involving the basilar artery. Each subject was assessed using a battery of perceptual and physiological techniques. The results for each case indicated that instrumental measures were effective in identifying the severity and nature of the underlying physiological impairments in the various subsystems of the speech mechanism, and highlighted the importance of verifying perceptual judgements with instrumental measures. The results are discussed in relation to the value of a combined perceptual and physiological approach in determining an accurate evaluation and diagnosis of the dysarthric speech impairment and in defining appropriate treatment goals.

The MMPI-2 and Closed-Head Injury

Abstract This study examined Minnesota Multiphasic Personality Inventory-2 (MMPI-2) profile configurations in a sample of closed-head injury (CHI) patients with mild head injury/concussion (n = 55) or moderate to severe closed-head injuries (n = 57). Fifty of these patients were involved in litigation related to their injury at the time of this evaluation, 62 were not. Head injury severity in non-litigating subjects was inversely related to profile elevations on MMPI-2 scales 1, 2, 3, and 7. Patients with less severe head injuries (concussions, with or without loss of consciousness, and mild closed-head injury) demon strated elevations of the magnitude previously reported in the MMPI and CHI literature, whereas patients with more severe closed-head injuries did not demonstrate elevations on these scales. Patients involved in litigation demonstrated elevations on these MMPI-2 scales independent of head injury severity. These findings suggest that the current methods of MMPI-2 profile neurocorrection may be...

Mental Fatigue after Very Severe Closed Head Injury: Sustained Performance, Mental Effort, and Distress at Two Levels of Workload in a Driving Simulator

In patients with very severe closed head injury (CHI), returning to work is often problematic. The present study focuses on a persistent complaint of these patients, viz. mental fatigue. To study this, the effect of sustained workload is assessed in a continuous dynamic divided attention task. Three types of measures are employed: performance loss with time-on-task, and subjective reports and cardiovascular measures of mental effort and distress. Eight very severe CHI patients (mean post-traumatic amnesia duration 51 days, mean age 23 years, (SD 6.4) and eight hospital controls (mean age 29 years, (SD 5.9) were tested. No differences were found between the patients and controls in the effects of task load on performance and the amount of mental effort, even in very demanding simulated work conditions. This parallels previous findings in less demanding laboratory tasks of sustained attention. Effects of CHI were found on both subjective and physiological indicators of distress. Compared to the controls, patients showed stronger effects on systolic blood pressure and subjectively experienced load.

Retrieving Familiar People's Names in Patients with Severe Closed-Head Injuries

Patients with closed-head injury frequently complain about difficulties with retrieving the names of familiar people, but very few studies have investigated these complaints by objective measurements. Three experiments are reported that compared personal name retrieval in patients with severe closed-head injuries and normal controls. The patients more frequently failed to produce the names of famous persons, and had longer naming latencies than the controls. Accuracy of recognizing familiar persons was normal in the patients, even though they were slower in this task than the controls. The patients' main problem appeared to involve a disturbance in activating the stored name information. The patients' response pattern shows clear resemblance with simulations of the effects of brain damage in models for person naming.

Slow information processing after very severe closed head injury: impaired access to declarative knowledge and intact application and acquisition of procedural knowledge

As an explanation of the pattern of slow information processing after closed head injury (CHI), hypotheses of impaired access to declarative memory and intact application and acquisition of procedural memory after CHI are presented. These two hypotheses were tested by means of four cognitive reaction-time tasks, a semantic memory task, a memory comparison task, a mental rotation task and a mirror reading task. These tasks were administered on two different days to 12 survivors of a CHI tested more than 5 years after injury and a healthy control group of comparable age and education. In three tasks the difficulty of access to declarative knowledge was varied and it was expected that this would slow the CHI group more than the controls. In two tasks opportunities for procedural learning were provided by repeatedly presenting the same cognitive tasks and in one task, the difficulty of access to procedural memory was varied. It was expected that the CHI group would profit as much from this as would the control group. Both hypotheses were supported.

88. Clinical Predictors and Neuropsychological Outcome in Severe Closed-Head Injury Patients R. Formisano, G. A. Carlesimo, M. Sabbadini, A. Loasses, F. Penta, and V. Vinicola (all from Rome, Italy

88. Clinical Predictors and Neuropsychological Outcome in Severe Closed-Head Injury Patients R. Formisano, G. A. Carlesimo, M. Sabbadini, A. Loasses, F. Penta, and V. Vinicola (all from Rome, Italy

Évaluation écologique des fonctions executives chez les traumatisés crâniens graves: pour une meilleure approche du handicap

Objective A disorder in executive functions is frequently observed after severe head injury; this compromises the patients' autonomy. The classical neuropsychological assessment presents some sensitivity and ecological validity limits. Materials and method New tests have been recently proposed, such as the Multiple Errands Test (MET), developed by Shallice and Burgess in 1991. This test consists in carrying out a number of tasks with definite rules in a pedestrian precinct unknown to the patient and puts the subject in situations requiring self-conceived strategies. We have adapted this test in French and tested twelve head injury patients several months after severe closed head injury, and a population of matched control subjects. Results The performances of the subjects in classical frontal tests and in the MET were compared. The results reveal dissociations between normal or subnormal performances in classical tests and disorders in the ecological test. Conclusion These results thus prove the higher sensitivity and ecological validity in the MET for the assessment of frontal dysfunction compared to classical tests, and it realises a better approach to the handicap. Moreover, the analysis of errors explains better the deficits within the actual cognitive models of executive functions.

Specific attention and executive function deficits in the long-term outcome of severe closed head injury.

Twenty-eight children (mean age= 10.9 years, SD= 1.9 years) who had experienced a severe closed head injury were assessed for outcome on tests of intelligence, attention and executive function at 1 year post-injury. The children with closed head injury were matched with children from a normative sample for age and intellectual ability. Specific deficits in attention and executive function were found in the closed head injury sample. The importance of including these outcome variables in child neuropsychological assessment is supported.

Carbamazepine in agitation and aggressive behaviour following severe closed-head injury: results of an open trial

Ten patients presenting agitation and anger outbursts at various stages following a severe closed head injury, were treated in a prospective open trial with carbamazepine, with doses ranging from 400 to 800 mg per day, during 8 weeks. Group analysis demonstrated astatistically significant improvement of a score made up from six target items from the neurobehavioural rating scale. Improvement mainly concerned irritability and disinhibition. A statistically significant improvement was also found with the Agitated Behaviour Scale. Social functioning, as assessed by family or staff ratings of the Katz Adjustment Scale, also significantly improved. No modification of global cognitive functioning was found with the Mini Mental Status Examination. Individual analysis demonstrated that the beneficial effect was important in five cases, moderate in three patientsand negligible in two cases. It is concluded that carbamazepine might help to reduce agitated behaviour in brain-injured patients. However, response to treatment demonstrated an important inter-individual variability.

Corpus Callosum Damage and InterhemispherIc Transfer of Information following Closed Head Injury in Children

We evaluated the relationship of corpus callosum atrophy and/or lesions on magnetic resonance imaging (MRI) to functional hemispheric disconnection following closed head injury (CHI) in 51 pediatric patients, including mild CHI, moderate to severe CHI with extracallosal lesions, and moderate to severe CHI with callosal atrophy and/or lesions. Interhemispheric transfer of information was assessed using auditory, motor, tactile, and visual tests in patients and in 16 uninjured children. Total and regional callosal areas were measured from the midsagittal MRI slice by morphometry. The corpus callosum lesion group demonstrated a greater right ear advantage on verbal dichotic listening than all other groups. Areas of the posterior corpus callosum were negatively correlated with laterality indices of verbal dichotic listening performance and tachistoscopic identification of verbal material. The relationship of corpus callosum atrophy and/or lesions to asymmetry in dichotic listening is consistent with previous investigation of posttraumatic hemispheric disconnection effects in adults.