Time Of Traumatic Brain Injury Research Articles

Timing of Traumatic Brain Injury in Childhood and Intellectual Outcome

Typically, studies on outcomes after traumatic brain injury (TBI) have investigated whether a younger age at injury is associated with poorer recovery by comparing 2 age groups rather than participants injured across childhood. This study extended previous research by examining whether the influence of age on recovery fits an early vulnerability or critical developmental periods model. Children with a TBI (n = 181) were categorized into 4 age-at-injury groups-infant, preschool, middle childhood, and late childhood--and were evaluated at least 2-years post-TBI on IQ. Overall, the middle childhood group had lower IQ scores across all domains. Infant and preschool groups performed below the late childhood group on nonverbal and processing speed domains. Contrary to expectations, children injured in middle childhood demonstrated the poorest outcomes; this age potentially coincides with a critical period of brain and cognitive development.

Multicenter Evaluation of the Course of Coagulopathy in Patients with Isolated Traumatic Brain Injury: Relation to CT Characteristics and Outcome

This prospective multicenter study investigated the association of the course of coagulation abnormalities with initial computed tomography (CT) characteristics and outcome in patients with isolated traumatic brain injury (TBI). Patient demographics, coagulation parameters, CT characteristics, and outcome data of moderate and severe TBI patients without major extracranial injuries were prospectively collected. Coagulopathy was defined as absent, early but temporary, delayed, or early and sustained. Delayed/sustained coagulopathy was associated with a higher incidence of disturbed pupillary responses (40% versus 27%; p<0.001) and higher Traumatic Coma Data Bank (TCDB) CT classification (5 (2-5) versus 2 (1-5); p=0.003) than in patients without or with early, but short-lasting coagulopathy. The initial CT of patients with delayed/sustained coagulopathy more frequently showed intracranial hemorrhage and signs of raised intracranial pressure (ICP) compared to patients with early coagulopathy only. This was paralleled by higher in-hospital mortality rates (51% versus 33%; p<0.05), and poorer 6-month functional outcome in patients with delayed/sustained coagulopathy. The relative risk for in-hospital mortality was particularly related to disturbed pupillary responses (OR 8.19; 95% CI 3.15,21.32; p<0.001), early, short-lasting coagulopathy (OR 6.70; 95% CI 1.74,25.78; p=0.006), or delayed/sustained coagulopathy (OR 5.25; 95% CI 2.06,13.40; p=0.001). Delayed/sustained coagulopathy is more frequently associated with CT abnormalities and unfavorable outcome at 6 months after TBI than early, short-lasting coagulopathy. Our finding that not only the mere presence but also the time course of coagulopathy holds predictive value for patient outcome underlines the importance of systematic hemostatic monitoring over time in TBI.

Clinical features of posttraumatic epilepsy in children

In order to identify clinicalage relationship in children with posttraumatic epilepsy (PTE), 78 patients aged from 3 to 14 years were examined. The mean duration of latent period was 8.9±0.79 month s. Studies have shown that the latent period of PTE in children is largely dependent on child's age at the time of traumatic brain injury (TBI) occurrence than on its severity. Moreover, each age group was characterized by certain types of epileptic attack s: polymorphic seizures with predominance of primarygeneralized ones prevailed in the younger agegroup children (3�6 years), secondarygeneralized seizures developed for 52.2% of the total number of paroxysms in the middle agegroup children (7�10 years) , and partial seizures appeared in the older agegroup (63.3 %).

Retrospective Posttraumatic Amnesia in Traumatic Brain Injury

Back to table of contents Previous article Next article LETTERFull AccessRetrospective Posttraumatic Amnesia in Traumatic Brain InjuryPaul M. AshlaAaron M. McMurtray M.D.Eliot Licht M.D.Mario F. Mendez M.D., Ph.D.,Paul M. AshlaSearch for more papers by this authorAaron M. McMurtray M.D.Search for more papers by this authorEliot Licht M.D.Search for more papers by this authorMario F. Mendez M.D., Ph.D.Search for more papers by this author,Published Online:1 Oct 2009AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: Clinicians may need to determine the severity of a traumatic brain injury (TBI) that occurred many years ago. This can be challenging when there is no direct information about the remote TBI. One method of retrospective assessment is the duration of posttraumatic amnesia, the period during which a person is disoriented and unable to lay down new memories after a head injury. 1 , 2 Few modern investigators have studied retrospective posttraumatic amnesia. 3 Our study investigates the value of retrospective assessment of posttraumatic amnesia in a stratified sample of post-TBI patients using the Rivermead Posttraumatic Amnesia Protocol. 4Methods We evaluated post-TBI (mostly motor vehicle) patients who presented for residual cognitive impairment. They underwent a Mini-Mental State Examination (MMSE) and tests of attention (digit span), verbal fluency (animals/minute), verbal memory (10-item verbal learning task), and the Frontal Assessment Battery (FAB) for executive functions. 5 No individual participants were identified, and the information was coded anonymously. All participants were men (U.S. veterans) with medical records on their prior TBI. Inclusion criteria included absence of prior cognitive rehabilitation, litigation, substance abuse, psychoactive medications, and other neurological or psychiatric disorder that might affect cognition. Participants were divided into a recent TBI group (23 patients 2–5 years post-TBI) and a remote TBI group (23 patients 6–15 years post-TBI). Group members were pairwise matched on medical record documentation of loss of consciousness (mild <60 minutes, moderate 1–24 hours, severe >24 hours), age (within 3 years), and education (within 3 years). The Rivermead Posttraumatic Amnesia Protocol, which consists of five questions, established the duration of posttraumatic amnesia to the nearest hour. 4ResultsThe recent and remote groups were comparable in current age (37.06±7.02 years versus 38.11±13.01), of age at the time of TBI (34.17±7.10 years versus 27.66±13.78), and years of education (13.72±2.27 years versus 12.85±3.01). The posttraumatic amnesia duration (hours) did not differ between the recent and remote groups (21.89±29.83 hours versus 20.76±28.29). Within the recent TBI group, the retrospective posttraumatic amnesia negatively correlated with four out of the five variables (MMSE: r=−0.79, F=19.60, df=1, 22, p<0.01; attention: r=−0.53, F=5.02, df=1, 22, p=0.03; verbal fluency: r=−0.61, F=8.45, df=1, 22, p=0.01; verbal memory: r=−0.66, F=8.55, df=1, 22, p=0.01). Within the remote TBI group, there were no significant posttraumatic amnesia-cognitive correlations.DiscussionClinicians often assess whether patients have cognitive deficits from an old traumatic brain injury. Without direct access to medical records about an old head injury, the retrospective posttraumatic amnesia is a potential indicator of residual cognitive deficits from TBI. Our preliminary study found that the retrospective posttraumatic amnesia duration correlated with cognitive impairments up to 5 years post-TBI. After 5 years, however, the retrospective posttraumatic amnesia did not correlate with cognitive deficits. Investigators previously tested the Rivermead Posttraumatic Amnesia Protocol for retrospective posttraumatic amnesia duration among patients who were within 2 years of injury, but not in those with more remote head injuries. 4 This study suggests that retrospectively obtained posttraumatic amnesia is useful up to 5 years post-TBI, but becomes unreliable after that. Despite limitations, such as the small number of male participants, the findings recommend further investigation exploring retrospective posttraumatic amnesia in larger populations and in comparisons with prospective measures of TBI. Departments of Neurology and Psychiatry & Biobehavioral Sciences, David Geffen School of Medicine, University of California at Los Angeles; The V.A. Greater Los Angeles Health Care System

Serum Biomarker Concentrations and Outcome after Pediatric Traumatic Brain Injury

Predicting outcome after pediatric traumatic brain injury (TBI) is important for providing information to families and prescribing rehabilitation services. The study objective was to assess whether biomarkers concentrations obtained at the time of injury are associated with outcome. Serial serum concentrations of neuron-specific enolase (NSE), S100B and myelin basic protein (MBP) were measured in 152 children with acute TBI. Outcome was assessed with the Glasgow Outcome Scale (GOS) score and/or GOS-Extended Pediatric (GOS-E Peds). Spearman's rank correlation and binary logistic regression assessed the relationship between biomarker concentrations and outcome. For all biomarkers and time points, higher biomarker concentrations were associated with worse outcome. Initial and peak NSE concentrations and initial MBP concentrations were more strongly correlated with outcome in children < or =4 years compared with those >4 years of age. Using binary logistic regression to evaluate the simultaneous affect of all biomarkers on outcome, there was significant overall model fit predicting a dichotomous GOS from biomarker concentrations with a 77% correct classification rate and a negative and positive predictive value of 97% and 75%, respectively. We conclude that NSE, S100B, and MBP concentrations obtained at the time of TBI may be useful in predicting outcome. Future studies should focus on assessing the differential benefit of biomarkers compared with clinical variables and in assessing a continuous rather than categorical outcome variable.

Short-term neuropsychological outcome following uncomplicated mild TBI: Effects of day-of-injury intoxication and pre-injury alcohol abuse.

Research suggests that individuals who are intoxicated at the time of traumatic brain injury (TBI) have worse cognitive outcome compared with those who are sober. Worse outcome in patients with day-of-injury intoxication might (a) be related to the increased magnitude of brain injury resulting from a variety of negative responses not present following TBI in nonintoxicated individuals, or (b) reflect the effect of pre-injury alcohol abuse that is prevalent in individuals intoxicated at the time of injury. Most studies in this area have focused on patients with moderate to severe TBIs, and on medium- to long-term neuropsychological outcome. The purpose of this study was to examine the relative contributions of day-of-injury intoxication versus pre-injury alcohol abuse on short-term cognitive recovery following mild TBI. Participants were 169 patients with uncomplicated mild TBIs who were assessed on 13 cognitive measures within 7 days postinjury. The prevalence of intoxication at the time of injury was 54.4%. The prevalence of possible pre-injury alcohol abuse was 46.2%. Overall, the results suggest that pre-injury alcohol abuse, compared with day-of-injury alcohol intoxication, had the most influence on short-term neuropsychological outcome from uncomplicated mild TBI. However, the influence of pre-injury alcohol abuse was considered small at best.

Isoflurane exerts neuroprotective actions at or near the time of severe traumatic brain injury

Isoflurane improves outcome vs. fentanyl anesthesia, in experimental traumatic brain injury (TBI). We assessed the temporal profile of isoflurane neuroprotection and tested whether isoflurane confers benefit at the time of TBI. Adult, male rats were randomized to isoflurane (1%) or fentanyl (10 mcg/kg iv bolus then 50 mcg/kg/h) for 30 min pre-TBI. Anesthesia was discontinued, rats recovered to tail pinch, and TBI was delivered by controlled cortical impact. Immediately post-TBI, rats were randomized to 1 h of isoflurane, fentanyl, or no additional anesthesia, creating 6 anesthetic groups (isoflurane:isoflurane, isoflurane:fentanyl, isoflurane:none, fentanyl:isoflurane, fentanyl:fentanyl, fentanyl:none). Beam balance, beam walking, and Morris water maze (MWM) performances were assessed over post-trauma d1-20. Contusion volume and hippocampal survival were assessed on d21. Rats receiving isoflurane pre- and post-TBI exhibited better beam walking and MWM performances than rats treated with fentanyl pre- and any treatment post-TBI. All rats pretreated with isoflurane had better CA3 neuronal survival than rats receiving fentanyl pre- and post-TBI. In rats pretreated with fentanyl, post-traumatic isoflurane failed to affect function but improved CA3 neuronal survival vs. rats given fentanyl pre- and post-TBI. Post-traumatic isoflurane did not alter histopathological outcomes in rats pretreated with isoflurane. Rats receiving fentanyl pre- and post-TBI had the worst CA1 neuronal survival of all groups. Our data support isoflurane neuroprotection, even when used at the lowest feasible level before TBI (i.e., when discontinued with recovery to tail pinch immediately before injury). Investigators using isoflurane must consider its beneficial effects in the design and interpretation of experimental TBI research.

Forensic Pathology Reviews: Volume 1

Edited by Michael Tsokos, 353 pp, with tables and illus, Totowa, NJ, Humana Press, 2004.This is the first in a review series of forensic pathology, starting with the premise that “over the last decade, the field of forensic science has expanded enormously, with the rapid emergence of new autopsy and laboratory techniques, and the identification of many new markers for specific pathological conditions.” This book is a good start in attempting to define these recent forensic pathology advances.The first chapter is a review of burned bodies, with black-and-white photographs that show charring with “puppet organs” and tables that compare grading schemes for thermal injury. Chapter 2 reviews the blunt force trauma experience in Germany from “stomping” and assault. Chapter 3 deals with timing of traumatic brain injury through immunohistochemical analysis. New to me was the extensive text and tables that summarize all the markers and the earliest and average times they are found after injury. Chapter 4 reviews the effects of drug abuse on the central nervous system, with 31 pages of 505 references. Chapter 5 is an up-to-date review of sudden cardiac death, and chapters 6 and 7 deal with the problems and pitfalls of neonaticide and sudden infant death syndrome, respectively.Chapters 8 and 9 review rare fatalities from Mycoplasma pneumoniae and Waterhouse-Friderichsen syndrome. Chapter 10 is a review of autoerotic deaths, with the history of the practice the most informative. The chapter on hypothermic deaths concentrates on the pitfall of misdiagnosing paradoxical undressing as homicide and the process of crawling into enclosed spaces during hypothermia called the hide and die syndrome, which is believed to be related to a hibernation reflex. The text, photographs, and concise tables in the review of maternal death from HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) are excellent.The most encyclopedic chapter is the review of the forensic aspects of postmortem alcohol interpretation, with all the biochemical calculations, pitfalls, and strengths in interpreting alcohol values thoroughly discussed. Cardiopulmonary resuscitation injuries are also reviewed. The last chapter on iliopsoas muscle hemorrhage deals with this rare autopsy finding, most likely related to sepsis, DIC, or trauma.Generally, the references at the end of the chapters are extensive, but unfortunately many to most in each chapter are in German. This reflects the different perspectives of the European practice environment of the editor and his mainly German coauthors. Some authors also seem to place a heavy emphasis on microscopic studies over the gross findings, which is different from the American forensic pathologist. I appreciated the summary sections at the end of each chapter. Forensic pathology is a visual discipline, and more photographs in the subsequent volumes would be beneficial.Finally, this volume contains timely, comprehensive reviews for the selected specialized topics. Although these reviews do not define many new advances in forensic pathology techniques or practices, this may reflect the field of forensic pathology itself rather that any deficit of the authors. I would recommend the first book in this series to the practicing forensic pathologist who wishes to fill in some gaps of the standard forensic pathology texts or as a starting point to begin to master the art of traumatic forensic neuroimmunohistochemistry.

Alcohol abuse and traumatic brain injury: quantitative magnetic resonance imaging and neuropsychological outcome.

Prior or concurrent alcohol use at the time of traumatic brain injury (TBI) was examined in terms of post-injury atrophic changes measured by quantitative analysis of magnetic resonance imaging (MRI) and neuropsychological outcome. Two groups of TBI subjects were examined: those with a clinically significant blood alcohol level (BAL) present at the time of injury (TBI + BAL) and those without a significant BAL (TBI-only). To explore the potential impact of both acute and chronic alcohol use, subjects in both groups were further clustered into one of four subgroups (NONE, MILD, MODERATE or HEAVY) based upon available information regarding their pre-injury alcohol use. One-way analysis of covariance (ANCOVA) and multiple analysis of covariance (MANCOVA) were used with subject grouping as the main factor. Age, injury severity as measured by Glasgow Coma Scale (GCS) score, years of education, total intracranial volume (TICV), and the number of days post-injury were included as covariates where appropriate. Increased general atrophy was observed in patients with (a) a positive BAL and/or (b) a history of moderate to heavy pre-injury alcohol use. In addition, performance on neuropsychological outcome variables (WAIS-R and WMS-R Index scores) was generally worse in the subgroups of patients with positive BAL and a history of preinjury alcohol use, as compared to the other TBI groups though not statistically significant. Implications of alcohol use, at the time of brain injury, are discussed.

Positive effects of Cerebrolysin on electroencephalogram slowing, cognition and clinical outcome in patients with postacute traumatic brain injury: an exploratory study

The potential effects of Cerebrolysin (EBEWE Pharma, Unterach, Austria), a peptide preparation with neurotrophic activity, on brain bioelectrical activity, cognitive performance and clinical outcome in postacute traumatic brain injury (TBI) patients, were investigated in an exploratory study. A decrease in slow electroencephalogram (EEG) activity and an increase in fast frequencies were observed after the administration of Cerebrolysin. This EEG-activating effect was not influenced by TBI time course or severity, nor by the chronic treatment with nootropic compounds. Cognitive performance, evaluated with the Syndrome Kurztest test, improved in TBI patients after Cerebrolysin treatment, independent of disease severity, time course or disability. A significant improvement in the patients' clinical outcome, only evident during the first year after brain trauma, was also found following Cerebrolysin infusions. No relevant changes in biological parameters nor drug-related adverse events were observed. These promising preliminary results suggest that Cerebrolysin might be a useful treatment to improve the recovery of patients with traumatic brain damage, and encourage the conduction of confirmatory clinical trials.

Predicting neuropsychologic outcome after traumatic brain injury in children

The ability to predict long-term neurologic and neuropsychologic outcomes in 22 children, ages 1 week to 14 years at the time of traumatic brain injury, was investigated using proton magnetic resonance spectroscopy acquired post injury and compared with standardized neurologic, intellectual, and neuropsychologic testing done 1-7 years later. Clinical indicators of acute injury severity including age at injury, electroencephalography, spectroscopy metabolite ratio variables ( N-acetyl aspartate/choline, choline/creatine) and lactate presence accurately classified children as functioning above or below the average range for most intellectual and neuropsychologic outcome measures. Combined clinical and spectroscopy variables accounted for approximately 50% of the variance in cognitive and neuropsychologic outcome confirming the validity of their predictive use. Of the injury severity indictors, presence of lactate is a particularly important prognostic marker of poor long-term intellectual and neuropsychologic functioning. Our findings indicate the potential for providing accurate estimates of long-term intellectual and neuropsychologic function after traumatic brain injury in infants and children using proton magnetic resonance spectroscopy in combination with clinical variables.

Estimation of the EEG power spectrum using MRI T2 relaxation time in traumatic brain injury

Objectives: To study the relationship between magnetic resonance imaging (MRI) T 2 relaxation time and the power spectrum of the electroencephalogram (EEG) in long-term follow up of traumatic brain injury. Methods: Nineteen channel quantitative electroencephalograms or qEEG, tests of cognitive function and quantitative MRI T 2 relaxation times (qMRI) were measured in 18 mild to severe closed head injured outpatients 2 months to 4.6 years after injury and 11 normal controls. MRI T 2 and the Laplacian of T 2 were then correlated with the power spectrum of the scalp electrical potentials and current source densities of the qEEG. Results: qEEG and qMRI T 2 were related by a frequency tuning with maxima in the alpha (8–12 Hz) and the lower EEG frequencies (0.5–5 Hz), which varied as a function of spatial location. The Laplacian of T 2 acted like a spatial–temporal ‘lens’ by increasing the spatial–temporal resolution of correlation between 3-dimensional T 2 and the ear referenced alert but resting spontaneous qEEG. Conclusions: The severity of traumatic brain injury can be modeled by a linear transfer function that relates the molecular qMRI to qEEG resonant frequencies.

Alcohol Level at Head Injury and Subsequent Psychotropic Treatment During Trauma Critical Care

Alcohol intoxication at the time of traumatic brain injury (TBI) presents many complications for critical care treatment. This is the first reported data on psychotropic dosages administered to TBI patients in the critical care setting. In this study, the blood alcohol level (BAL)-positive patients (n = 14) tended to be older (P = 0.095), have lower admission Glascow Coma Scores (P = 0.031), and spent more days on respirators (P = 0.125) than the BAL-zero patients (n = 21). The BAL-positive group received more days of narcotics and benzodiazepines with markedly higher average daily doses, not statistically significant. These results are a basis for studying relationships between medication, treatment variables, and outcomes for TBI patients and then developing specific medication guidelines.