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Post-traumatic amnesia (PTA) is an early significant stage of recovery from traumatic brain injury (TBI). Current prospective PTA scales do not assess the full range of PTA symptomatology. This study conducted a novel integrated assessment of cognition and behaviour during PTA.
Twenty-four moderate-to-severe TBI participants in PTA and 23 TBI controls emerged from PTA were matched for age, gender, and years of education. All completed PTA measures (Galveston Orientation and Amnesia Test: GOAT, Westmead Post-traumatic Amnesia Scale: WPTAS), a cognitive battery; and behaviour ratings scored by 2 independent raters (informant and staff).
Significantly poorer performance was found during PTA for attention, processing speed, delayed verbal free recall and recognition, and visual learning. A large effect size was found for category fluency only. Behaviour ratings were significantly higher during PTA. Five behaviours were rated as high frequency (>50%) by both raters: Inattention, Impulsivity, Sleep Disturbance, Daytime Arousal, and Self-Monitoring. Prospective PTA measures produced significantly different duration estimates from 2 days (GOAT vs. WPTAS 1st day) to 9 days (WPTAS 1st day vs. 3-day). The WPTAS correlated most highly with processing speed and language tasks; whilst the GOAT correlated most highly with language and executive control of verbal memory.
New prospective measures are needed that integrate core cognitive and behavioural features are brief, easy to administer, and capable of measuring emergence. The term PTA is a misnomer that requires revision to better accommodate the clinical syndrome.
Behavioral changes are common after acquired brain injury (ABI) and may be caused by social cognition impairments. We investigated whether impaired emotion recognition, specifically Negative Emotion Recognition (NER) and Anger Misattribution (AM), after ABI was related to behavioral problems, so-called Behaviors of Concern (BoC).
The study included 139 participants with ABI and 129 healthy controls. BoC was measured using four scales of the Brock Adaptive Functioning Questionnaire (BAFQ): Impulsivity, Aggression, Social Monitoring, and Empathy. Both self-ratings and informant ratings of BoC were obtained. Emotion recognition was measured with the Ekman 60 Faces Test (FEEST). A NER score was composed of the summed scores on Anger, Disgust, Fear, and Sadness. An AM score was composed of the number of facial expressions wrongly recognized as Anger.
Total FEEST scores in ABI participants were significantly worse than in healthy controls. The effect size is moderate. Informants rated significantly more problems in Social Monitoring and Empathy than participants. Effect sizes were small. Scores on FEEST total, NER, and AM were significantly correlated to informant ratings of Social Monitoring. Correlations were weak to moderate.
Worse NER and more profound AM were related to more informant-rated problems in social monitoring. In addition, informants rated more problems in social monitoring and empathy than participants. This strongly suggests problems in self-awareness in ABI participants. Consequently, social cognition tests and informant ratings should be used in clinical practice to improve the detection and treatment of BoC after ABI.
Traumatic brain injury is recognised as a significant and pervasive health issue among offender populations. Despite this, no qualitative research exists exploring the experiences and perceptions of offenders with TBI in prison.
Qualitative interviews were conducted with male and female offenders housed in a UK prison. Interviews examined what participants felt led them to offend, experiences of incarceration, and post-release plans. Presence of TBI was assessed via the Brain Injury Screening Index. Data were analysed by means of inductive content analysis.
Both male and female prisoners primarily attributed their incarceration to drugs and alcohol use, with males also referencing more issues with aggression, while mental illness and past abuse were more commonly mentioned among females. A lack of recognition for the possible role of TBI was noted, with several males describing themselves as ‘stupid’ or prone to making ‘poor lifestyle choices’. Both groups indicated a desire to return to education or work post-release.
Despite significant rates of injury, there is a clear lack of understanding and consideration of the role of TBI in the behaviour and presentation of offenders. There is need for improved identification and education around TBI early in the criminal justice process.
This study aimed to understand state-level variation in participation in the State/Federal Vocational Rehabilitation (State VR) System in the United States among transition-aged youth (persons under the age of 22 years at application for State VR services) with traumatic brain injury (TBI) in Federal Fiscal Year 2016. A weighted least squares regression analysis was conducted to determine the relationship of state-level population size, unemployment rate, and per-capita income to the number of State VR closures in each state for transition-aged youth with TBI. Population size and per-capita income significantly predicted closures, while there was no relationship between closures and unemployment rate. Research is needed that further explores and explains state-level disparities in participation among transition-aged youth with TBI.
The aim of this qualitative study was to understand processes involved in the maintenance and development of friendships after a person sustains a traumatic brain injury (TBI).
Four people with severe TBI from rural settings in Australia identified one-to-two friends to be interviewed. A total of nine friends participated in a semi-structured interview. Interviews were transcribed verbatim and data was analyzed using principles of grounded theory.
The overall conceptualisation that emerged from the data described the process of friends actively placing themselves within the friendship with the person with TBI. Two major processes were evident which enabled friends to actively place themselves within the friendship. They were (1) making sense of the TBI and its consequences and (2) maintaining normality in the friendship.
Friendships can be maintained following a TBI when friends actively place themselves within the friendships. Friends are able to do this when they make sense of the TBI and its consequences and maintain normality. There are a variety of ways that friends achieve this.
Neuropsychological tests of episodic memory often include a measure of memory retention to facilitate the diagnosis of memory disorders. However, the traditional percent retention (PR) score has limited interpretability when smaller amounts of information are both initially learned and later recalled, creating a pseudo-ceiling effect. To improve psychometrics of PR, we investigated a scoring procedure that incorporates levels of certainty into estimates of memory retention based on learning level.
Word-list recall data from adults with traumatic brain injury were modeled using a uniform prior in the Bayesian framework. From the resultant posterior probability distributions, we derived a measure referred to as retention probability (RPr), which distinguishes the retention of relatively good and poor learners. PR and RPr scores were compared on their distributional properties and associations with theoretically related memory measures.
Significant distributional differences between PR and RPr were observed. RPr removed the conspicuous ceiling of PR, resulting in stronger correlational and predictive relationships with other memory measures.
A Bayesian procedure for quantifying memory retention has psychometric advantages and potentially widespread applicability for measuring the change in behavioral features over time. Future directions are briefly discussed. A sample RPr calculator is provided for interactive exploration of the method.
The legacy of apartheid that legalized racial separation and discrimination continues to haunt South African society as evidenced in the growing number of verbal and violent racist attacks. Socially disadvantaged children and youth in South Africa lack social support and access to healthcare. The high incidence of head trauma in South Africa is related to the increasing rate of mental illness. In particular, mild traumatic brain injuries pose serious threats to the mental and physical health of children and adolescents. This chapter highlights the vulnerability to further trauma facing children with mild traumatic head injury when confronting security challenges and argues for the evolution of mental education to law enforcement and legal structures to provide appropriate protective care to child and adolescent victims of mild traumatic head injuries.
In Ontario, there are approximately 66,000 adults living with a diagnosis of intellectual and developmental disabilities (IDD). These individuals are nearly twice as likely to experience an injury compared to the general population. Falls are an important contributor to injuries in persons with IDD and in the general population, and are consistently found to be the leading cause of traumatic brain injury (TBI). There is currently no literature that quantitatively examines TBI among persons with IDD. The purpose of this study was to compare the risk of TBI for adults with and without IDD in Ontario over time and by demographic information.
Using administrative health databases, two main cohorts were identified: (1) adults with IDD, and (2) a random 10% sample of adults without IDD. Within each cohort, annual crude and adjusted incidence of TBI were calculated among unique individuals for each fiscal year from April 1, 2002 to March 31, 2017.
Over the 15-year study period, the average annual adjusted incidence of TBI was approximately 2.8 new cases per 1000 among Ontario adults with IDD, compared to approximately 1.53 per 1000 among those without IDD. In both cohorts, a higher proportion of TBI cases were younger (19–29 years) and male.
During the study period, persons with IDD experienced a significantly higher risk of TBI compared to the general population indicating the possibility, and need, for targeted TBI prevention.
Parental acquired communication disability has long-lasting impacts on children, including increased child stress and behavioural problems. However, speech-language pathologists’ (SLPs) current practice in providing information, education and counselling support to these children is unknown. Therefore, we explored SLPs’ perceived needs, current practices and barriers and facilitators to working with children of people with acquired communication disability (PwCD).
An online survey sought information on Australian SLPs’ current practices in providing education and counselling to children of PwCD. Perceived barriers and facilitators were mapped to the COM-B, a model that considers Capability, Opportunity and Motivation as domains that influence behaviour.
75% of participants (n = 76) perceived a need to provide both information and counselling, but ‘never’ or ‘rarely’ provided either aspect of care. Barriers relating to ‘Opportunity’ were most frequently identified, such as not having access to children in therapy and lack of parental support/engagement. Capability (e.g., knowledge and skills) and Motivation (e.g., confidence) barriers were also identified.
There is potential for SLPs to provide services to children of PwCD either directly through information and/or counselling-type interactions or indirectly through referral to other services. This study highlights the need for more research into these areas of practice.
Traumatic brain injuries (TBIs) are an important cause of mortality and disability around the world. Early intervention and stabilization are necessary to obtain optimal outcomes, yet little is written on the topic in low- and middle-income countries (LMICs). The aim is to provide a descriptive analysis of patients with TBI treated by Service d’Aide Medicale Urgente (SAMU), the prehospital ambulance service in Kigali, Rwanda.
What is the incidence and nature of TBI seen on the ambulance in Kigali, Rwanda?
A retrospective descriptive analysis was performed using SAMU records captured on an electronic database from December 2012 through May 2016. Variables included demographic information, injury characteristics, and interventional data.
Patients with TBIs accounted for 18.0% (n = 2,012) of all SAMU cases. The incidence of TBIs in Kigali was 234 crashes per 100,000 people. The mean age was 30.5 (SD = 11.5) years and 81.5% (n = 1,615) were men. The most common mechanisms were road traffic incidents (RTIs; 78.5%, n = 1,535), assault (10.7%, n=216), and falls (7.8%, n=156). Most patients experienced mild TBI (Glasgow Coma Score [GCS] ≥ 13; 83.5%, n = 1,625). The most common interventions were provision of pain medications (71.0%, n = 1,429), placement of a cervical collar (53.6%, n = 1,079), and administration of intravenous fluids (48.7%, n = 979). In total, TBIs were involved in 67.0% of all mortalities seen by SAMU.
Currently, TBIs represent a large burden of disease managed in the prehospital setting of Kigali, Rwanda. These injuries are most often caused by RTIs and were observed in 67% of mortalities seen by SAMU. Rwanda has implemented several initiatives to reduce the incidence of TBIs with a specific emphasis on road safety. Further efforts are needed to better prevent these injuries. Countries seeking to develop prehospital care capacity should train providers to manage patients with TBIs.
Cortical spreading depolarization (CSD) is recognized as a cause of transient neurological symptoms (TNS) in various clinical entities. Although scientific literature has been flourishing in the field of CSD, it remains an underrecognized pathophysiology in clinical practice. The literature evoking CSD in relation to subdural hematoma (SDH) is particularly scarce. Patients with SDH frequently suffer from TNS, most being attributed to seizures despite an atypical semiology, evolution, and therapeutic response. Recent literature has suggested that a significant proportion of those patients’ TNS represent the clinical manifestations of underlying CSD. Recently, the term Non-Epileptical Stereoytpical Intermittent Symptoms (NESIS) has been proposed to describe a subgroup of patients presenting with TNS in the context of SDH. Indirect evidence and recent research suggest that the pathophysiology of NESIS could represent the clinical manifestation of CSD. This review should provide a concise yet thorough review of the current state of literature behind the pathophysiology of CSD with a particular focus on recent research and knowledge regarding the presence of CSD in the context of subdural hematoma. Although many questions remain in the evolution of knowledge in this field would likely have significant diagnostic, therapeutic, and prognostic implications.
To determine clinically meaningful subgroups of persons with traumatic brain injury (TBI) who have failed performance validity testing.
Study participants were selected from a cohort of 674 participants with definitive medical evidence of TBI. Participants were those who failed performance validity testing (the Word Memory Test, using the standard cutoffs). Participants were administered cognitive tests and self-report questionnaires. Test and questionnaire results were summarized as 12 dimension scores. Cluster analysis using the k-means method was performed.
Cluster analysis for the 143 retained participants indicated three subgroups. These subgroups differed on patterns of scores. Subgroup 1 was impaired for memory and had no excessive complaints. Subgroup 2 had impaired memory and processing speed as well as concern regarding cognition function. Subgroup 3 showed impairment on all cognitive tests and excess complaints in multiple areas.
These results provide a preliminary basis for improved understanding of poor performance validity.
To synthesise the current best evidence on both pharmacological and non-pharmacological behaviour management interventions for adult patients in the acute hospital setting with traumatic brain injury (TBI) or post-traumatic amnesia (PTA).
A comprehensive search of 10 electronic databases was completed.
Systematic reviews (SRs) published in English before September 2018 were included. Initial search resulted in 4604 citations, 2916 for title and abstract screening with duplicates removed, and 2909 articles failed to meet the inclusion criteria leaving seven reviews for inclusion. Five reporting pharmacological management approaches, two reporting non-pharmacological management approaches, and one reporting both pharmacological and non-pharmacological management approaches.
Methodological quality was assessed independently by two reviewers using the Critical Appraisal Skills Programme Tool for SRs. Data were extracted from the studies based on the recommendations of the Joanna Briggs Institute (JBI) Methodology for JBI Umbrella Reviews.
The SRs were of low-to-moderate quality overall. High-quality SRs were characterised by low numbers of studies and significant biases. The evidence relating to pharmacological interventions demonstrates low level and variable quality. The evidence relating to non-pharmacological interventions was limited and of low quality.
The current evidence for the management of challenging behaviours in patients with acute TBI/PTA is generally equivocal, potentially reflecting the heterogeneity of patients with TBI and their clinical behaviours. More studies with rigorous methodologies are required to investigate the most suitable pharmacological and non-pharmacological behavioural interventions for the acute phase of TBI or PTA.
Introduction: The primary objective of this study was to determine the incidence of clinically significant traumatic intracranial haemorrhage (T-ICH) following minor head trauma in older adults. Secondary objective was to investigate the impact of anticoagulant and antiplatelet therapies on T-ICH incidence. Methods: This retrospective cohort study extracted data from electronic patient records. The cohort consisted of patients presenting after a fall and/or head injury and presented to one of five ED between 1st March 2010 and 31st July 2017. Inclusion criteria were age ≥ 65 years old and a minor head trauma defined as an impact to the head without fulfilling criteria for traumatic brain injury. Results: From the 1,000 electronic medical records evaluated, 311 cases were included. The mean age was 80.1 (SD 7.9) years. One hundred and eighty-nine (189) patients (60.8%) were on an anticoagulant (n = 69), antiplatelet (n = 130) or both (n = 16). Twenty patients (6.4%) developed a clinically significant T-ICH. Anticoagulation and/or antiplatelets therapies were not associated with an increased risk of clinically significant T-ICH in this cohort (Odds ratio (OR) 2.7, 95% CI 0.9-8.3). Conclusion: In this cohort of older adults presenting to the ED following minor head trauma, the incidence of clinically significant T-ICH was 6.4%.
Present article introduces the case of a patient who had traumatic brain injury (TBI) in 2010. During examination V. demonstrated mild sensory aphasia, frontal lobes deficit, memory disorder, limiting beliefs, lack of adequate coping strategies, emotional reactions and disability to describe his feelings and body awareness.
Objectives and aim
Neuropsychological, correction and psychological counseling performance, considering neuropsychological deficit profile.
counseling was carried out over six weeks in the form of 2 hour sessions once a week. Speech perception impairment was taken into consideration. The process was started with frontal lobe deficit correction. Goal management training was used in conjunction with external control of distractions. Training in structured organization of information has highly improved memorization. Techniques of CBT were used to work with cognitive distortions, dysfunctional beliefs, and self-restricting behavior. Body-oriented therapy was offered to cope with stress factors and vegetative reactions.
V. compensated memory disorder using external sources and motivation. Some adaptive strategies of interaction with people and the outer world were formed. He improved time management skills and learned to follow the priority of current task without distractions. Moreover, he actively started to use body-oriented techniques to regulate his emotional condition. A considerable progress was achieved in understanding his limits and difficulties in everyday life.
Implementation of psychological consulting according to neuropsychological deficit profile may be effective in interdisciplinary holistic rehabilitation of patients after TBI.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Interhemispheric subdural hematomas (IHSDHs) are thought to be rare. Surgical management of these lesions presents a challenge as they are in close proximity to the sagittal sinus and bridging veins. IHSDHs are poorly characterized clinically and their exact incidence is unknown. There are also no clear guidelines for the management of IHSDH.
This is a retrospective review of all admitted patients with a diagnosis of traumatic brain injury over a 4-year period at a Level I trauma centre. Clinical characteristics of all patients with subdural hematoma (SDH) and IHSDH were collected.
Of 2165 admissions, 1182 patients had acute traumatic SDHs, 420 patients had IHSDHs (1.9% of admissions and 35.5% of SDH), 35 (8.3% of IHSDH) were ≥8 mm in width. IHSDH was isolated in 16 (3.8%) of the cases. Average age was 61.7 ± 21.5 years for all IHSDHs and 77.1 ± 10.4 for large IHSDH (p < 0.001). For large IHSDH, a transient loss of consciousness (LOC) occurred in 51.5% of individuals, post-traumatic amnesia (PTA) in 47.8% of cases, and motor weakness in 37.9% of patients. Five of the large IHSDH patients presented with motor deficits directly related to the IHSDH, and weakness resolved in four of these five individuals. None were treated surgically. Progression of IHSDH width occurred in one patient.
IHSDHs are often referred to as rare entities. Our results show they are common. Conservative management is appropriate to manage most IHSDHs, as most resolve spontaneously, and their symptoms resolve as well.
In Mexico, physicians have become part of public service prehospital care. Head injured patients are a sensitive group that can benefit from early advanced measures to protect the airway, with the objective to reduce hypoxia and maintain normocapnia.
The occurrence of endotracheal intubation to patients with severe head injuries by prehospital physicians working at Mexico City’s Service of Emergency Medical Care (SAMU) is unknown.
A retrospective analysis of five-year data (2012-2016) from Mexico City’s Medical Emergencies Regulation Center was performed. Only SAMU ambulance services were analyzed. Adult patients with a prehospital diagnosis of head injury based on mechanism of injury and physical examination with a Glasgow Coma Scale (GCS) <nine were included.
A total of 293 cases met the inclusion criteria; the mean GCS was five points. Of those, 150 (51.1%) patients were intubated. There was no difference in the occurrence of intubation among the different GCS scales, or if the patient was considered to have isolated head trauma versus polytrauma. Fifteen patients were intubated using sedation and neuromuscular blockage. Four patients were intubated with sedation alone and six patients with neuromuscular blockage alone. One patient was intubated using opioid analgesia, sedation, and neuromuscular blockage.
Patients with severe head injuries cared by prehospital physicians in Mexico City were intubated 51.1% of the time and were more likely to be intubated without the assistance of anesthetics.
Traumatic brain injury (TBI) is a main cause of death and disabilities in young adults. Although learning and memory impairments are a major clinical manifestation of TBI, the consequences of TBI on the hippocampus are still not well understood. In particular, how lesions to the sensorimotor cortex damage the hippocampus, to which it is not directly connected, is still elusive. Here, we study the effects of sensorimotor cortex ablation (SCA) on the hippocampal dentate gyrus, by applying a highly sensitive gray-level co-occurrence matrix (GLCM) analysis. Using GLCM analysis of granule neurons, we discovered, in our TBI paradigm, subtle changes in granule cell (GC) morphology, including textual uniformity, contrast, and variance, which is not detected by conventional microscopy. We conclude that sensorimotor cortex trauma leads to specific changes in the hippocampus that advance our understanding of the cellular underpinnings of cognitive impairments in TBI. Moreover, we identified GLCM analysis as a highly sensitive method to detect subtle changes in the GC layers that is expected to significantly improve further studies investigating the impact of TBI on hippocampal neuropathology.