Injury patterns, severity and outcomes among older adults who sustained brain injury following a same level fall: a retrospective analysis

INTRODUCTION

The objectives of this study were to: identify the incidence and types of brain injuries; classify brain injury severity; identify additional injuries; and identify predictors of length of stay, mortality and trauma center admission.

METHODS

This secondary analysis used the NY State Inpatient Databases Healthcare Cost and Utilization Project. Inclusion criteria were: age 65 years and older, admitted to a hospital following a same level fall, primary hospital discharge diagnosis of traumatic brain injury. Descriptive and regression analyses were performed.

RESULTS

3331 patient records were analyzed. Intracranial hemorrhage accounted for 70% of the brain injuries. Younger age, higher household income, insurance status, ethnicity, patient location, increasing number of chronic diseases and diagnoses predicted trauma center admission. Age, trauma center admission, comorbidities, and brain injury severity predicted mortality. Age, race, major surgery, and number of diagnoses predicted length of stay.

DISCUSSION

Brain injuries are common sequelae from falls among older adults. Additional research is needed to understand sociodemographic factors that are associated with trauma center admission.

A retrospective audit of hundred patients of orbitozygomatic fractures with brain injury

BACKGROUND

Orbitozygomatic fracture that most commonly accompanies craniofacial injury is a challenge for medical science to reduce complications and to attain aesthetically satisfying results.

OBJECTIVE

To summarize our experiences with the optimum management of orbito-zygomatic fractures.

MATERIALS AND METHODS

This retrospective study was aimed at investigating indications and surgical approaches for orbitozygomatic fractures with clinical follow-up, particularly with regard to postoperative complications. Since 2010, 100 cases with faciomaxillary injury were assessed for Orbitozygomatic fractures with the help of physical examination, non-invasive investigations including computed tomography of the orbit. Patients were retrospectively analysed for data, such as mechanism of injury, classification of fracture, and complications.

RESULTS

Amongst 100 consecutive patients with orbito-zygomatic fractures an overwhelming majority were males (n=83). In the age distribution a great majority (45%) were in 30-45 years age group, followed by 15-30 years (22%) and 45-60 years (18%). So in the productive age group i.e. 15-60 years age group were affected mostly (85%) in our series. Among different injury mechanism, Road traffic accident affected most (69%) that landed up in orbito-zygomatic fractures followed by altercations (22%). We preferred Open reduction and internal fixation (ORIF) for 68% of the patients with orbito- zygomatic fractures, followed by closed reduction (12%).

CONCLUSION

Ophthalmology consultation is recommended for all patients presenting with orbitozygomatic fractures, and is essential for patients with orbital blowout fractures, based on the high incidence of clinical ocular findings and injuries in this subgroup of patients.

Recovery over 6 months of medical decision-making capacity after traumatic brain injury

OBJECTIVE

To investigate recovery of medical decision-making capacity (MDC) over 6 months in persons with traumatic brain injury (TBI) stratified by injury severity.

DESIGN

Longitudinal study comparing controls and patients with TBI 1 month after injury (t1) and 6 months after injury (t2).

SETTING

Inpatient TBI rehabilitation unit and outpatient neurology department.

PARTICIPANTS

Participants (N=151) consisted of control subjects (n=60) and patients with TBI (n=91) stratified by injury severity: mild TBI (mTBI; n=27), complicated mild TBI (cmTBI; n=20), and moderate/severe TBI (msevTBI; n=44).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

We used the Capacity to Consent to Treatment Instrument to evaluate MDC performance on 5 consent standards (expressing choice, reasonable choice, appreciation, reasoning, and understanding). We also assigned capacity impairment ratings on the consent standards to each participant with TBI using cut scores referenced to control performance.

RESULTS

Control performance was stable across time on the consent standards. Patients with mTBI and cmTBI performed below controls on the understanding standard at t1 but not t2. Patients with msevTBI performed below controls on appreciation, reasoning, and understanding at t1, and on appreciation and understanding at t2, but showed substantial improvement over time.

CONCLUSIONS

Regardless of injury severity, all groups with TBI demonstrated baseline impairment of MDC with subsequent partial or full recovery of MDC over a 6-month period. However, a sizeable proportion of individual patients with TBI in each group continued to demonstrate capacity compromise at 6 months postinjury. Clinically, this finding suggests that individuals with TBI, regardless of injury severity, need continued monitoring regarding MDC for at least 6 months after injury.

Racial/ethnic disparities in mental health over the first 2 years after traumatic brain injury: a model systems study

OBJECTIVE

To determine whether racial/ethnic disparities occur in depression, anxiety, and satisfaction with life at 1 and 2 years postdischarge.

DESIGN

A prospective, longitudinal, multicenter study of individuals with traumatic brain injury (TBI) participating in the National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems project. Medical, demographic, and outcome data were obtained from the Model Systems database at baseline, as well as 1 and 2 years postdischarge.

SETTING

A total of 16 TBI Model Systems hospitals in the United States.

PARTICIPANTS

Individuals with moderate or severe TBI (N=1662) aged 16 years or older consecutively discharged between January 2008 and June 2011 from acute care and comprehensive inpatient rehabilitation at a Model Systems hospital.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

The Patient Health Questionnaire-9, Generalized Anxiety Disorder 7-item scale, and Satisfaction with Life Scale assessed depression, anxiety, and satisfaction with life at 1 and 2-year follow-ups.

RESULTS

After controlling for all possible covariates, hierarchal linear models found that black individuals had elevated depression across the 2 time points relative to white individuals. Asian/Pacific Islanders' depression increased over time in comparison to the decreasing depression in those of Hispanic origin, which was a greater decrease than in white individuals. Black individuals had lower life satisfaction than did white and Hispanic individuals, but only marginally greater anxiety over time than did white individuals and similar levels of anxiety as did Asian/Pacific Islanders and Hispanic individuals.

CONCLUSIONS

Mental health trajectories of individuals with TBI differed as a function of race/ethnicity across the first 2 years postdischarge, providing the first longitudinal evidence of racial/ethnic disparities in mental health after TBI during this time period. Further research will be required to understand the complex factors underlying these differences.

Utilization of behavioral therapy services long-term after traumatic brain injury in young children

OBJECTIVE

To examine associations of clinical need, defined by elevated parent ratings of child behavior problems and utilization of behavioral health services in young children with traumatic brain injury (TBI) and an orthopedic injury (OI) comparison group.

DESIGN

Parents completed outcome measures 18 months after injury and at an extended follow-up conducted an average of 38 months postinjury.

SETTING

Children's hospitals and a general hospital.

PARTICIPANTS

Participants included parents of 3 groups of children injured between 3 and 7 years of age (N=139): 47 children with complicated mild to moderate TBI, 18 with severe TBI, and 74 with OI.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Parents completed ratings of child behavior, mental health symptomology, and family functioning at both visits; at the extended follow-up, they reported utilization of behavior therapy or counseling services since the 18-month follow-up visit.

RESULTS

Children with TBI had more behavior problems than those with OI. Although clinical need at both follow-ups was associated with greater service utilization at the extended follow-up, all groups had unmet needs as defined by a clinical need in the absence of services. Lower socioeconomic status was associated with higher rates of unmet need across groups.

CONCLUSIONS

The results document unmet long-term behavioral health needs after both TBI and OI in children and underscore the importance of monitoring and treatment of postinjury behavior problems.

Adherence to guidelines for management of cerebral perfusion pressure and outcome in patients who have severe traumatic brain injury

PURPOSE

The aims of this study are to assess adherence to the Brain Trauma Foundation (BTF) cerebral perfusion pressure (CPP) guidelines and to determine if adherence is associated with mortality in patients who have a severe traumatic brain injury.

MATERIALS AND METHODS

Retrospective cohort study of 127 patients admitted to one intensive care unit between 2006 and 2012. Adherence to BTF guidelines was measured as the time that the CPP was within 50 to 70 mm Hg divided by the total time of CPP monitoring (CPP time index).

RESULTS

The percentage of time that the CPP was within the recommended range was 31.6% (SD, 22.2); CPP was greater than 70 mm Hg for 63.9% (SD, 26.2) of the time and less than 50 mm Hg for 4.5% of the time (SD, 16.3). After adjustment for covariates, CPP time index (between 50 and 70 mm Hg) was not associated with hospital mortality (odds ratio [OR], 1.2; 95% confidence interval [CI], 0.98-1.6; P= .079). The time indices for CPP ≥70 and <50 mm Hg were associated with decreased (OR, 0.66; 95%CI, 0.52-0.82; P< .0001) and increased (OR, 9.9; 95% CI, 1.4-69.6; P= .021) mortality, respectively.

CONCLUSION

Cerebral perfusion pressure was greater than 70 mm Hg for most of the time. This level of CPP was associated with decreased hospital mortality.

A pilot study of cerebrovascular reactivity autoregulation after pediatric cardiac arrest

AIM

Improved survival after cardiac arrest has placed greater emphasis on neurologic resuscitation. The purpose of this pilot study was to evaluate the relationship between cerebrovascular autoregulation and neurologic outcomes after pediatric cardiac arrest.

METHODS

Children resuscitated from cardiac arrest had autoregulation monitoring during the first 72h after return of circulation with an index derived from near-infrared spectroscopy in a pilot study. The range of mean arterial blood pressure (MAP) with optimal vasoreactivity (MAPOPT) was identified. The area under the curve (AUC) of the time spent with MAP below MAPOPT and MAP deviation below MAPOPT was calculated. Neurologic outcome measures included placement of a new tracheostomy or gastrostomy, death from a primary neurologic etiology (brain death or withdrawal of support for neurologic futility), and change in the Pediatric Cerebral Performance Category score (ΔPCPC).

RESULTS

Thirty-six children were monitored. Among children who did not require extracorporeal membrane oxygenation (ECMO), children who received a tracheostomy/gastrostomy had greater AUC during the second 24h after resuscitation than those who did not (P=0.04; n=19). Children without ECMO who died from a neurologic etiology had greater AUC during the first 48h than did those who lived or died from cardiovascular failure (P=0.04; n=19). AUC below MAPOPT was not associated with ΔPCPC when children with or without ECMO were analyzed separately.

CONCLUSIONS

Deviation from the blood pressure with optimal autoregulatory vasoreactivity may predict poor neurologic outcomes after pediatric cardiac arrest. This experimental autoregulation monitoring technique may help individualize blood pressure management goals after resuscitation.

Influence of self-efficacy and coping on quality of life and social participation after acquired brain injury: a 1-year follow-up study

OBJECTIVES

To investigate the relations linking self-efficacy and coping to quality of life (QOL) and social participation and what effect self-efficacy, changes in self-efficacy, and coping style have on long-term QOL and social participation.

DESIGN

Prospective clinical cohort study.

SETTING

General hospitals, rehabilitation centers.

PARTICIPANTS

Patients with newly acquired brain injury (ABI) (N=148) were assessed at baseline (start outpatient rehabilitation or discharge hospital/inpatient rehabilitation; mean time since injury, 15wk) and 1 year later (mean time since injury, 67wk).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

QOL was measured with the EuroQuol 5D (the EQ-5D index and the EQ-5D visual analog scale [EQ VAS]) and the 9-item Life Satisfaction Questionnaire (LiSat-9), social participation with the modified Frenchay Activities Index, coping with the Coping Inventory for Stressful Situations, and self-efficacy with the Traumatic Brain Injury Self-efficacy Questionnaire.

RESULTS

At baseline, self-efficacy moderated the effect of emotion-oriented coping on the EQ-5D index and of avoidance coping on the EQ VAS. Self-efficacy mediated the relation between emotion-oriented coping and LiSat-9. An increase in self-efficacy over time predicted better scores on the EQ-5D index (β=.30), the EQ VAS (β=.49), and LiSat-9 (β=.44) at follow-up. In addition, higher initial self-efficacy (β=.40) predicted higher LiSat-9 scores at follow-up; higher initial emotion-oriented coping (β=-.23) predicted lower EQ VAS scores at follow-up. Higher modified Frenchay Activities Index scores at follow-up were predicted by higher self-efficacy (β=.19) and higher task-oriented coping (β=.14) at baseline (combined R(2)=5.1%).

CONCLUSIONS

Self-efficacy and coping predict long-term QOL but seem less important in long-term social participation. High self-efficacy protects against the negative effect of emotion-oriented coping. Enhancing self-efficacy in the early stage after ABI may have beneficial long-term effects.

Systematic review and meta-analysis of noninvasive cranial nerve neuromodulation for nervous system disorders

OBJECTIVE

To systematically review the medical literature and comprehensively summarize clinical research done on rehabilitation with a novel portable and noninvasive electrical stimulation device called the cranial nerve noninvasive neuromodulator in patients suffering from nervous system disorders.

DATA SOURCES

PubMed, MEDLINE, and Cochrane Database of Systematic Reviews from 1966 to March 2013.

STUDY SELECTION

Studies were included if they recruited adult patients with peripheral and central nervous system disorders, were treated with the cranial nerve noninvasive neuromodulator device, and were assessed with objective measures of function.

DATA EXTRACTION

After title and abstract screening of potential articles, full texts were independently reviewed to identify articles that met inclusion criteria.

DATA SYNTHESIS

The search identified 12 publications: 5 were critically reviewed, and of these 5, 2 were combined in a meta-analysis. There were no randomized controlled studies identified, and the meta-analysis was based on pre-post studies. Most of the patients were individuals with a chronic balance dysfunction. The pooled results demonstrated significant improvements in the dynamic gait index postintervention with a mean difference of 3.45 (95% confidence interval, 1.75-5.15; P<.001), Activities-specific Balance Confidence scale with a mean difference of 16.65 (95% confidence interval, 7.65-25.47; P<.001), and Dizziness Handicap Inventory with improvements of -26.07 (95% confidence interval, -35.78 to -16.35; P<.001). Included studies suffered from small sample sizes, lack of randomization, absence of blinding, use of referral populations, and variability in treatment schedules and follow-up rates.

CONCLUSIONS

Given these limitations, the results of the meta-analysis must be interpreted cautiously. Further investigation using rigorous randomized controlled trials is needed to evaluate this promising rehabilitation tool for nervous system disorders.

Psychometric properties of the disorders of consciousness scale

OBJECTIVE

To provide evidence for psychometric properties of the Disorders of Consciousness Scale (DOCS).

DESIGN

Prospective observational cohort.

SETTINGS

Seven rehabilitation facilities.

PARTICIPANTS

Patients (N=174) with severe brain injury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE DOCS RESULTS

Initial analyses suggested eliminating 6 items to maximize psychometrics, resulting in the DOCS-25. The 25 items form a unidimensional hierarchy, rating scale categories are ordered, there are no misfitting items, and differential item functioning was not found according to sex, type of brain injury, veteran status, and days from onset. Person separation reliability (.91) indicates that the DOCS-25 is appropriate for individual patient measurement. Items are well targeted to the sample, with the difference between mean person and item calibrations less than 1 logit. DOCS-25 Rasch measures result in a 62% gain in relative precision over total raw scores. Internal consistency is very good (Cronbach α=.86); interrater agreement is excellent (intracIass correlation coefficient=.90) for both the DOCS-25 and the sensory subscales. The DOCS-25 total measure, but not subscale measures, correlates with the Glasgow Coma Scale and the Coma/Near-Coma Scales and distinguishes significantly between vegetative and minimally conscious states, indicating concurrent validity.

CONCLUSIONS

The DOCS-25 is psychometrically strong. It has excellent measurement precision and captures a broad range of patient function, which is critical for capturing recovery of consciousness. The sensory subscales are clinically informative but should not be reported as separate measures. The Keyform synthesizes clinical observations to visualize response patterns with potential for informing clinical decision-making. Future studies should determine sensitivity to change, examine issues of rater severity, and explore the usefulness of the Keyform in clinical practice.

Acute traumatic coagulopathy in the setting of isolated traumatic brain injury: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

Acute traumatic coagulopathy (ATC) has been reported in the setting of isolated traumatic brain injury (iTBI) and associated with high mortality and poor outcomes. The aim of this systematic review was to examine the incidence and outcome of patients with ATC in the setting of iTBI.

METHODS

We conducted a search of the MEDLINE database and Cochrane library, focused on subject headings and keywords involving coagulopathy and TBI. Design and results of each study were described. Studies were assessed for heterogeneity and the pooled incidence of ATC in the setting of iTBI determined. Reported outcomes were described.

RESULTS

There were 22 studies selected for analysis. A statistically significant heterogeneity among the studies was observed (p<0.01). Using the random effects model the pooled proportion of patients with ATC in the setting of iTBI was 35.2% (95% CI: 29.0-41.4). Mortality of patients with ATC and iTBI ranged between 17% and 86%. Higher blood transfusion rates, longer hospital stays, longer ICU stays, decreased ventilator free days, higher rates of single and multiple organ failure and higher incidence of delayed injury and disability at discharge were reported among patients with ATC.

CONCLUSIONS

ATC is commonly associated with iTBI and almost uniformly associated with worse outcomes. Any disorder of coagulation above the normal range appears to be associated with worse outcomes and therefore a clinically important target for management. Earlier identification of patients with ATC and iTBI, for recruitment into prospective trials, presents avenues for further research.

Social behaviour following severe traumatic brain injury: contribution of emotion perception deficits

OBJECTIVE

This theoretically driven study aimed to determine contribution of emotional perception impairments to social behaviour following traumatic brain injury (TBI).

METHODS

Adults with severe TBI (n = 24) participated. Emotion perception predictors included: (i) appraisal: Montreal Set of Facial Displays of Emotion, The Adapted Story Task, (ii) affective state: Depression, Anxiety and Stress Scale (DASS-21), Interpersonal Reactivity Index (IRI) and (iii) regulation: Delis Kaplan Executive Function System - Colour Word Interference and Word Fluency. Social behavioural outcomes were (i) interpersonal: Key Behaviors Change Inventory (KBCI) - Interpersonal Difficulties and (ii) communication: KBCI - Communication Problems.

RESULTS

Social behaviours correlated with affective state, but not appraisal or regulation. Simultaneous regression analyses revealed significant independent contributions of affective state: (i) the IRI Perspective Taking to the KBCI Interpersonal Difficulties and (ii) the DASS-21 (composite) and IRI Perspective Taking to the KBCI Communication Problems. The models explained 52% and 72% of the variance of the KBCI Interpersonal Difficulties and Communication Problems respectively.

CONCLUSIONS

This study provides evidence that impairments in certain aspects of emotion perception: affective state [empathy (perspective taking) and mood], but not appraisal and regulation, contribute to social behaviour difficulties in patients with severe TBI, which has important implications for rehabilitation.

New rehabilitation models for neurologic inpatients in Brazil

PURPOSE

To describe the effects of a rehabilitation program in a neurological inpatient unit in terms of independence for activities of daily living and return to work.

METHOD

Retrospective study with 148 adults with stroke, traumatic brain injury (TBI), spinal cord injury, and Guillain-Barré syndrome admitted as rehabilitation inpatients within a 1-year period for hospitalization at the Instituto de Reabilitação Lucy Montoro, Brazil. According to their diagnostic groups, subjects undergone semi-standardized models of intensive multidisciplinary rehabilitation for 4-6 weeks.

PRIMARY OUTCOME MEASURES

Functional Independence Measure (FIM), Modified Rankin scale (Rankin), and Glasgow Outcome Scale (GOS Subjects were evaluated at admission, discharge, and 6 months after discharge.

RESULTS

Improvement in motor FIM™, Rankin and GOS was observed in all groups. Cognitive FIM increase was less evident in TBI patients. After 6 months, 37.6% of patients were unemployed, 34% underwent outpatient rehabilitation, and 65.2% maintained gains.

CONCLUSIONS

This is the first report on the effects from an inpatients rehabilitation model in Brazil. After a short intensive rehabilitation, there were motor and cognitive gains in all groups. Heterogeneity in functional gains suggests more individualized programs may be indicated. Controlled studies are required with larger samples to compare inpatient and outpatient programs.

Individuals with chronic traumatic brain injury improve walking speed and mobility with intensive mobility training

OBJECTIVE

To determine the feasibility and impact of different dosages of Intensive Mobility Training (IMT) on mobility, balance, and gait speed in individuals with chronic traumatic brain injury (TBI).

DESIGN

Prospective, single group design with 3-month follow-up.

SETTING

University research laboratory.

PARTICIPANTS

Volunteer sample of participants with chronic TBI (N=10; ≥3 mo post-TBI; able to ambulate 3.05 m with or without assistance; median age, 35.4 y; interquartile range, 23.5-46 y; median time post-TBI, 9.91 y; interquartile range, 6.3-14.2 y). Follow-up data were collected for all participants.

INTERVENTIONS

Twenty days (5 d/wk for 4 wk), with 150 min/d of repetitive, task-specific training equally divided among balance; gait training; and strength, coordination, and range.

MAIN OUTCOME MEASURES

Pain and fatigue were recorded before and after each session to assess feasibility. Treatment outcomes were assessed before training (pre), after 10 sessions (interim), after 20 sessions (post), and at 3-months follow-up and included the Berg Balance Scale and gait speed.

RESULTS

Participants averaged 150.1±2.7 minutes per session. Median presession and postsession pain scores were 0 (out of 10) for 20 sessions; median presession fatigue scores ranged from 0 to 2.5 (out of 10); and postsession scores ranged from 3 to 5.5 (out of 10). Four outcome measures demonstrated significant improvement from the pretest to interim, with 7 out of 10 participants exceeding the minimal detectable change (MDC) for fast walking speed. At the posttest, 2 additional measures were significant, with more participants exceeding the MDCs. Changes in fast walking speed and Timed Up and Go test were significant at follow-up.

CONCLUSIONS

Limited fluctuations in pain and fatigue scores indicate feasibility of IMT in this population. Participants demonstrated improvements in walking speed, mobility, and balance postintervention and maintained gains in fast walking speed and mobility at 3 months.

Pulse pressure variations to guide fluid therapy in donors: a multicentric echocardiographic observational study

PURPOSE

Preload responsiveness parameters could be useful in the hemodynamic management of septic shock.

METHODS

A multicentric prospective echocardiographic observational study was conducted from March 2009 to August 2011. Clinically brain-dead subjects were included. Pulse pressure variations (ΔPPs) were recorded. Cardiac index, variation of the maximum flow velocity of aortic systolic blood flow, and right ventricular function parameters were evaluated via transthoracic echocardiography. Fluid responsiveness was defined by at least 15% cardiac index increase, 30 minutes after a 500-mL colloid solution infusion. The number of organs harvested was recorded.

RESULTS

Twenty-five subjects were included. Pulse pressure variation could not discriminate responders (n=15) from nonresponders (n=10). The best ΔPP threshold (20%) could discriminate responders with a sensitivity of 100% and a specificity of 40%. Variation of the maximum flow velocity of aortic systolic blood flow, tricuspid annular plane systolic excursion, and right ventricle dilation could not discriminate responders from nonresponders. Eighteen subjects underwent organ harvesting. The number of organs harvested was higher in responders (3.5 [3-5]) than in nonresponders (2.5 [2-3]; P=.03).

CONCLUSIONS

A ΔPP threshold of 13% is insufficient to guide volume expansion in donors. The best threshold is 20%. Fluid responsiveness monitoring could enhance organ harvesting.

[Rosai-Dorfman disease with spinal and cranial tumors. A clinical case reported]

Rosai-Dorfman disease, known as well as sinus histiocytosis with massive lymphadenopathy, is a histiocytic proliferative disorder which may affect, with an extranodal presentation, the central nervous system, in 5 % of cases with exceptional reports of simultaneous development of spinal and cranial tumors. When it affects the central nervous system it appears more in men and it is shown as a mass in the cranial dura mater or in the spinal cord. The clinical symptoms of Rosai-Dorfman disease are fever, general malayse, weight loss, and nocturnal diaphoresis. Also, when Rosai-Dorfman disease affects the spinal cord, it has an impact on the thoracic spine, which causes paraparesis, quadriparesis, and sensory disorder. Histopathologically, the lymph nodes show emperipolesis. The diagnosis of Rosai-Dorfman disease is usually good, since 40 % of the patients present a spontaneous remission if they are treated with oral corticosteroids, even though the lesion can be managed with fractionated radiotherapy or with radical surgery. We report the case of a 34-year-old male who started with spinal injuries, and a year later showed intracranial lesions.

Significance of intracranial pressure monitoring after early decompressive craniectomy in patients with severe traumatic brain injury

OBJECTIVE

Early decompressive craniectomy (DC) has been used as the first stage treatment to prevent secondary injuries in cases of severe traumatic brain injury (TBI). Postoperative management is the major factor that influences outcome. The aim of this study is to investigate the effect of postoperative management, using intracranial pressure (ICP) monitoring and including consecutive DC on the other side, on the two-week mortality in severe TBI patients treated with early DC.

METHODS

Seventy-eight patients with severe TBI [Glasgow Coma Scale (GCS) score <9] underwent early DC were retrospectively investigated. Among 78 patients with early DC, 53 patients were managed by conventional medical treatments and the other, 25 patients were treated under the guidance of ICP monitoring, placed during early DC. In the ICP monitoring group, consecutive DC on the other side were performed on 11 patients due to a high ICP of greater than 30 mm Hg and failure to respond to any other medical treatments.

RESULTS

The two-week mortality rate was significantly different between two groups [50.9% (27 patients) and 24% (6 patients), respectively, p=0.025]. After adjusting for confounding factors, including sex, low GCS score, and pupillary abnormalities, ICP monitoring was associated with a 78% lower likelihood of 2-week mortality (p=0.021).

CONCLUSION

ICP monitoring in conjunction with postoperative treatment, after early DC, is associated with a significantly reduced risk of death.

Rasch analysis of the community integration measure in persons with traumatic brain injury

OBJECTIVE

To examine the measurement properties of the Community Integration Measure (CIM) in persons with traumatic brain injury (TBI).

DESIGN

Rasch analysis was used to retrospectively evaluate the CIM.

SETTING

Rehabilitation hospital.

PARTICIPANTS

Persons (N=279) 1 to 15 years after a TBI.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

CIM RESULTS: The CIM met Rasch expectations of unidimensionality and reliability (person separation ratio=2.01, item separation ratio=4.52). However, item endorsibility was poorly targeted to the participants' level of community integration. A ceiling effect was found with this sample.

CONCLUSIONS

The CIM is a relatively reliable and unidimensional scale. Future iterations might benefit from the addition of items that are more difficult to endorse (ie, improved targeting).

Outcomes of a nontransfer protocol for mild traumatic brain injury with abnormal head computed tomography in a rural hospital setting

OBJECTIVE

This study sought to investigate outcomes after a novel nontransfer protocol for mild traumatic brain injuries patients with small intracranial hemorrhage (ICH) in a rural trauma center without neurosurgical capabilities.

METHODS

This was a retrospective cohort study. In 2007, a nontransfer protocol was implemented at a Level III Trauma Center. It included adult patients from April 2007 through December 2012 with mild traumatic brain injury (mTBI) (Glasgow Coma Scale score 13 to 15) and computed tomography (CT) showing small ICH and no coagulopathy. The following ICHs were allowed: 1) minimal or small traumatic subarachnoid hemorrhage, 2) punctuate or minimal superficial cerebral contusion, 3) punctuate or minimal intraparenchymal hemorrhage, or 4) very small subdural hemorrhage (SDH) without mass effect (a very thin smear SDH along the tentorium or falx). CT scans were reviewed by the on-call neurosurgeon at an affiliated Level I Trauma Center, and consensus was obtained on the suitability for nontransfer.

RESULTS

A total of 76 patients were included. The median hospital length of stay was 1 day (interquartile range = 1 day). No patient required a neurosurgical intervention or postadmission transfer to a Level I facility. There were no in-hospital deaths, and all patients were discharged with stable head CTs and in good neurologic condition. Two patients were readmitted for nonprotocol-related reasons: 1 acute-on-chronic SDH 6 weeks postdischarge, and 1 visual eye change with normal CT 2 days postdischarge.

CONCLUSIONS

Our 6-year study corroborates the low neurosurgical rate reported in the literature for mTBI with small ICH. Nontransfer protocols may lead to a more efficient use of hospital resources while providing safe, effective and economical health care.

Instrumenting the balance error scoring system for use with patients reporting persistent balance problems after mild traumatic brain injury

OBJECTIVE

To determine whether alterations to the Balance Error Scoring System (BESS), such as modified conditions and/or instrumentation, would improve the ability to correctly classify traumatic brain injury (TBI) status in patients with mild TBI with persistent self-reported balance complaints.

DESIGN

Cross-sectional study.

SETTING

Outpatient clinic.

PARTICIPANTS

Subjects (n=13; age, 16.3±2y) with a recent history of concussion (mild TBI group) and demographically matched control subjects (n=13; age, 16.7±2y; control group).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Outcome measures included the BESS, modified BESS, instrumented BESS, and instrumented modified BESS. All subjects were tested on the noninstrumented BESS and modified BESS and were scored by visual observation of instability in 6 and 3 stance conditions, respectively. Instrumentation of these 2 tests used 1 inertial sensor with an accelerometer and gyroscope to quantify bidirectional body sway.

RESULTS

Scores from the BESS and the modified BESS tests were similar between groups. However, results from the instrumented measures using the inertial sensor were significantly different between groups. The instrumented modified BESS had superior diagnostic classification and the largest area under the curve when compared with the other balance measures.

CONCLUSIONS

A concussion may disrupt the sensory processing required for optimal postural control, which was measured by sway during quiet stance. These results suggest that the use of portable inertial sensors may be useful in the move toward more objective and sensitive measures of balance control postconcussion, but more work is needed to increase sensitivity.

Community integration after traumatic brain injury: a systematic review of the clinical implications of measurement and service provision for older adults

OBJECTIVE

To explore the scope, reliability, and validity of community integration measures for older adults after traumatic brain injury (TBI).

DATA SOURCES

A search of peer-reviewed articles in English from 1990 to April 2011 was conducted using the EBSCO Health and Scopus databases. Search terms included were community integration, traumatic brain injury or TBI, 65 plus or older adults, and assessment.

STUDY SELECTION

Forty-three eligible articles were identified, with 11 selected for full review using a standardized critical review method.

DATA EXTRACTION

Common community integration measures were identified and ranked for relevance and psychometric properties. Of the 43 eligible articles, studies reporting community integration outcomes post-TBI were identified and critically reviewed. Older adults' community integration needs post-TBI from high quality studies were summarized.

DATA SYNTHESIS

There is a relative lack of evidence pertaining to older adults post-TBI, but indicators are that older adults have poorer outcomes than their younger counterparts. The Community Integration Questionnaire (CIQ) is the most widely used community integration measurement tool used in research for people with TBI. Because of some limitations, many studies have used the CIQ in conjunction with other measures to better quantify and/or monitor changes in community integration.

CONCLUSIONS

Enhancing integration of older adults after TBI into their community of choice, with particular emphasis on social integration and quality of life, should be a primary rehabilitation goal. However, more research is needed to inform best practice guidelines to meet the needs of this growing TBI population. It is recommended that subjective tools, such as quality of life measures, are used in conjunction with well-established community integration measures, such as the CIQ, during the assessment process.

Evaluation of the short-term executive plus intervention for executive dysfunction after traumatic brain injury: a randomized controlled trial with minimization

OBJECTIVE

To determine whether the Short-Term Executive Plus (STEP) cognitive rehabilitation program improves executive dysfunction after traumatic brain injury (TBI).

DESIGN

Randomized, waitlist controlled trial with minimization and blinded outcome assessment.

SETTING

Community.

PARTICIPANTS

Participants with TBI and executive dysfunction (N=98; TBI severity 50% moderate/severe; mean time since injury ± SD, 12±14y; mean age ± SD, 45±14y; 62% women; 76% white).

INTERVENTION

STEP program: 12 weeks (9h/wk) of group training in problem solving and emotional regulation and individual sessions of attention and compensatory strategies training.

MAIN OUTCOME MEASURES

Factor analysis was used to create a composite executive function measure using the Problem Solving Inventory, Frontal Systems Behavior Scale, Behavioral Assessment of the Dysexecutive Syndrome, and Self-Awareness of Deficits Interview. Emotional regulation was assessed with the Difficulties in Emotion Regulation Scale. The primary attention measure was the Attention Rating and Monitoring Scale. Secondary measures included neuropsychological measures of executive function, attention, and memory and measures of affective distress, self-efficacy, social participation, and quality of life.

RESULTS

Intention-to-treat mixed-effects analyses revealed significant treatment effects for the composite executive function measure (P=.008) and the Frontal Systems Behavior Scale (P=.049) and Problem Solving Inventory (P=.016). We found no between-group differences on the neuropsychological measures or on measures of attention, emotional regulation, self-awareness, affective distress, self-efficacy, participation, or quality of life.

CONCLUSIONS

The STEP program is efficacious in improving self-reported post-TBI executive function and problem solving. Further research is needed to identify the roles of the different components of the intervention and its effectiveness with different TBI populations.

Education attenuates the negative impact of traumatic brain injury on cognitive status

OBJECTIVE

To investigate whether the cognitive reserve hypothesis helps to explain differential cognitive impairment among survivors of traumatic brain injury (TBI), whereby survivors with greater intellectual enrichment (estimated with education) are less vulnerable to cognitive impairment.

DESIGN

Cross-sectional study.

SETTING

Medical rehabilitation research center.

PARTICIPANTS

Survivors of moderate or severe TBI (n=44) and healthy controls (n=36).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Intellectual enrichment was estimated with educational attainment. Group was defined as TBI or healthy control. Current cognitive status (processing speed, working memory, episodic memory) was evaluated with neuropsychological tasks.

RESULTS

TBI survivors exhibited worse cognitive status than healthy persons (P<.001), and education was positively correlated with cognitive status in TBI survivors (r=.54, P<.001). Most importantly, regression analysis revealed an interaction between group and education (R(2) change=.036, P=.004), whereas higher education attenuated the negative impact of TBI on cognitive status. TBI survivors with lower education performed much worse than matched healthy persons, but this TBI-related performance discrepancy was attenuated at higher levels of education.

CONCLUSIONS

Higher intellectual enrichment (estimated with education) reduces the negative effect of TBI on cognitive outcomes, thereby supporting the cognitive reserve hypothesis in persons with TBI. Future work is necessary to investigate whether intellectual enrichment can build cognitive reserve as a rehabilitative intervention in survivors of TBI.

Long-term disability and survival in traumatic brain injury: results from the National Institute on Disability and Rehabilitation Research Model Systems

OBJECTIVES

To document long-term survival in 1-year survivors of traumatic brain injury (TBI); to compare the use of the Disability Rating Scale (DRS) and FIM as factors in the estimation of survival probabilities; and to investigate the effect of time since injury and secular trends in mortality.

DESIGN

Cohort study of 1-year survivors of TBI followed up to 20 years postinjury. Statistical methods include standardized mortality ratio, Kaplan-Meier survival curve, proportional hazards regression, and person-year logistic regression.

SETTING

Postdischarge from rehabilitation units.

PARTICIPANTS

Population-based sample of persons (N=7228) who were admitted to a TBI Model Systems facility and survived at least 1 year postinjury. These persons contributed 32,505 person-years, with 537 deaths, over the 1989 to 2011 study period.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Survival.

RESULTS

Survival was poorer than that of the general population (standardized mortality ratio=2.1; 95% confidence interval, 1.9-2.3). Age, sex, and functional disability were significant risk factors for mortality (P<.001). FIM- and DRS-based proportional hazards survival models had comparable predictive performance (C index: .80 vs .80; Akaike information criterion: 11,005 vs 11,015). Time since injury and current calendar year were not significant predictors of long-term survival (both P>.05).

CONCLUSIONS

Long-term survival prognosis in TBI depends on age, sex, and disability. FIM and DRS are useful prognostic measures with comparable statistical performance. Age- and disability-specific mortality rates in TBI have not declined over the last 20 years. A survival prognosis calculator is available online (http://www.LifeExpectancy.org/tbims.shtml).

Disorders of consciousness: outcomes, comorbidities, and care needs

Over the last decade, research on patients with disorders of consciousness (DOC) has suggested that their prognosis for functional recovery early after injury is surprisingly positive, particularly for those with traumatic etiologies; that meaningful recovery proceeds for longer intervals than previously appreciated; and that such individuals are often medically complex and challenging to manage. However, access to intensive specialty rehabilitation is limited for most individuals with DOC in the United States. The evolving understanding of DOC calls for a reconsideration of appropriate models of care. This collection of articles provides insight into the functional recovery of individuals with DOC, new tools for assessing prognosis, and the patterns of comorbidity that complicate the recovery process. In addition, models of care from the United States and Europe that attempt to address the needs of patients as well as their caregivers are presented.