The Postconcussion Syndrome and the Sequelae of Mild Head Injury

Psychosis

Psychosis is the term used to describe a mental state of dysfunction in behavior and thought processes. In patients with psychoses, mental capacity is grossly distorted and thought is disorganized. These factors cause an inability to recognize reality or relate to others in a meaningful way. A medical cause is found in approximately 20% of patients with acute psychosis. Emergency medicine physicians must differentiate psychotic symptoms caused by general medical conditions from psychosis caused by a primary psychiatric disorder. A careful evaluation must be performed to identify the cause of the psychosis. Correction of reversible causes, sedation, and appropriate disposition are the keys to the successful management of these patients.

Neuropsychiatric sequelae of traumatic brain injury

The authors review the psychiatric disturbances associated with traumatic brain injury. They highlight the close link between traumatic brain injury and psychiatry and provide an overview of the epidemiology, risk factors, classification, and mechanisms of traumatic brain injury. They describe various neuropsychiatric sequelae, and the respective treatments are outlined with emphasis on a multidisciplinary approach.

Minor head injury: predicting follow-up after discharge from the Emergency Department

BACKGROUND

Up to 50% of ED patients discharged within a minor head injury (MHI) will develop postconcussive syndrome (PCS) within 1 month of injury. The follow-up visit is an important opportunity to identify and treat PCS before it becomes persistent.

OBJECTIVE

To identify factors predictive of follow-up (FU) after ED discharge in patients presenting with MHI.

METHODS

Prospective, observational study of a convenience sample of 71 MHI presenting within 24 hours of injury to the ED of a university teaching hospital between February 1996 and October 1997. MHI defined as loss of consciousness not greater than 10 minutes or amnesia, GCS 15, no skull fracture on PE, no new focality to neurologic exam and no brain injury on CT if one was done. Neurobehavioural test scores, clinical information and demographic data collected via use of standardized patient encounter form. All patients were discharged with written instructions to FU with their private physician within 1-2 weeks. Patients without a follow-up physician were assigned one. At 1 month post-injury, all patients were telephoned to determine if they had followed-up.

ANALYSIS

Stepwise, multivariate, logistic regression.

RESULTS

Thirty one out of 71 (43.7%) reported FU with a physician within 1 month. Factors associated with FU were performance of a head CT in the ED (OR = 3.58, 95% CI = 1.12-11.37), associated laceration (OR = 8.84, 95% CI = 1.69-42.55), female gender (OR = 3.19, 95% CI = 1.04-9.82), and African-American race (OR = 0.36, 95% CI = 0.13-0.99).

CONCLUSIONS

Several factors predict FU after ED discharge for MHI. Patients unlikely to FU may benefit from an assessment of PCS risk before they leave the ED.

Acute traumatic brain injury in amateur boxing

Via neuropsychological testing, this research team found post-match cognitive impairment in amateur boxers despite the fighters' use of headgear.

BACKGROUND

Acute traumatic brain injury (ATBI) represents the neurologic consequence of concussive and subconcussive blows to the head. Evidence suggests that ATBI may be associated with boxing and collision sports such as American football and soccer, thus potentially exposing millions of athletes annually.

OBJECTIVE

The objectives of this study were to determine whether significant ATBI occurs in boxers who compete and, if present, the nature of the cognitive impairment. A secondary objective was to determine if headgear could reduce the risk for ATBI in amateur boxing.

DESIGN

In this inception cohort study, 38 amateur boxers underwent neuropsychological examination before and shortly after a boxing match and were compared with a control group of 28 amateur boxers who were tested before and after a comparable physical test. The main outcome measures were neuropsychological tests (memory, mental and fine-motor speed, planning, and attention) proven to be sensitive to cognitive changes incurred in contact and collision sports.

RESULTS

The boxers who competed exhibited an ATBI pattern of impaired performance in planning, attention, and memory capacity when compared with controls. They had significantly different findings in the Categorization Task Test (P = 0.047); Digit Symbol Test (P = 0.02); Logical Memory: Short Term Memory and Long Term Memory subtests (both tests, P < 0.001); and Visual Reproduction: Short Term Memory subtest (P < 0.001) and Long Term Memory subtest (P < 0.03).

CONCLUSION

Participation in amateur boxing matches may diminish neurocognitive functioning despite the use of headgear. The neurocognitive impairment resembles cognitive symptoms due to concussions. Guidelines are needed to reduce the risk for repeated ATBI.

Effects of acute injury characteristics on neuropsychological status and vocational outcome following mild traumatic brain injury

Despite recent attempts to define acute injury characteristics of mild traumatic brain injury (MTBI), neuropsychological outcome is often unpredictable. One hundred MTBI cases were prospectively collected, which were consecutive referrals to a concussion clinic, and the roles of various acute neurologic variables were examined in relation to neuropsychological status and vocational outcome. Significant differences were found between subgroups of patients classified by (1) mechanism of injury (i.e. acceleration/deceleration trauma in which the head strikes an object (HSO) versus acceleration/deceleration trauma in which the head does not strike an object (HNSO) versus trauma in which an object strikes the head (OSH), and (2) type of injury (i.e. motor vehicle collision, fall, assault, motor vehicle-pedestrian collision, falling object, sports/recreation). There was no difference, with respect to neuropsychological status or vocational outcome, between patients who had positive findings on computerized tomography (CT) versus those who were CT negative. Additionally, there was no difference between patients who had suffered brief loss of consciousness (LOC) and those without LOC. These findings suggest that selective acute injury characteristics may be used to classify subtypes of MTBI patients.

Assessment of Mild Head Injury with ERPs and Neuropsychological Tasks

Abstract Mild head injury can result in the development of persistent symptoms including impairments of memory and attention in a small but significant minority. The problem in assessing these difficulties in such cases is the likely interaction of psychogenic and organic causes. The aim of the present research is to more accurately characterize the nature of these cognitive deficits. Twelve asymptomatic volunteers, who had experienced a mild head injury in the last 3.5 years, were compared to a matched control group. ERPs were recorded during the performance of the paced auditory serial addition task (PASAT) and a 3-stimulus auditory “oddball” task. Verbal paired associate. Trails A and B, Digit Symbol, Rey Figure Recall, NART, and Digit Span were also administered. The mild head injured group showed evidence of a mild impairment of episodic memory, slowing of attention shifting, but no changes in reaction time or error rates in either the “oddball” task or the PASAT. Although there was no evidence of impairment of brain orienting responses in the 3-stimulus auditory oddball task, there was evidence of reduced frontal negativity associated with changes in task demand in the PASAT. This particular ERP feature appears similar to those associated with activation of selective attention mechanisms, thus suggesting that these asymptomatic individuals may be showing signs of a mild impairment of allocation of attention resources.

[Chronic post-traumatic headache after mild head injuries]

Current evidence indicates that chronic post-traumatic headache (cPTH) has organic causes. Nevertheless, these patients are considered as neurotics or malingering by health professionals, mainly if the headache originates from mild head injuries (MHI). Our aim was to identify the features of cPTH after MHI. We studied 27 consecutive patients fulfilling the criteria established for cPTH and MHI. Headache began on the same day of the trauma in 51.8% of patients. The clinical features allowed the following diagnosis: migraine (70.3%); tension type headache (51.8%); cervicogenic headache (11.1%). Concomitance of migraine and tension type headache was found in 29.6%. Thirty three percent of employees, 40% of housewives and 50% of students in our series referred prejudice in their productive activities. However, only three patients (11.1%) were claiming for compensation. The lack of potential gain and the uniformity of the clinical presentation are suggestive that the cPTH has an organic cause.

Epidemiology and pathogenesis of posttraumatic headache

This article presents an overview of the epidemiology and pathophysiology of posttraumatic headache. It reviews definitions of mild head injury (MHI), mild traumatic brain injury (MTBI), and concussion, and discusses the confusion that often occurs with these terms. Headache types and their pathophysiology are examined in detail. Just as the exact pathophysiology is unknown for migraine and other types of headache, the exact pathophysiology of headache after trauma is also still unknown in many cases. Possible connections between head or neck injuries and headache are reviewed, as well as hypothesized neurochemical changes that may occur in both migraine and traumatic brain injury (TBI). Psychological and legal factors are also considered.

Evaluation of the patient with closed head trauma: an evidence based approach

This article approaches the subject of closed head trauma from the time-sensitive vantage point of the emergency physician. As the clinical scenario unfolds, he or she constantly evaluates the need for diagnostic tests as information is received from paramedics, nurses, and the history and physical examination. This article provides a synopsis and a critique of original clinical trials to aid the emergency physician in making an evidence based decision.

An evaluation of subjective and objective measures of fatigue in patients with brain injury and healthy controls

Three self-report scales and an objective measure were examined for their value in assessing fatigue in patients with brain injury. Patients with brain injury and healthy controls completed the Fatigue Impact Scale (FIS), Visual Analogue Scale for Fatigue (VAS-F) and Fatigue Severity Scale (FSS). Fatigue was objectively measured via a continuous thumb pressing task. Patients scored higher on all fatigue measures than did participants without brain injury. Significant group differences were found on the FIS, the vigour subscale of the VAS-F, and the FSS. The FIS provided a comprehensive assessment of patients' fatigue experience. The FSS, although differentiating between groups, did not provide as comprehensive an examination of fatigue as the FIS and the scale's internal consistency requires review. No significant group differences in fatigue ratings were found on the VAS-F, possibly due to the scale's failure to differentiate between fatigue and sleepiness. The objective measure of fatigue found patients with brain injury fatigued more quickly than participants without brain injury. Although group differences were not significant, this trend suggest that further examination of this fatigue measure is warranted. Overall, patients with brain injury were found to experience significant levels of fatigue and the FIS provided the most comprehensive examination of fatigue.

Nonepileptic posttraumatic seizures

PURPOSE

Epileptic posttraumatic seizures (PTSs) are a well-recognized consequence of head injury (HI), but HI and nonepileptic seizures (NESs) have not been related. We describe a significant subset of patients with NESs who had their seizures attributed to HI.

METHODS

We reviewed the records of all patients diagnosed with NES at the University of Maryland Medical Center over a 6-year period (1989-1995) and selected patients with seizures attributed to a head injury occurring < or =3 years before the onset of their seizures.

RESULTS

Of 157 patients with video-EEG confirmed NES, 37 (24%) had the onset of their seizures attributed to an HI. Their average age was 34 years (range, 15-56 years); 68% were women. Nonepileptic PTS usually developed within the first year after HI (89%). Convulsive symptoms were present in 54%. Whereas epileptic PTSs characteristically follow severe HI, the majority (78%) of our patients with nonepileptic PTSs sustained only mild HI. Before their HI, 76% of our patients were employed, working in the home, or students, but only 11% could continue those activities after developing nonepileptic PTSs.

CONCLUSIONS

Nonepileptic PTSs are frequently mistaken for epileptic PTSs and result in serious disability. The misdiagnosis of nonepileptic PTSs leads to ineffective and inappropriate treatment. Patients with intractable seizures after HIs, particularly mild HIs, should be carefully evaluated for NESs.

The management of minor traumatic brain injury

Minor traumatic brain injury accounts for the majority of the one million head trauma attendances at A&E departments in the United Kingdom. Guidelines have been established listing criteria for skull films, admission to hospital, computed tomography, and neurosurgical consultation. These are currently undergoing revision and were the subject of a satellite symposium to the J Douglas Miller memorial meeting held in October 1996 in Edinburgh. In the East Anglia Region the current guidelines have been issued as memo-cards for A&E officers. The aim of admission is to observe for deterioration, predominantly caused by intracranial haematomas. The indicators for the development of such lesions are an impaired level of consciousness and presence of a skull fracture. Such patients should therefore undergo regular and frequent neurological observations, and be admitted for at least 12 hours. Following discharge, routine follow up should be considered to identify and treat patients with postconcussion symptoms and signs. The possible way forward for the management of these patients is adopting a greater emphasis on preventative aspects, and establishing, implementing, and auditing evidence based guidelines. Improved teaching in the form of formal induction seminars and computerised teaching aids is required, and a better understanding of the aetiology and treatment of the postconcussion syndrome.

Mild head trauma

Patients with mild traumatic brain injury constitute the overwhelming majority of head-injured patients seen in the emergency department. The indications for radiologic imaging in these patients are still undergoing study and revision. The Glasgow Coma Scale is a widely used triage score for head injury, but is less useful at identifying which patients with mild head injuries have intracranial pathology. There have been several retrospective studies and a few prospective studies examining the indications for imaging in mild to moderate head trauma. They all show that it is not easy to predict which patients will have CT abnormalities, and that some of these patients do go on to require neurosurgery. No set of clinical predictors have yet been put together that is capable of identifying all patients who are safe to be discharged without a CT scan. Pharmacologic therapy to help reduce axonal damage after head trauma and thus minimize the postconcussive sequelae of mild traumatic brain injury remains a challenge for physicians and neurobiologists into the next century.

Longitudinal sleep EEG power spectral analysis studies in adolescents with minor head injury

Power spectral analysis (PSA) was used to evaluate the longitudinal overnight electroencephalographic (EEG) sleep recordings of eight subjects, between the ages of 15 and 19 years, who had sustained a minor head injury (MHI). Recordings occurred within 72 h, 6 weeks, and 12 weeks following MHI. A conditioning night preceded the first study night during which EEG electrodes were in place and subjects slept at least 7.5 h with a mean sleep efficiency of 91%. PSA was performed on four channels of EEG data recorded from fronto-temporal (F3-T3, F4-T4), and temporal (T3-T5, T4-T6) electrodes. The three waveforms associated with sleep, Delta, Theta, and Alpha-1 were all significantly elevated within 72 h post-MHI. Over time all wave forms decreased in mean log power. Theta in rapid eye movement (REM) sleep Cycle 1 decreased significantly within 6 weeks postinjury. The greatest number of significant changes, over the 12-week period were recorded during the non-REM (NREM) sleep. Changes included (1) significant decreases in mean log power of Theta and Alpha-1 in Cycle 1 from fronto-temporal leads; (2) significant decreases in Delta, Theta, and Alpha-1 in Cycle 2 from fronto-temporal leads, and (3) significant decreases in Delta and Theta for consistency during Cycle 2 from temporal leads. The intrusion of Theta into the first REM cycle within 6 weeks and its subsequent decrease within 6 weeks suggested the initiation of recovery toward baseline values. This was followed by decreased levels of Theta power during NREM Cycles 1 and 2, and Delta power in Cycle 2, both of which approached their lowest levels within 12 wks. The decrease in Alpha-1 power occurred last. Alpha-1 remained elevated through both Cycles 1 and 2 of the 6th week and then showed a precipitous decrease between the sixth and twelfth week. These findings suggested that following MHI, the brain has a specific sequence of recovery as illustrated by Delta, Theta, and Alpha-1 powers requiring different time frames to reach their lowest levels.

Readiness to change alcohol drinking habits after traumatic brain injury

OBJECTIVE

To describe how motivated are persons with recent traumatic brain injury (TBI) to change their alcohol drinking habits and what factors affect their motivation.

DESIGN

Survey.

SETTING

Acute inpatient rehabilitation program.

PATIENTS

Subjects were 50 patients with recent TBI during inpatient rehabilitation.

MAIN OUTCOME MEASURES

Readiness to Change (RTC) questionnaire, Michigan Alcoholism Screening Test (MAST), and alcohol use questions.

RESULTS

Subjects were 36 years old; 86% were men. Eighty-four percent fell in the contemplation or action phases. Comparisons with a separate medical patient sample suggested that TBI may be associated with greater contemplation of change and greater readiness to take action to change alcohol use. Multivariate analyses indicated that within the TBI sample a positive history of alcoholism, alcohol involved in the accident, and higher daily consumption were associated with greater readiness to change (especially contemplation scores).

CONCLUSIONS

Soon after TBI, drinkers frequently contemplate changing their alcohol use. This situation may represent an underutilized window of opportunity to reduce postinjury alcohol use and abuse. Motivational interviewing techniques seem well suited to facilitate change during this period.

Does routine follow up after head injury help? A randomised controlled trial

OBJECTIVE

To evaluate the Medical Disability Society's 1988 recommendation that "every patient attending hospital after a head injury should be registered and offered an outpatient follow up appointment" by determining whether offering a routine follow up service to patients presenting to hospital with a head injury of any severity affects outcome six months later.

DESIGN

A randomised controlled trial design with masked assessment of outcome.

SETTING

A mixed rural and urban health district with a population of about 560000.

PATIENTS

1156 consecutive patients resident in Oxfordshire aged between 16 and 65 years presenting over 13 months to accident and emergency departments or admitted to hospital and diagnosed as having a head injury of any severity, including those with other injuries.

INTERVENTIONS

Patients were registered and randomised to one of two groups. Both groups continued to receive the standard service offered by the hospitals. The early follow up group were approached at 7-10 days after injury and offered additional information, advice, support, and further intervention as needed. All randomised patients were approached for follow up assessment six months after injury by independent clinicians blind to their group.

MAIN OUTCOME MEASURES

Validated questionnaires were used to elicit ratings of post-concussion symptoms (the Rivermead postconcussion symptoms questionnaire), and changes in work, relationships, leisure, social, and domestic activities (the Rivermead head injury follow up questionnaire).

RESULTS

The two groups were comparable at randomisation. Data was obtained at six months on 226 of 577 "control" patients and 252 of 579 "trial" patients (59% were lost to follow up). There were no significant differences overall between the trial and control groups at follow up, but subgroup analysis of the patients with moderate or severe head injuries (posttraumatic amnesia > or = one hour, or admitted to hospital), showed that those in the early intervention group had significantly fewer difficulties with everyday activities (P = 0.03).

CONCLUSIONS

The results from the 41% of patients followed up do not support the recommendation of offering a routine follow up to all patients with head injury, but they do suggest that routine follow up is most likely to be beneficial to patients with moderate or severe head injuries. Some of those with less severe injuries do continue to experience difficulties and need access to services. A further trial is under way to test these conclusions.

Posttraumatic movement disorders after moderate or mild head injury

We examined the occurrence of posttraumatic movement disorders after moderate or mild head injury with a three-level follow-up study including questionnaires, telephone interviews, and personal examinations 4-6 years after the trauma (mean 5.2 years). Sixteen of 158 patients (10.1%) for whom a detailed follow-up was available had developed movement disorders most probably related to craniocerebral trauma. The most frequent finding was a low-amplitude postural/intention tremor that appeared to resemble enhanced physiological or essential tremor. Twelve patients reported transient tremor, two patients had persistent tremor, one patient had transient tremor and persistent hyperekplexia, and another patient had mild persistent cervical myoclonic twitches. Overall, the movement disorder was transient in 12 patients (7.6%) and persisted in only 4 patients (2.6%). These movement disorders were not disabling and did not require medical therapy. Taking into account possible bias by selection of the sample group, the frequency of movement disorders secondary to moderate or mild head trauma might be lower than 10.1%. Posttraumatic movement disorders occurred significantly more often in the group of patients with Glasgow Coma Scores between 9 and 14 than in those with a score of 15. Severe movement disorders such as low-frequency kinetic tremor or hemidystonia were not identified in this survey.

Sleep complaints in chronic postconcussion syndrome

This study was designed to identify the incidence of sleep complaints in 39 patients with chronic postconcussion syndrome compared to those of a control group of 27 patients with orthopedic injuries. Patients with orthopedic injuries were selected as a comparison group to control for the effects of traumatic injury or chronic pain. There were no differences in age, sex distribution, or time from injury between the patient groups. Type and frequency of sleep disturbances in a mean two-year postinjury period were evaluated. Patients with chronic postconcussion syndrome reported more difficulty in initiating and maintaining sleep at night and greater difficulty with sleepiness during the day.

Sleep and pain complaints in symptomatic traumatic brain injury and neurologic populations

OBJECTIVE

To compare the incidence of sleep and pain complaints in symptomatic traumatic brain injury (TBI) (mild vs moderate/severe) and neurologic populations.

DESIGN

Case-control study.

SETTING

Outpatient neuropsychology service at a university-affiliated tertiary care center.

PATIENTS

A consecutive sample of mild (n = 127) and moderate to severe (n = 75) patients with TBI and a general neurologic (non-TBI) group (n = 123) referred for neuropsychological assessment.

MAIN OUTCOME MEASURES

Patient report of sleep and/or pain problems.

RESULTS

TBI subjects had significantly more insomnia (56.4% vs 30.9%) and pain complaints (58.9% vs 22%) than non-TBI subjects (p < .0001). For both subject groups, the presence of pain increased insomnia approximately twofold. Poor sleep maintainance was the most common sleep problem. In those subjects without pain, TBI patients reported more sleep complaints that non-TBI patients (p = .05). Mild TBI patients reported significantly (p < .0001) more pain than patients with a moderate to severe injury (70% vs 40%). In TBI subjects without pain, there were significantly more insomnia complaints in mild than in moderate to severe injuries (p < .01).

CONCLUSIONS

TBI patients with persistent cognitive complaints have more sleep and pain concerns than general neurologic patients. Pain is strongly associated with sleep problems. Aggressive evaluation and treatment of pain and sleep problems in the TBI, especially mild TBI, population appears warranted and may contribute to increased disability. The etiology of greater sleep and pain problems in the mild than in the more severe TBI patients requires further study.

A taxonomy of neurobehavioral functions applied to neuropsychological assessment after head injury

Neuropsychological dysfunctions after traumatic brain injury are classified into a taxonomy to plan a comprehensive examination, and organize and report findings for diagnosis and treatment: consciousness, information processing, sensorimotor, neurophysiological, cerebral personality disorders, intelligence, memory, language, stress, psychodynamic, identity and weltanschauung, adaptation, complex adaptive functions, and development of children. Wide-range sampling enhances the detection of acute and late-developing dysfunctions, and diagnosis of complex syndromes. Historical, personality, and injury data are components of the assessment. Issues discussed include underestimation of brain injury, malingering, interaction of symptoms, symptom persistence, and noncerebral lesional contributors to impairment after mild head injury.

Long-term persisting cognitive sequelae of traumatic brain injury and the effect of age

This study examined the notion that mild to moderate traumatic brain injury (TBI) may have persistent effects that become evident upon neurocognitive testing in a phase in which the effects of physiological aging become manifest. Neurocognitive performance was tested in 25 middle-aged and 20 old subjects who had sustained mild to moderate TBI, on average, several decades earlier. The TBI subjects regarded themselves as normal and healthy. The performance of the TBI subjects was inferior to that of matched healthy controls on all aspects of primary and secondary memory and on the majority of tests used to measure speed of performance. There was no interaction between the effects of TBI and those of age, and the performance of middle-aged TBI subjects was similar to that of old controls. The results are taken to indicate that TBI sustained earlier in life may cause permanent sequelae in specific domains of cognitive functioning and that it might attenuate the age-related decline in cognitive functioning. Most striking, however, was that these deficits were not perceived as a limiting factor in everyday life, which suggests that coping strategies may be important.

Emotional, neuropsychological, and organic factors: their use in the prediction of persisting postconcussion symptoms after moderate and mild head injuries

BACKGROUND

After mild and moderate head injuries a range of postconcussion symptoms (PCS) are often reported by patients. Both organic and psychogenic factors can contribute to these. Full recovery from PCS usually occurs within three months of the injury. A significant minority, however, continue to experience symptoms beyond this time. To date, no means of identifying these patients early after injury has been reported. This study investigates whether a combination of neuropsychological, emotional, and traditional measures of severity of head injury taken early after the injury can help predict severity of PCS three months after injury.

METHODS

50 patients with mild or moderate head injury had a range of measures administered at 7-10 days after injury. These included three tests of divided attention, a PCS rating scale-the Rivermead postconcussion symptoms questionnaire (RPQ), the hospital anxiety and depression scale (HADS), the impact of event scale (IES), and post-traumatic amnesia. An RPQ was then completed by all patients three months after injury.

RESULTS

Stepwise multiple regression analysis was performed with the RPQ score at three months as the dependent measure. A combination of eight of the scores from the early measures gave a multiple correlation coefficient of R = 0.86 accounting for 74% of the variance in RPQ scores. The most predictive individual measures were the HADS and IES. Regression analysis with RPQ score at 7-10 days as dependent measure showed that 10 of the scores gave a coefficient of R = 0.84 accounting for 71% of the variance.

CONCLUSIONS

A combination of measures may significantly aid the prediction of persistent PCS. Five measures: HADS, post-traumatic amnesia, SOMC, PASAT, and RPQ are recommended for their predictive value and clinical utility. Independent cross validation studies are required before these results can be generally applied. They do, however, provide valuable indications regarding those measures that are most likely to demonstrate utility.

The Rivermead head injury follow up questionnaire: a study of a new rating scale and other measures to evaluate outcome after head injury

OBJECTIVE

To develop and evaluate a short (10 item) simple measure of outcome mainly for use with patients with mild to moderate head injuries.

DESIGN

Two studies on patients at three and six months after injury, comparing different methods of administration (two raters and postal questionnaire), and comparing ratings with other assessments.

SUBJECTS

Forty three patients seen three months after injury and 46 seen six months after injury; both groups had head injuries covering a range of severity from minor to severe.

MAIN OUTCOME MEASURES

Differences between ratings in different groups of patients (Mann-Whitney U test); differences in ratings used different methods of administration (Wilcoxon signed rank test); and correlation between ratings from the same patient (Spearman r).

RESULTS

The sum total ratings were consistent between raters and between methods (postal questionnaire v face to face interview) with no evidence of selective bias between rates or methods. Ratings on individual items were also reasonably consistent. The sum total rating varied as anticipated between groups divided by clinical judgement of recovery and patient assessment of recovery, and related as expected to the extent of post-concussion symptomatology. The 10 items included covered the most important problem areas reported by patients.

CONCLUSION

The Rivermead head injury follow up questionnaire (RHFUQ) is a short, simple, adequately reliable, and valid measure of outcome, across the entire range of severity, but particularly after mild to moderate head injury.

Diagnostic testing for the evaluation of headaches

Headaches are one of the most common symptoms that neurologists evaluate. Although most are caused by primary disorders, the list differential diagnoses is one of the longest in all of medicine, with over 300 different types and causes. The cause or type of most headaches can be determined by a careful history supplemented by a general and neurologic examination. Reasons for obtaining neuroimaging include medical indications as well as anxiety of patients and families and medico-legal concerns. In the era of managed care, concerns over deselection and negative capitation may dissuade the physician from ordering even a medically indicated scan. The yield of neuroimaging in the evaluation of patients with headache and a normal neurologic examination is quite low. Combining the results of multiple studies performed since 1977 for a total of 3026 scans reveals the overall percentages of various pathologies as: brain tumors, 0.8%; arteriovenous malformations, 0.2%; hydrocephalus, 0.3%; aneurysm, 0.1%; subdural hematoma, 0.2%; and strokes, including chronic ischemic processes, 1.2%. EEG is not useful in the routine evaluation of patients with headache. Similarly, the yield of neuroimaging in the evaluation of migraine is quite low. Combining the results of multiple studies performed since 1976 for a total of 1440 scans of patients with various types of migraine, the overall percentages of various pathologies are: brain tumor, 0.3%; arteriovenous malformation, 0.07%; and saccular aneurysm, 0.07%. WMA have been reported on MRI studies of patients with all types of migraine, with a range from 12% to 46%. The cause of WMA in migraine is not certain. Cerebral atrophy has been variable reported as more frequent and no more frequent in migraineurs compared with controls. The "first or worst" headache has a long list of possible causes and always includes the possibility of acute subarachnoid hemorrhage. Headaches--especially the sentinel type caused by SAH--often are misdiagnosed. The probability of detecting an aneurysmal hemorrhage of CT scans performed at various intervals after the ictus is: day 0.95%; day 3, 74%; 1 week, 50%; 2 weeks, 30%; and 3 weeks, almost nil. The location of a ruptured saccular aneurysm often is suggested by the predominant site of the SAH. The probability of detecting xanthochromia with spectrophotometry in the CSF at various times after a subarachnoid hemorrhage is: 12 hours, 100%; 1 week, 100%; 2 weeks, 100%; 3 weeks, more than 70%; and 4 weeks, more than 40%. The management of thunderclap headaches with normal CT scan and CSF examinations is controversial. Most patients have a benign course but an unruptured saccular aneurysm occasionally may be responsible for the headache. MR angiography may be a reasonable test to obtain instead of a cerebral arteriogram in many of these cases. About 30% to 90% of patients have headaches of various types and causes after mild head injury. Although most headaches are relatively benign, perhaps 1% to 3% of these patients have life-threatening pathology, including subdural and epidural hematomas, that are detected on CT and MRI scans. Headaches caused by subdural hematomas can be nonspecific. When new-onset headaches begin in patients over the age of 50 years, the physician always should consider whether it may be a secondary headache disorder requiring specific diagnostic testing and treatment. Up to 15% of patients 65 years and over who present to neurologists with new-onset headaches may have serious pathology such as stroke, TA, neoplasm, and subdural hematoma. Headaches are the most common symptom of TA, reported by 60% to 90%. The only over the temple. The diagnosis of TA is based on a high index of clinical suspicion that usually but not always is confirmed by laboratory testing. The erythrocyte sedimentation rate can be normal in 10% to 36% of patients with TA. A superficial temporal artery biopsy can give a false-negative result in 5% to 44% of patients.

The Rivermead Post Concussion Symptoms Questionnaire: a measure of symptoms commonly experienced after head injury and its reliability

After head injuries, particularly mild or moderate ones, a range of post-concussion symptoms (PCS) are often reported by patients. Such symptoms may significantly affect patients' psychosocial functioning. To date, no measure of the severity of PCS has been developed. This study presents the Rivermead Post Concussion Symptoms Questionnaire (RPQ) as such a measure, derived from published material, and investigates its reliability. The RPQ's reliability was investigated under two experimental conditions. Study 1 examined its test-retest reliability when used as a self-report questionnaire at 7-10 days after injury. Forty-one head-injured patients completed an RPQ at 7-10 days following their head injury and again approximately 24 h later. Study 2 examined the questionnaire's inter-rater reliability when used as a measure administered by two separate investigators. Forty-six head-injured patients had an RPQ administered by an investigator at 6 months after injury. A second investigator readministered the questionnaire approximately 7 days later. Spearman rank correlation coefficients were calculated for ratings on the total symptom scores, and for individual items. High reliability was found for the total PCS scores under both experimental conditions (Rs = + 0.91 in study 1 and Rs = + 0.87 in study 2). Good reliability was also found for individual PCS items generally, although with some variation between different symptoms. The results are discussed in relation to the major difficulties involved when looking for appropriate experimental criteria against which measures of PCS can be validated.

Neuropsychiatric sequelae of stroke and traumatic brain injury: the role of psychostimulants

OBJECTIVE

The primary purpose of this article is to review certain neuropsychiatric sequelae of stroke and traumatic brain injury (TBI), and the role of the psychostimulants methylphenidate (MPD) and dextroamphetamine (DAMP) in their treatment.

METHOD

A general review of the topic is presented. Controlled and uncontrolled studies involving the use of the psychostimulants are discussed. These consist of 11 studies listed with Medline 2000 that deal specifically with stroke or head injury, with the oldest study reviewed dating back to 1984. Studies concerning the use of psychostimulants in the medically or neurologically ill are reviewed to the extent that they are pertinent.

RESULTS

The current literature consists primarily of uncontrolled case studies. However, these are reviewed and found to suggest a role for the use of the psychostimulants, which is discussed.

CONCLUSIONS

In general, these drugs appear to be a reasonable treatment choice for certain types of mood, behavior, and cognitive symptoms following brain injury. However, it is noted that larger scale controlled studies are needed to adequately assess the clinical usefulness of these drugs.