Recommendations for the use of common outcome measures in traumatic brain injury research

Common Data Elements for Disorders of Consciousness: Recommendations from the Working Group on Outcomes and Endpoints

BACKGROUND

Clinical management of persons with disorders of consciousness (DoC) is dedicated largely to optimizing recovery. However, selecting a measure to evaluate the extent of recovery is challenging because few measures are designed to precisely assess the full range of potential outcomes, from prolonged DoC to return of preinjury functioning. Measures that are designed specifically to assess persons with DoC are often performance-based and only validated for in-person use. Moreover, there are no published recommendations addressing which outcome measures should be used to evaluate DoC recovery. The resulting inconsistency in the measures selected by individual investigators to assess outcome prevents comparison of results across DoC studies. The National Institute of Neurological Disorders and Stroke (NINDS) common data elements (CDEs) is an amalgamation of standardized variables and tools that are recommended for use in studies of neurologic diseases and injuries. The Neurocritical Care Society Curing Coma Campaign launched an initiative to develop CDEs specifically for DoC and invited our group to recommend CDE outcomes and endpoints for persons with DoCs.

METHODS

The Curing Coma Campaign Outcomes and Endpoints CDE Workgroup, consisting of experts in adult and pediatric neurocritical care, neurology, and neuroscience, used a previously established five-step process to identify and select candidate CDEs: (1) review of existing NINDS CDEs, (2) nomination and systematic vetting of new CDEs, (3) CDE classification, (4) iterative review and approval of panel recommendations, and (5) development of case report forms.

RESULTS

Among hundreds of existing NINDS outcome and endpoint CDE measures, we identified 20 for adults and 18 for children that can be used to assess the full range of recovery from coma. We also proposed 14 new outcome and endpoint CDE measures for adults and 5 for children.

CONCLUSIONS

The DoC outcome and endpoint CDEs are a starting point in the broader effort to standardize outcome evaluation of persons with DoC. The ultimate goal is to harmonize DoC studies and allow for more precise assessment of outcomes after severe brain injury or illness. An iterative approach is required to modify and adjust these outcome and endpoint CDEs as new evidence emerges.

Improving Outcomes After Post-Cardiac Arrest Brain Injury: A Scientific Statement From the International Liaison Committee on Resuscitation

This scientific statement presents a conceptual framework for the pathophysiology of post-cardiac arrest brain injury, explores reasons for previous failure to translate preclinical data to clinical practice, and outlines potential paths forward. Post-cardiac arrest brain injury is characterized by 4 distinct but overlapping phases: ischemic depolarization, reperfusion repolarization, dysregulation, and recovery and repair. Previous research has been challenging because of the limitations of laboratory models; heterogeneity in the patient populations enrolled; overoptimistic estimation of treatment effects leading to suboptimal sample sizes; timing and route of intervention delivery; limited or absent evidence that the intervention has engaged the mechanistic target; and heterogeneity in postresuscitation care, prognostication, and withdrawal of life-sustaining treatments. Future trials must tailor their interventions to the subset of patients most likely to benefit and deliver this intervention at the appropriate time, through the appropriate route, and at the appropriate dose. The complexity of post-cardiac arrest brain injury suggests that monotherapies are unlikely to be as successful as multimodal neuroprotective therapies. Biomarkers should be developed to identify patients with the targeted mechanism of injury, to quantify its severity, and to measure the response to therapy. Studies need to be adequately powered to detect effect sizes that are realistic and meaningful to patients, their families, and clinicians. Study designs should be optimized to accelerate the evaluation of the most promising interventions. Multidisciplinary and international collaboration will be essential to realize the goal of developing effective therapies for post-cardiac arrest brain injury.

Longitudinal changes in sodium concentration and in clinical outcome in mild traumatic brain injury

Ionic imbalances and sodium channel dysfunction, well-known sequelae of traumatic brain injury (TBI), promote functional impairment in affected subjects. Therefore, non-invasive measurement of sodium concentrations using 23Na MRI has the potential to detect clinically relevant injury and predict persistent symptoms. Recently, we reported diffusely lower apparent total sodium concentrations (aTSC) in mild TBI patients compared to controls, as well as correlations between lower aTSC and worse clinical outcomes. The main goal of this study was to determine whether these aTSC findings, and their changes over time, predict outcomes at 3- and 12-month from injury. Twenty-seven patients previously studied with 23Na MRI and outcome measures at 22 ± 10 days (average ± standard deviation) after injury (visit-1, v1) were contacted at 3- (visit-2, v2) and 12-month after injury (visit-3, v3) to complete the Rivermead post-concussion symptoms questionnaire (RPQ), the extended Glasgow outcome scale (GOSE), and the brief test of adult cognition by telephone (BTACT). Follow-up 1H and 23Na MRI were additionally scheduled at v2. Linear regression was used to calculate aTSC in global grey and white matters. Six hypotheses were tested in relation to the serial changes in outcome measures and in aTSC, and in relation to the cross-sectional and serial relationships between aTSC and outcome. Twenty patients contributed data at v2 and fifteen at v3. Total RPQ and composite BTACT z-scores differed significantly for v2 and v3 in comparison to v1 (each P < 0.01), reflecting longitudinally reduced symptomatology and improved performance on cognitive testing. No associations between aTSC and outcome were observed at v2. Previously lower grey and white matter aTSC normalized at v2 in comparison to controls, in line with a statistically detectable longitudinal increase in grey matter aTSC between v1 and v2 (P = 0.0004). aTSC values at v1 predicted a subset of future BTACT subtest scores, but not future RPQ scores nor GOSE-defined recovery status. Similarly, aTSC rates of change correlated with BTACT rates of change, but not with those of RPQ. Tissue aTSC, previously shown to be diffusely decreased compared to controls at v1, was no longer reduced by v2, suggesting normalization of the sodium ionic equilibrium. These changes were accompanied by marked improvement in outcome. The results support the notion that early aTSC from 23Na MRI predicts future BTACT, but not RPQ scores, nor future GOSE status.

Asking questions that are "close to the bone": integrating thematic analysis and natural language processing to explore the experiences of people with traumatic brain injuries engaging with patient-reported outcome measures

Introduction

Patient-reported outcomes measures (PROMs) are valuable tools for assessing health-related quality of life and treatment effectiveness in individuals with traumatic brain injuries (TBIs). Understanding the experiences of individuals with TBIs in completing PROMs is crucial for improving their utility and relevance in clinical practice.

Methods

Sixteen semi-structured interviews were conducted with a sample of individuals with TBIs. The interviews were transcribed verbatim and analysed using Thematic Analysis (TA) and Natural Language Processing (NLP) techniques to identify themes and emotional connotations related to the experiences of completing PROMs.

Results

The TA of the data revealed six key themes regarding the experiences of individuals with TBIs in completing PROMs. Participants expressed varying levels of understanding and engagement with PROMs, with factors such as cognitive impairments and communication difficulties influencing their experiences. Additionally, insightful suggestions emerged on the barriers to the completion of PROMs, the factors facilitating it, and the suggestions for improving their contents and delivery methods. The sentiment analyses performed using NLP techniques allowed for the retrieval of the general sentimental and emotional "tones" in the participants' narratives of their experiences with PROMs, which were mainly characterised by low positive sentiment connotations. Although mostly neutral, participants' narratives also revealed the presence of emotions such as fear and, to a lesser extent, anger. The combination of a semantic and sentiment analysis of the experiences of people with TBIs rendered valuable information on the views and emotional responses to different aspects of the PROMs.

Discussion

The findings highlighted the complexities involved in administering PROMs to individuals with TBIs and underscored the need for tailored approaches to accommodate their unique challenges. Integrating TA-based and NLP techniques can offer valuable insights into the experiences of individuals with TBIs and enhance the interpretation of qualitative data in this population.

Liberal or Restrictive Transfusion Strategy in Patients with Traumatic Brain Injury

BACKGROUND

The effect of a liberal transfusion strategy as compared with a restrictive strategy on outcomes in critically ill patients with traumatic brain injury is unclear.

METHODS

We randomly assigned adults with moderate or severe traumatic brain injury and anemia to receive transfusion of red cells according to a liberal strategy (transfusions initiated at a hemoglobin level of ≤10 g per deciliter) or a restrictive strategy (transfusions initiated at ≤7 g per deciliter). The primary outcome was an unfavorable outcome as assessed by the score on the Glasgow Outcome Scale-Extended at 6 months, which we categorized with the use of a sliding dichotomy that was based on the prognosis of each patient at baseline. Secondary outcomes included mortality, functional independence, quality of life, and depression at 6 months.

RESULTS

A total of 742 patients underwent randomization, with 371 assigned to each group. The analysis of the primary outcome included 722 patients. The median hemoglobin level in the intensive care unit was 10.8 g per deciliter in the group assigned to the liberal strategy and 8.8 g per deciliter in the group assigned to the restrictive strategy. An unfavorable outcome occurred in 249 of 364 patients (68.4%) in the liberal-strategy group and in 263 of 358 (73.5%) in the restrictive-strategy group (adjusted absolute difference, restrictive strategy vs. liberal strategy, 5.4 percentage points; 95% confidence interval, -2.9 to 13.7). Among survivors, a liberal strategy was associated with higher scores on some but not all the scales assessing functional independence and quality of life. No association was observed between the transfusion strategy and mortality or depression. Venous thromboembolic events occurred in 8.4% of the patients in each group, and acute respiratory distress syndrome occurred in 3.3% and 0.8% of patients in the liberal-strategy and restrictive-strategy groups, respectively.

CONCLUSIONS

In critically ill patients with traumatic brain injury and anemia, a liberal transfusion strategy did not reduce the risk of an unfavorable neurologic outcome at 6 months. (Funded by the Canadian Institutes of Health Research and others; HEMOTION ClinicalTrials.gov number, NCT03260478.).

Isolated Traumatic Subarachnoid Hemorrhage on Head Computed Tomography Scan May Not Be Isolated: A Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study (TRACK-TBI) Study

Isolated traumatic subarachnoid hemorrhage (tSAH) after traumatic brain injury (TBI) on head computed tomography (CT) scan is often regarded as a "mild" injury, with reduced need for additional workup. However, tSAH is also a predictor of incomplete recovery and unfavorable outcome. This study aimed to evaluate the characteristics of CT-occult intracranial injuries on brain magnetic resonance imaging (MRI) scan in TBI patients with emergency department (ED) arrival Glasgow Coma Scale (GCS) score 13-15 and isolated tSAH on CT. The prospective, 18-center Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study (TRACK-TBI; enrollment years 2014-2019) enrolled participants who presented to the ED and received a clinically-indicated head CT within 24 h of TBI. A subset of TRACK-TBI participants underwent venipuncture within 24 h for plasma glial fibrillary acidic protein (GFAP) analysis, and research MRI at 2-weeks post-injury. In the current study, TRACK-TBI participants age ≥17 years with ED arrival GCS 13-15, isolated tSAH on initial head CT, plasma GFAP level, and 2-week MRI data were analyzed. In 57 participants, median age was 46.0 years [quartile 1 to 3 (Q1-Q3): 34-57] and 52.6% were male. At ED disposition, 12.3% were discharged home, 61.4% were admitted to hospital ward, and 26.3% to intensive care unit. MRI identified CT-occult traumatic intracranial lesions in 45.6% (26 of 57 participants; one additional lesion type: 31.6%; 2 additional lesion types: 14.0%); of these 26 participants with CT-occult intracranial lesions, 65.4% had axonal injury, 42.3% had subdural hematoma, and 23.1% had intracerebral contusion. GFAP levels were higher in participants with CT-occult MRI lesions compared with without (median: 630.6 pg/mL, Q1-Q3: [172.4-941.2] vs. 226.4 [105.8-436.1], p = 0.049), and were associated with axonal injury (no: median 226.7 pg/mL [109.6-435.1], yes: 828.6 pg/mL [204.0-1194.3], p = 0.009). Our results indicate that isolated tSAH on head CT is often not the sole intracranial traumatic injury in GCS 13-15 TBI. Forty-six percent of patients in our cohort (26 of 57 participants) had additional CT-occult traumatic lesions on MRI. Plasma GFAP may be an important biomarker for the identification of additional CT-occult injuries, including axonal injury. These findings should be interpreted cautiously given our small sample size and await validation from larger studies.

Psychological distress and gender predict cognitive complaint after adult civilian mild traumatic brain injury in pre-morbidly healthy adults

Subjective cognitive symptoms are common after mild traumatic brain injury (mTBI), and are associated with important outcome factors including return to work. This study examined self-reported cognitive symptoms in mTBI and trauma controls (TCs), and explored psychological distress and gender as predictors of these symptoms. Pre-morbidly healthy adults with mTBI (n = 68) and general trauma (n = 40) were prospectively recruited from inpatient hospital wards and assessed 6-10 weeks post-injury. Primary measures included self-reported cognitive symptoms, post-concussion symptoms, and psychological distress. Groups were matched on all background variables, including objective cognitive performance. Within this context, subjective cognitive symptoms were significantly elevated after mTBI relative to TCs (t = 3.396, p = .001). In contrast, there was no difference in post-concussion symptoms between groups (t = 1.275, p = .206). Psychological distress (β = .536, p < .001) and gender (β = .253, p = .012) predicted subjective cognitive symptoms in mTBI, with females and those with higher distress reporting greater symptoms. Unlike general post-concussion symptoms, subjective cognitive symptoms were elevated after mTBI relative to TCs, suggesting that mTBI-specific factors underly this elevation. Females and individuals with high psychological distress are important subgroups to consider for potential intervention following mTBI.

The Australian Traumatic Brain Injury Initiative: Review and Recommendations for Outcome Measures for Use With Adults and Children After Moderate-to-Severe Traumatic Brain Injury

The Australian Traumatic Brain Injury Initiative (AUS-TBI) aims to select a set of measures to comprehensively predict and assess outcomes following moderate-to-severe traumatic brain injury (TBI) across Australia. The aim of this article was to report on the implementation and findings of an evidence-based consensus approach to develop AUS-TBI recommendations for outcome measures following adult and pediatric moderate-to-severe TBI. Following consultation with a panel of expert clinicians, Aboriginal and Torres Strait Islander representatives and a Living Experience group, and preliminary literature searches with a broader focus, a decision was made to focus on measures of mortality, everyday functional outcomes, and quality of life. Standardized searches of bibliographic databases were conducted through March 2022. Characteristics of 75 outcome measures were extracted from 1485 primary studies. Consensus meetings among the AUS-TBI Steering Committee, an expert panel of clinicians and researchers and a group of individuals with lived experience of TBI resulted in the production of a final list of 11 core outcome measures: the Functional Independence Measure (FIM); Glasgow Outcome Scale-Extended (GOS-E); Satisfaction With Life Scale (SWLS) (adult); mortality; EuroQol-5 Dimensions (EQ5D); Mayo-Portland Adaptability Inventory (MPAI); Return to Work /Study (adult and pediatric); Functional Independence Measure for Children (WEEFIM); Glasgow Outcome Scale Modified for Children (GOS-E PEDS); Paediatric Quality of Life Scale (PEDS-QL); and Strengths and Difficulties Questionnaire (pediatric). These 11 outcome measures will be included as common data elements in the AUS-TBI data dictionary. Review Registration PROSPERO (CRD42022290954).

Clinical Outcomes After Traumatic Brain Injury and Exposure to Extracranial Surgery: A TRACK-TBI Study

Importance

Traumatic brain injury (TBI) is associated with persistent functional and cognitive deficits, which may be susceptible to secondary insults. The implications of exposure to surgery and anesthesia after TBI warrant investigation, given that surgery has been associated with neurocognitive disorders.

Objective

To examine whether exposure to extracranial (EC) surgery and anesthesia is related to worse functional and cognitive outcomes after TBI.

Design, Setting, and Participants

This study was a retrospective, secondary analysis of data from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study, a prospective cohort study that assessed longitudinal outcomes of participants enrolled at 18 level I US trauma centers between February 1, 2014, and August 31, 2018. Participants were 17 years or older, presented within 24 hours of trauma, were admitted to an inpatient unit from the emergency department, had known Glasgow Coma Scale (GCS) and head computed tomography (CT) status, and did not undergo cranial surgery. This analysis was conducted between January 2, 2020, and August 8, 2023.

Exposure

Participants who underwent EC surgery during the index admission were compared with participants with no surgery in groups with a peripheral orthopedic injury or a TBI and were classified as having uncomplicated mild TBI (GCS score of 13-15 and negative CT results [CT- mTBI]), complicated mild TBI (GCS score of 13-15 and positive CT results [CT+ mTBI]), or moderate to severe TBI (GCS score of 3-12 [m/sTBI]).

Main Outcomes and Measures

The primary outcomes were functional limitations quantified by the Glasgow Outcome Scale-Extended for all injuries (GOSE-ALL) and brain injury (GOSE-TBI) and neurocognitive outcomes at 2 weeks and 6 months after injury.

Results

A total of 1835 participants (mean [SD] age, 42.2 [17.8] years; 1279 [70%] male; 299 Black, 1412 White, and 96 other) were analyzed, including 1349 nonsurgical participants and 486 participants undergoing EC surgery. The participants undergoing EC surgery across all TBI severities had significantly worse GOSE-ALL scores at 2 weeks and 6 months compared with their nonsurgical counterparts. At 6 months after injury, m/sTBI and CT+ mTBI participants who underwent EC surgery had significantly worse GOSE-TBI scores (B = -1.11 [95% CI, -1.53 to -0.68] in participants with m/sTBI and -0.39 [95% CI, -0.77 to -0.01] in participants with CT+ mTBI) and performed worse on the Trail Making Test Part B (B = 30.1 [95% CI, 11.9-48.2] in participants with m/sTBI and 26.3 [95% CI, 11.3-41.2] in participants with CT+ mTBI).

Conclusions and Relevance

This study found that exposure to EC surgery and anesthesia was associated with adverse functional outcomes and impaired executive function after TBI. This unfavorable association warrants further investigation of the potential mechanisms and clinical implications that could inform decisions regarding the timing of surgical interventions in patients after TBI.

Improvement in Functional Outcome from 6 to 12 Months After Moderate and Severe Traumatic Brain Injury Is Frequent, But May Not Be Detected With the Glasgow Outcome Scale Extended

The aims of this study were (1) to report outcome and change in outcome in patients with moderate and severe traumatic brain injury (mo/sTBI) between 6 and 12 months post-injury as measured by the Glasgow Outcome Scale Extended (GOSE), (2) to explore if demographic/injury-related variables can predict improvement in GOSE score, and (3) to investigate rate of improvement in Disability Rating Scale (DRS) score, in patients with a stable GOSE. All surviving patients ≥16 years of age who were admitted with mo/sTBI (Glasgow Coma Scale [GCS] score ≤13) to the regional trauma center in Central Norway between 2004 and 2019 were prospectively included (n = 439 out of 503 eligible). GOSE and DRS were used to assess outcome. Twelve-months post-injury, 13% with moTBI had severe disability (GOSE 2-4) versus 27% in sTBI, 26% had moderate disability (GOSE 5-6) versus 41% in sTBI and 62% had good recovery (GOSE 7-8) versus 31% in sTBI. From 6 to 12 months post-injury, 27% with moTBI and 32% with sTBI had an improvement, whereas 6% with moTBI and 6% with sTBI had a deterioration in GOSE score. Younger age and higher GCS score were associated with improved GOSE score. Improvement was least frequent for patients with a GOSE score of 3 at 6 months. In patients with a stable GOSE score of 3, an improvement in DRS score was observed in 22 (46%) patients. In conclusion, two thirds and one third of patients with mo/sTBI, respectively, had a good recovery. Importantly, change, mostly improvement, in GOSE score between 6 and 12 months was frequent and argues against the use of 6 months outcome as a time end-point in research. The GOSE does, however, not seem to be sensitive to actual change in function in the lower categories and a combination of outcome measures may be needed to describe the consequences after TBI.

Critical ICP thresholds in relation to outcome: Is 22 mmHg really the answer?

PURPOSE

Intensive care for patients with traumatic brain injury (TBI) aims, among other tasks, at avoiding high intracranial pressure (ICP), which is perceived to worsen motor and cognitive deficits and increase mortality. International recommendations for threshold values for ICP were increased from 20 to 22 mmHg in 2016 following the findings in a study by Sorrentino et al., which were based on an observational study of patients with TBI of averaged ICP values. We aimed to reproduce their approach and validate the findings in a separate cohort.

METHODS

Three hundred thirty-one patients with TBI were included and categorised according to survival/death and favourable/unfavourable outcome at 6 months (based on Glasgow Outcome Score-Extended of 6-8 and 1-5, respectively). Repeated chi-square tests of survival and death (or favourable and unfavourable outcome) vs. high and low ICP were conducted with discrimination between high and low ICP sets at increasing values (integers) between 10 and 35 mmHg, using the average ICP for the entire monitoring period. The ICP limit returning the highest chi-square score was assumed to be the threshold with best discriminative ability. This approach was repeated after stratification by sex, age, and initial Glasgow Coma Score (GCS).

RESULTS

An ICP limit of 18 mmHg was found for both mortality and unfavourable outcome for the entire cohort. The female and the low GCS subgroups both had threshold values of 18 mmHg; for all other subgroups, the threshold varied between 16 and 30 mmHg. According to a multiple logistic regression analysis, age, initial GCS, and average ICP are independently associated with mortality and outcome.

CONCLUSIONS

Using identical methods and closely comparable cohorts, the critical thresholds for ICP found in the study by Sorrentino et al. could not be reproduced.

Disorders of Consciousness Programs: Components, Organization, and Implementation

Rehabilitation of patients with disorders of consciousness (DoC) presents unique challenges requiring comprehensive and specialized care. This article reviews the components, organization, and implementation of an inpatient DoC program under the framework of recent evidence-based practice guidelines and minimum competency recommendations. The evidence and clinical applications of these recommendations are elaborated upon with the goal of offering providers a reference to translate guidelines into clinical practice.

Associations of MRI-Derived Glymphatic System Impairment With Global White Matter Damage and Cognitive Impairment in Mild Traumatic Brain Injury: A DTI-ALPS Study

BACKGROUND

Assessing the glymphatic function using diffusion tensor image analysis along the perivascular space (DTI-ALPS) may be helpful for mild traumatic brain injury (mTBI) management.

PURPOSE

To assess glymphatic function using DTI-ALPS and its associations with global white matter damage and cognitive impairment in mTBI.

STUDY TYPE

Prospective.

POPULATION

Thirty-four controls (44.1% female, mean age 49.2 years) and 58 mTBI subjects (43.1% female, mean age 48.7 years), including uncomplicated mTBI (N = 32) and complicated mTBI (N = 26).

FIELD STRENGTH/SEQUENCE

3-T, single-shot echo-planar imaging sequence.

ASSESSMENT

Magnetic resonance imaging (MRI) was done within 1 month since injury. DTI-ALPS was performed to assess glymphatic function, and peak width of skeletonized mean diffusivity (PSMD) was used to assess global white matter damage. Cognitive tests included Auditory Verbal Learning Test and Digit Span Test (forward and backward).

STATISTICAL TESTS

Neuroimaging findings comparisons were done between mTBI and control groups. Partial correlation and multivariable linear regression assessed the associations between DTI-ALPS, PSMD, and cognitive impairment. Mediation effects of PSMD on the relationship between DTI-ALPS and cognitive impairment were explored. P-value <0.05 was considered statistically significant, except for cognitive correlational analyses with a Bonferroni-corrected P-value set at 0.05/3 ≈ 0.017.

RESULTS

mTBI showed lower DTI-ALPS and higher PSMD, especially in complicated mTBI. DTI-ALPS was significantly correlated with verbal memory (r = 0.566), attention abilities (r = 0.792), executive function (r = 0.618), and PSMD (r = -0.533). DTI-ALPS was associated with verbal memory (β = 8.77, 95% confidence interval [CI] 5.00, 12.54), attention abilities (β = 5.67, 95% CI 4.56, 6.97), executive function (β = 2.34, 95% CI 1.49, 3.20), and PSMD (β = -0.79, 95% CI -1.15, -0.43). PSMD mediated 46.29%, 20.46%, and 24.36% of the effects for the relationship between DTI-ALPS and verbal memory, attention abilities, and executive function.

DATA CONCLUSION

Glymphatic function may be impaired in mTBI reflected by DTI-ALPS. Glymphatic dysfunction may cause cognitive impairment related to global white matter damage after mTBI.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY: Stage 2.

The utility of the Cognitive Reserve Index questionnaire in chronic traumatic brain injury

Objective: This study examined the relationship between cognitive reserve measured with the Cognitive Reserve Index questionnaire (CRIq) and cognitive and functional outcomes in a chronic traumatic brain injury (TBI) cohort compared to a non-TBI cohort. The utility of the CRIq was compared to common proxies of cognitive reserve (premorbid IQ and years of education) in TBI and non-TBI cohorts. Method: Participants were 105 individuals with moderate-severe TBI (10-33 years post injury) and 91 participants without TBI. Cognitive outcome was examined across four cognitive factors; verbal memory, visual ability and memory, executive attention, and episodic memory. Functional outcome was measured using the Glasgow Outcome Scale Extended. The CRIq total score and three subscale scores (education, work, leisure) were examined. Results: In the TBI cohort, associations were identified between two CRIq subscales and cognitive factors (CRIq education and verbal memory; CRIq work and executive attention). There were no associations between CRIq leisure and cognitive outcomes, or between CRIq and functional outcome. Model selection statistics suggested premorbid IQ and years of education provided a better fit than the CRIq for the relationship between cognitive reserve with two cognitive factors and functional outcome, with neither model providing an improved fit for the remaining two cognitive factors. This finding was broadly consistent in the non-TBI cohort. Conclusion: Cognitive reserve contributes significantly to long-term clinical outcomes following moderate-severe TBI. The relationship between cognitive reserve and long-term cognitive and functional outcomes following TBI is best characterised with traditional proxies of cognitive reserve, mainly premorbid IQ, rather than the CRIq.

Data-driven distillation and precision prognosis in traumatic brain injury with interpretable machine learning

Traumatic brain injury (TBI) affects how the brain functions in the short and long term. Resulting patient outcomes across physical, cognitive, and psychological domains are complex and often difficult to predict. Major challenges to developing personalized treatment for TBI include distilling large quantities of complex data and increasing the precision with which patient outcome prediction (prognoses) can be rendered. We developed and applied interpretable machine learning methods to TBI patient data. We show that complex data describing TBI patients' intake characteristics and outcome phenotypes can be distilled to smaller sets of clinically interpretable latent factors. We demonstrate that 19 clusters of TBI outcomes can be predicted from intake data, a ~ 6× improvement in precision over clinical standards. Finally, we show that 36% of the outcome variance across patients can be predicted. These results demonstrate the importance of interpretable machine learning applied to deeply characterized patients for data-driven distillation and precision prognosis.

Cerebral microhaemorrhage count is related to processing speed, but not level of symptom reporting, independently of age, psychological status and premorbid functioning, after first-ever mild traumatic brain injury

Cerebral microhaemorrhage is a commonly identified neuropathological consequence of mild traumatic brain injury (mTBI) and can be identified in vivo using susceptibility weighted imaging (SWI). This study aimed to determine whether SWI-detected microhaemorrhages are more common in individuals after a single, first-ever, mTBI event relative to trauma controls (TC) and to investigate whether a linear relationship exists between microhaemorrhage numbers and cognition or symptom reporting in the post-acute period after injury, independently of age, psychological status and premorbid level of functioning. Microhaemorrhagic lesions were identified by expert clinical examination of SWI for 78 premorbidly healthy adult participants who were admitted to hospital after a traumatic injury and had suffered a first-ever mTBI (n = 47) or no head strike (n = 31). Participants underwent objective cognitive examination of processing speed, attention, memory, and executive function as well as self-reported post-concussion symptomatology. Bootstrapping analyses were used as data were not normally distributed. Analyses revealed that the mTBI group had significantly more microhaemorrhages than the TC group (Cohen's d = 0.559). These lesions were only evident in 28% of individuals. The mTBI participants demonstrated a significant linear association between number of microhaemorrhages and processing speed, independently of age, psychological status, or premorbid level of functioning. This study shows that a single mTBI causes cerebral microhaemorrhages to occur in a minority of premorbidly healthy individuals. Greater microhaemorrhage count is independently associated with slower processing speed, but not symptom reporting, during the post-acute injury period.

Profiles of Cognitive Functioning at 6 Months After Traumatic Brain Injury Among Patients in Level I Trauma Centers: A TRACK-TBI Study

Importance

Cognitive dysfunction is common after traumatic brain injury (TBI), with a well-established dose-response relationship between TBI severity and likelihood or magnitude of persistent cognitive impairment. However, patterns of cognitive dysfunction in the long-term (eg, 6-month) recovery period are less well known.

Objective

To characterize the prevalence of cognitive dysfunction within and across cognitive domains (processing speed, memory, and executive functioning) 6 months after injury in patients with TBI seen at level I trauma centers.

Design, Setting, and Participants

This prospective longitudinal cohort study used data from Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) and included patients aged 17 years or older presenting at 18 US level I trauma center emergency departments or inpatient units within 24 hours of head injury, control individuals with orthopedic injury recruited from the same centers, and uninjured friend and family controls. Participants were enrolled between March 2, 2014, and July 27, 2018. Data were analyzed from March 5, 2020, through October 3, 2023.

Exposures

Traumatic brain injury (Glasgow Coma Scale score of 3-15) or orthopedic injury.

Main Outcomes and Measures

Performance on standard neuropsychological tests, including premorbid cognitive ability (National Institutes of Health Toolbox Picture Vocabulary Test), verbal memory (Rey Auditory Verbal Learning Test), processing speed (Wechsler Adult Intelligence Scale [4th edition] Processing Speed Index), and executive functioning (Trail Making Test).

Results

The sample included 1057 persons with TBI (mean [SD] age, 39.3 [16.4] years; 705 [67%] male) and 327 controls without TBI (mean [SD] age, 38.4 [15.1] years; 222 [68%] male). Most persons with TBI demonstrated performance within 1.5 SDs or better of the control group (49.3% [95% CI, 39.5%-59.2%] to 67.5% [95% CI, 63.7%-71.2%] showed no evidence of impairment). Similarly, 64.4% (95% CI, 54.5%-73.4%) to 78.8% (95% CI, 75.4%-81.9%) of participants demonstrated no evidence of cognitive decline (defined as performance within 1.5 SDs of estimated premorbid ability). For individuals with evidence of either cognitive impairment or decline, diverse profiles of impairment across memory, speed, and executive functioning domains were observed (ie, the prevalence was >0 in each of the 7 combinations of impairment across these 3 cognitive domains for most TBI subgroups).

Conclusions and Relevance

In this cohort study of patients seen at level I trauma centers 6 months after TBI, many patients with TBI demonstrated no cognitive impairment. Impairment was more prevalent in persons with more severe TBI and manifested in variable ways across individuals. The findings may guide future research and treatment recommendations.

Pediatric Traumatic Brain Injury: Impact on the Developing Brain

Traumatic brain injury (TBI) is a serious public health concern impacting millions of children and adolescents each year. Experiencing a brain injury during key critical periods of brain development can affect the normal formation of brain networks that are responsible for a range of complex neurocognitive outcomes. In addition, there are multiple pre- and postinjury factors that influence the trajectory of recovery and outcomes. In this review, we will focus on the current state of the literature within pediatric TBI; systematically review the available research on developmental aspects of TBI in children, focusing on the pathophysiology of the injury and its impact on the developing brain; and highlight knowledge gaps for further exploration.

Longitudinal Recovery Following Repetitive Traumatic Brain Injury

Importance

One traumatic brain injury (TBI) increases the risk of subsequent TBIs. Research on longitudinal outcomes of civilian repetitive TBIs is limited.

Objective

To investigate associations between sustaining 1 or more TBIs (ie, postindex TBIs) after study enrollment (ie, index TBIs) and multidimensional outcomes at 1 year and 3 to 7 years.

Design, Setting, and Participants

This cohort study included participants presenting to emergency departments enrolled within 24 hours of TBI in the prospective, 18-center Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study (enrollment years, February 2014 to July 2020). Participants who completed outcome assessments at 1 year and 3 to 7 years were included. Data were analyzed from September 2022 to August 2023.

Exposures

Postindex TBI(s).

Main Outcomes and Measures

Demographic and clinical factors, prior TBI (ie, preindex TBI), and functional (Glasgow Outcome Scale-Extended [GOSE]), postconcussive (Rivermead Post-Concussion Symptoms Questionnaire [RPQ]), psychological distress (Brief Symptom Inventory-18 [BSI-18]), depressive (Patient Health Questionnaire-9 [PHQ-9]), posttraumatic stress disorder (PTSD; PTSD Checklist for DSM-5 [PCL-5]), and health-related quality-of-life (Quality of Life After Brain Injury-Overall Scale [QOLIBRI-OS]) outcomes were assessed. Adjusted mean differences (aMDs) and adjusted relative risks are reported with 95% CIs.

Results

Of 2417 TRACK-TBI participants, 1572 completed the outcomes assessment at 1 year (1049 [66.7%] male; mean [SD] age, 41.6 [17.5] years) and 1084 completed the outcomes assessment at 3 to 7 years (714 [65.9%] male; mean [SD] age, 40.6 [17.0] years). At 1 year, a total of 60 participants (4%) were Asian, 255 (16%) were Black, 1213 (77%) were White, 39 (2%) were another race, and 5 (0.3%) had unknown race. At 3 to 7 years, 39 (4%) were Asian, 149 (14%) were Black, 868 (80%) were White, 26 (2%) had another race, and 2 (0.2%) had unknown race. A total of 50 (3.2%) and 132 (12.2%) reported 1 or more postindex TBIs at 1 year and 3 to 7 years, respectively. Risk factors for postindex TBI were psychiatric history, preindex TBI, and extracranial injury severity. At 1 year, compared with those without postindex TBI, participants with postindex TBI had worse functional recovery (GOSE score of 8: adjusted relative risk, 0.57; 95% CI, 0.34-0.96) and health-related quality of life (QOLIBRI-OS: aMD, -15.9; 95% CI, -22.6 to -9.1), and greater postconcussive symptoms (RPQ: aMD, 8.1; 95% CI, 4.2-11.9), psychological distress symptoms (BSI-18: aMD, 5.3; 95% CI, 2.1-8.6), depression symptoms (PHQ-9: aMD, 3.0; 95% CI, 1.5-4.4), and PTSD symptoms (PCL-5: aMD, 7.8; 95% CI, 3.2-12.4). At 3 to 7 years, these associations remained statistically significant. Multiple (2 or more) postindex TBIs were associated with poorer outcomes across all domains.

Conclusions and Relevance

In this cohort study of patients with acute TBI, postindex TBI was associated with worse symptomatology across outcome domains at 1 year and 3 to 7 years postinjury, and there was a dose-dependent response with multiple postindex TBIs. These results underscore the critical need to provide TBI prevention, education, counseling, and follow-up care to at-risk patients.

Validity of Glasgow outcome scale-extended (GOSE) mobile application for assessment of outcome in traumatic brain injury patients

PURPOSE

To develop the Glasgow Outcome Scale-Extended (GOSE) mobile application and examine the validity of the application against GOSE scoring based on traditional interview method.

METHODS

Concurrent validity was determined by comparing two independent raters' scoring for GOSE of 102 patients with traumatic brain injury, who had attended outpatient department of a tertiary neuro hospital. Agreement was assessed between the traditional interview-based pen and paper scoring and algorithm based mobile application scoring of GOSE.

RESULTS

Agreement was tested using Cohen's kappa, and the analysis revealed near perfect agreement between two raters (0.89) (p < 0.01).

CONCLUSION

The GOSE mobile application can measure GOSE Score similar to the traditional interview method. This application may help fasten the process of assessing outcome in TBI patients in clinical practice and in research.

Facial affect recognition in context in adults with and without TBI

Introduction

Several studies have reported impaired emotion recognition in adults with traumatic brain injury (TBI), but studies have two major design features that limit application of results to real-world contexts: (1) participants choose from among lists of basic emotions, rather than generating emotion labels, and (2) images are typically presented in isolation rather than in context. To address these limitations, we created an open-labeling task with faces shown alone or in real-life scenes, to more closely approximate how adults with TBI label facial emotions beyond the lab.

Methods

Participants were 55 adults (29 female) with moderate to severe TBI and 55 uninjured comparison peers, individually matched for race, sex, and age. Participants viewed 60 photographs of faces, either alone or in the pictured person's real-life context, and were asked what that person was feeling. We calculated the percent of responses that were standard forced-choice-task options, and also used sentiment intensity analysis to compare verbal responses between the two groups. We tracked eye movements for a subset of participants, to explore whether gaze duration or number of fixations helped explain any group differences in labels.

Results

Over 50% of responses in both groups were words other than basic emotions on standard affect tasks, highlighting the importance of eliciting open-ended responses. Valence of labels by participants with TBI was attenuated relative to valence of Comparison group labels, i.e., TBI group responses were less positive to positive images and the same was true for negative images, although the TBI group responses had higher lexical diversity. There were no significant differences in gaze duration or number of fixations between groups.

Discussion

Results revealed qualitative differences in affect labels between adults with and without TBI that would not have emerged on standard forced-choice tasks. Verbal differences did not appear to be attributable to differences in gaze patterns, leaving open the question of mechanisms of atypical affect processing in adults with TBI.

Determining the Minimally Clinically Important Difference for the Disability Rating Scale in Persons With Chronic Traumatic Brain Injury

The Extended Glasgow Outcome Scale (GOSE) is accepted as the primary outcome measure in registrational studies for traumatic brain injury (TBI). The Disability Rating Scale (DRS) is used to assess functional progress from initial acute injury, through rehabilitation and reintegration into the community and life. For these reasons, the DRS is an alternative measure for assessing meaningful global outcomes in chronic TBI. The objective of this study was to determine the minimally clinically important difference (MCID) for the DRS in chronic TBI, by determining the magnitude of DRS change associated with the MCID for the GOSE of 1 point. This study is a retrospective analysis of the multi-center, prospective, longitudinal, Traumatic Brain Injury Model Systems National Database of persons with outcomes at 1, 2, and 5 years and every 5 years thereafter post-injury. Spearman's correlations for dynamic and static relationships between the DRS and GOSE were significant. For the 1-point MCID for the GOSE, the dynamic MCID estimate for the DRS of a -0.68-point change was calculated as the mean DRS change associated with the difference of the GOSE score between year 1 and year 2 (score range, 3-8), using all persons in the study (n = 11,102), whereas the exploratory static MCID estimate for the DRS of -1.28 points was calculated from the slope of the best-fit line between the DRS and GOSE at year 1 follow-up (score range, 3-8; n = 13,415). The final MCID for the DRS was calculated by using the triangulation method (i.e., the arithmetic mean of the dynamic and exploratory static MCID estimates), which resulted in a -1.0-point change. The significant correlation between the DRS and GOSE has allowed for the establishment of a -1.0-point MCID for the DRS, which supports the use of the DRS as an alternative primary outcome measure for chronic TBI research studies, including clinical trials.

Evaluating the implementation of the Mayo-Portland Adaptability Inventory-4 (MPAI-4) in three rehabilitation settings in Quebec: a mixed-methods study protocol

INTRODUCTION

Stroke is a leading cause of morbidity and mortality worldwide, placing an immense burden on patients and the health system. Timely access to rehabilitation services can improve stroke survivors' quality of life. The use of standardised outcome measures is endorsed for optimising patient rehabilitation outcomes and improving clinical decision-making. This project results from a provincially mandated recommendation to use the fourth version of the Mayo-Portland Adaptability Inventory (MPAI-4) to measure changes in social participation of stroke survivors and to maintain commitment to evidence-informed practices in stroke care. This protocol outlines the implementation process of the MPAI-4 for three rehabilitation centres. The objectives are to: (a) describe the context of MPAI-4 implementation; (b) determine clinical teams' readiness for change; (c) identify barriers and enablers to implementing the MPAI-4 and match the implementation strategies; (d) evaluate the MPAI-4 implementation outcomes including the degree of integration of the MPAI-4 into clinical practice and (e) explore participants' experiences using the MPAI-4.

METHODS AND ANALYSIS

We will use a multiple case study design within an integrated knowledge translation (iKT) approach with active engagement from key informants. Each case is a rehabilitation centre implementing MPAI-4. We will collect data from clinicians and programme managers using mixed methods guided by several theoretical frameworks. Data sources include surveys, focus groups and patient charts. We will conduct descriptive, correlational and content analyses. Ultimately, we will analyse, integrate data from qualitative and quantitative components and report them within and across participating sites. Results will provide insights about iKT within stroke rehabilitation settings that could be applied to future research projects.

ETHICS AND DISSEMINATION

The project received Institutional Review Board approval from the Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal. We will disseminate results in peer-reviewed publications and at local, national and international scientific conferences.

Comparison of veterans affairs and NIDILRR traumatic brain injury model systems participants with disorders of consciousness

OBJECTIVE

To characterize demographic, pre-injury, and outcome data within the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) and Veterans Affairs (VA) Traumatic Brain Injury Model Systems (TBIMS) cohorts with severe traumatic brain injury (TBI) with no command-following ability at time of admission to acute rehabilitation.

DESIGN

Retrospective cohort.

SETTING

NIDILRR and VA TBI Model Systems (TBIMS) centers.

PARTICIPANTS

396 NIDILRR and 72 VA participants without command-following ability who experienced TBI with subsequent Disorder of Consciousness (DoC).

MAIN OUTCOME MEASURE

Pre-injury and injury characteristics, rehabilitation outcomes, and 1-year self-reported outcomes.

RESULTS

VA TBIMS cohort included individuals who were active duty or had military service before their injury. The VA cohort were more likely to be re-hospitalized at 1-year follow-up or residing in a long-term care or rehab setting. The NIDILRR TBIMS cohort had higher FIM and DRS scores at rehabilitation discharge, while the VA participants saw longer lengths of stay and higher numbers of "violent" injury types.

CONCLUSIONS

This study allows for a better understanding of the comparability between VA and NIDILRR DoC cohorts providing guidance on how veteran and civilian samples might be merged in future TBIMS studies to explore predictors of recovery from a DoC.

Associations of Preexisting Vascular Risk Factors With Outcomes After Traumatic Brain Injury: A TRACK-TBI Study

OBJECTIVE

To evaluate associations of preinjury vascular risk factors with traumatic brain injury (TBI) outcomes.

SETTING

The level 1 trauma center-based T ransforming R esearch a nd C linical K nowledge in TBI (TRACK-TBI) Study.

PARTICIPANTS

A total of 2361 acute TBI patients 18 years or older who presented to the emergency department within 24 hours of head trauma warranting clinical evaluation with a noncontrast head CT between February 26, 2014, and August 8, 2018.

DESIGN

A multicenter prospective cohort study.

MAIN MEASURES

Vascular risk factors (hypertension, diabetes, hyperlipidemia, and smoking) were assessed at baseline by self- or proxy-report and chart review. The primary outcome was the 6-month Glasgow Outcome Scale-Extended TBI version (GOSE-TBI). Secondary 6-month outcomes included the Rivermead Post-Concussion Symptoms Questionnaire (RPQ), the Satisfaction with Life Scale (SWLS), and the 18-item Brief Symptom Inventory Global Severity Index (BSI-18-GSI).

RESULTS

Mean age of participants was 42 years, 31% were women, and 16% were Black. Current smoking was the most common vascular risk factor (29%), followed by hypertension (17%), diabetes (8%), and hyperlipidemia (6%). Smoking was the only risk factor associated with worse scores on all 4 outcome indices. Hypertension and diabetes were associated with worse RPQ scores, and hypertension was associated with worse BSI-18-GSI scores (all P < .05). Compared with individuals with no vascular risk factors, individuals with 1 but not 2 or more vascular risk factors had significantly worse GOSE-TBI and SWLS scores, while a higher burden of vascular risk factors was significantly associated with worse RPQ and BSI-18-GSI scores.

CONCLUSION

Our study found that preinjury vascular risk factors, especially smoking, are associated with worse outcomes after TBI. Aggressive postinjury treatment of vascular risk factors may be a promising strategy to improve TBI outcomes.

Diffusion-Weighted Imaging in Mild Traumatic Brain Injury: A Systematic Review of the Literature

There is evidence that diffusion-weighted imaging (DWI) is able to detect tissue alterations following mild traumatic brain injury (mTBI) that may not be observed on conventional neuroimaging; however, findings are often inconsistent between studies. This systematic review assesses patterns of differences in DWI metrics between those with and without a history of mTBI. A PubMed literature search was performed using relevant indexing terms for articles published prior to May 14, 2020. Findings were limited to human studies using DWI in mTBI. Articles were excluded if they were not full-length, did not contain original data, if they were case studies, pertained to military populations, had inadequate injury severity classification, or did not report post-injury interval. Findings were reported independently for four subgroups: acute/subacute pediatric mTBI, acute/subacute adult mTBI, chronic adult mTBI, and sport-related concussion, and all DWI acquisition and analysis methods used were included. Patterns of findings between studies were reported, along with strengths and weaknesses of the current state of the literature. Although heterogeneity of sample characteristics and study methods limited the consistency of findings, alterations in DWI metrics were most commonly reported in the corpus callosum, corona radiata, internal capsule, and long association pathways. Many acute/subacute pediatric studies reported higher FA and lower ADC or MD in various regions. In contrast, acute/subacute adult studies most commonly indicate lower FA within the context of higher MD and RD. In the chronic phase of recovery, FA may remain low, possibly indicating overall demyelination or Wallerian degeneration over time. Longitudinal studies, though limited, generally indicate at least a partial normalization of DWI metrics over time, which is often associated with functional improvement. We conclude that DWI is able to detect structural mTBI-related abnormalities that may persist over time, although future DWI research will benefit from larger samples, improved data analysis methods, standardized reporting, and increasing transparency.

Predictors of Social Participation Outcome after Traumatic Brain Injury Differ According to Rehabilitation Pathways

Social participation (SP) is one of many objectives in the rehabilitation of patients with traumatic brain injury (TBI). Studies on predictors of SP specific to post-acute universally accessible specialized rehabilitation pathways following TBI are scarce. Our objectives were to: 1) characterize SP, as well as a set of pre-injury, injury-related, and post-injury variables in individuals participating in inpatient-outpatient or outpatient rehabilitation pathways within a universally accessible and organized trauma continuum of care; and 2) examine the ability of pre-injury, injury-related, and post-injury variables in predicting SP outcome after TBI according to rehabilitation path. Participants (N = 372) were adults admitted to an inpatient-outpatient rehabilitation pathway or an outpatient rehabilitation pathway after sustaining a TBI between 2016 and 2020, and for whom Mayo-Portland Adaptability Intentory-4 (MPAI-4) outcomes were prospectively obtained at the start and end of rehabilitation. Additional data was collected from medical files. For both rehabilitation pathways, predicted SP outcome was MPAI-4 Participation score at discharge from outpatient rehabilitation. Multiple regression models investigated the predictive value of each variable for SP outcome, separately for each care pathway. Main findings show that for the inpatient-outpatient sample, three variables (education years, MPAI-4 Ability and Adjustment scores at rehabilitation intake) significantly predicted SP outcome, with the regression model accounting for 49% of the variance. For the outpatient sample, five variables (pre-morbid hypertension and mental health diagnosis, total indirect rehabilitation hours received, MPAI-4 Abilities and Adjustment scores at rehabilitation intake) significantly predicted SP outcome, with the regression model accounting for 47% of the variance. In conclusion, different pre-morbid and post-injury variables are involved in predicting SP, depending on the rehabilitation path followed. The predictive value of those variables could help clinicians identify patients more likely of showing poorer SP at discharge and who may require additional or different interventions.

An Observational Cohort Study of the Role of Level of Effort in Post-Acute Brain Injury Rehabilitation

OBJECTIVE

To investigate the role of participant level of effort (LoE) on outcome in post-acute brain injury rehabilitation with the hypothesis that greater effort is associated with more positive outcomes.

DESIGN

Observational cohort study.

SETTING

Comprehensive integrated rehabilitation program for brain injury within a skilled nursing facility.

PARTICIPANTS

Consecutive admissions with acquired brain injury (N=101).

INTERVENTIONS

Individualized interdisciplinary brain injury rehabilitation; therapist rating of participant LoE with Acquired Brain Injury LoE Scale (ABI-LoES) during physical therapy, occupational therapy, and speech and language pathology sessions.

MAIN OUTCOME MEASURES

Mayo-Portland Adaptability Inventory, fourth edition (MPAI-4); Supervision Rating Scale (SRS).

RESULTS

Linear regression showed that discharge MPAI-4 Total T scores were significantly associated with mean ABI-LoES rating, admission MPAI-4 Total T scores, age at admission, and days from injury but not with standard deviation of ABI-LoES rating, sex, injury type, length of stay, or treatment before or during the COVID-19 pandemic. Discharge SRS scores were significantly associated with mean ABI-LoES rating, admission SRS scores, and age. A 1-unit increase in mean ABI-LoES rating was associated with 5.1-unit lower discharge MPAI-4 Total T scores and 1.5 lower discharge SRS scores, after controlling for other variables. Logistic regression showed that the odds of achieving a minimal clinically important difference on the MPAI-4 were 8.34 times higher with each 1-unit increase in mean ABI-LoES rating after controlling for other variables. Admission MPAI-4 was negatively associated with mean ABI-LoES rating (β=-0.07, t=-8.85, P<.0001).

CONCLUSIONS

After controlling for nonmodifiable variables, average ABI-LoES rating is positively associated with outcome. Initial level of disability is negatively associated with mean ABI-LoES rating.

Replicability of proton MR spectroscopic imaging findings in mild traumatic brain injury: Implications for clinical applications

PURPOSE

Proton magnetic resonance spectroscopy (1H MRS) offers biomarkers of metabolic damage after mild traumatic brain injury (mTBI), but a lack of replicability studies hampers clinical translation. In a conceptual replication study design, the results reported in four previous publications were used as the hypotheses (H1-H7), specifically: abnormalities in patients are diffuse (H1), confined to white matter (WM) (H2), comprise low N-acetyl-aspartate (NAA) levels and normal choline (Cho), creatine (Cr) and myo-inositol (mI) (H3), and correlate with clinical outcome (H4); additionally, a lack of findings in regional subcortical WM (H5) and deep gray matter (GM) structures (H6), except for higher mI in patients' putamen (H7).

METHODS

26 mTBI patients (20 female, age 36.5 ± 12.5 [mean ± standard deviation] years), within two months from injury and 21 age-, sex-, and education-matched healthy controls were scanned at 3 Tesla with 3D echo-planar spectroscopic imaging. To test H1-H3, global analysis using linear regression was used to obtain metabolite levels of GM and WM in each brain lobe. For H4, patients were stratified into non-recovered and recovered subgroups using the Glasgow Outcome Scale Extended. To test H5-H7, regional analysis using spectral averaging estimated metabolite levels in four GM and six WM structures segmented from T1-weighted MRI. The Mann-Whitney U test and weighted least squares analysis of covariance were used to examine mean group differences in metabolite levels between all patients and all controls (H1-H3, H5-H7), and between recovered and non-recovered patients and their respectively matched controls (H4). Replicability was defined as the support or failure to support the null hypotheses in accordance with the content of H1-H7, and was further evaluated using percent differences, coefficients of variation, and effect size (Cohen's d).

RESULTS

Patients' occipital lobe WM Cho and Cr levels were 6.0% and 4.6% higher than controls', respectively (Cho, d = 0.37, p = 0.04; Cr, d = 0.63, p = 0.03). The same findings, i.e., higher patients' occipital lobe WM Cho and Cr (both p = 0.01), but with larger percent differences (Cho, 8.6%; Cr, 6.3%) and effect sizes (Cho, d = 0.52; Cr, d = 0.88) were found in the comparison of non-recovered patients to their matched controls. For the lobar WM Cho and Cr comparisons without statistical significance (frontal, parietal, temporal), unidirectional effect sizes were observed (Cho, d = 0.07 - 0.37; Cr, d = 0.27 - 0.63). No differences were found in any metabolite in any lobe in the comparison between recovered patients and their matched controls. In the regional analyses, no differences in metabolite levels were found in any GM or WM region, but all WM regions (posterior, frontal, corona radiata, and the genu, body, and splenium of the corpus callosum) exhibited unidirectional effect sizes for Cho and Cr (Cho, d = 0.03 - 0.34; Cr, d = 0.16 - 0.51).

CONCLUSIONS

We replicated findings of diffuse WM injury, which correlated with clinical outcome (supporting H1-H2, H4). These findings, however, were among the glial markers Cho and Cr, not the neuronal marker NAA (not supporting H3). No differences were found in regional GM and WM metabolite levels (supporting H5-H6), nor in putaminal mI (not supporting H7). Unidirectional effect sizes of higher patients' Cho and Cr within all WM analyses suggest widespread injury, and are in line with the conclusion from the previous publications, i.e., that detection of WM injury may be more dependent upon sensitivity of the 1H MRS technique than on the selection of specific regions. The findings lend further support to the corollary that clinic-ready 1H MRS biomarkers for mTBI may best be achieved by using high signal-to-noise-ratio single-voxels placed anywhere within WM. The biochemical signature of the injury, however, may differ and therefore absolute levels, rather than ratios may be preferred. Future replication efforts should further test the generalizability of these findings.

Outcome measures in neurosurgery: Is a unified approach better? A literature review

Background

Accurate assessment and evaluation of health interventions are crucial to evidence-based care. The use of outcome measures in neurosurgery grew with the introduction of the Glasgow Coma Scale. Since then, various outcome measures have appeared, some of which are disease-specific and others more generally. This article aims to address the most widely used outcome measures in three major neurosurgery subspecialties, "vascular, traumatic, and oncologic," focusing on the potential, advantages, and drawbacks of a unified approach to these outcome measures.

Methods

A literature review search was conducted by using PubMed MEDLINE and Google scholar Databases. Data for the three most common outcome measures, The Modified Rankin Scale (mRS), The Glasgow Outcome Scale (GOS), and The Karnofsky Performance Scale (KPS), were extracted and analyzed.

Results

The original objective of establishing a standardized, common language for the accurate categorization, quantification, and evaluation of patients' outcomes has been eroded. The KPS, in particular, may provide a common ground for initiating a unified approach to outcome measures. With clinical testing and modification, it may offer a simple, internationally standardized approach to outcome measures in neurosurgery and elsewhere. Based on our analysis, Karnofsky's Performance Scale may provide a basis of reaching a unified global outcome measure.

Conclusion

Outcome measures in neurosurgery, including mRS, GOS, and KPS, are widely utilized assessment tools for patients' outcomes in various neurosurgical specialties. A unified global measure may offer solutions with ease of use and application; however, there are limitations.

Mental effort and recovery from task-induced fatigue in people with traumatic brain injury

PURPOSE

This exploratory case-controlled study examined whether the same amount of effort leads to similar feelings of fatigue and whether feelings of fatigue decline at the same rate in people with traumatic brain injury (pwTBI) compared to controls.

METHODS

Twenty pwTBI and 20 healthy controls (HC) completed an adaptive n-back task to induce fatigue and reported mental effort upon task completion and state-fatigue pre-task and several times during 30-minutes rest-period post-task. Task difficulty adapted to performance allowing both groups to invest substantial amounts of mental effort.

RESULTS

Fatigue and effort levels were higher in pwTBI compared to controls. Multiple linear regression analyses showed that effort was positively related to post-task fatigue and this relationship did not differ between groups. Pre-task fatigue was the only predictor of post-task fatigue. Multilevel models showed no significant difference in decline of fatigue over the rest-period between groups.

CONCLUSIONS

Excessive feelings of fatigue following TBI could not be explained by a higher vulnerability to the fatigue-inducing effects of mental effort needed to perform a specific task. In pwTBI pre-task fatigue levels might be more related to the complex demands of everyday life. Future studies should investigate recovery of fatigue and applications of this knowledge to rehabilitation interventions.Implications for rehabilitationPeople with TBI experience long-term fatigue as one of the most frequent and disabling symptoms and this long-term fatigue is a risk factor for development of secondary psychiatric symptoms such as depression or anxiety.Since people with TBI did not show a higher vulnerability to the fatigue-inducing effects of mental effort, fatigue following TBI might be better explained by the complex demands of everyday life such as external (environment) and internal (emotions) factors.Rehabilitation programs should be directed to this complex and highly individual interplay of fatigue in relation to other factors.

Use of Olanzapine to Treat Agitation in Traumatic Brain Injury: A Series of N-of-One Trials

Agitation is common during post-traumatic amnesia (PTA) following traumatic brain injury (TBI) and is associated with risk of harm to patients and caregivers. Antipsychotics are frequently used to manage agitation in early TBI recovery despite limited evidence to support their efficacy, safety, and impact upon patient outcomes. The sedating and cognitive side effects of these agents are theorized to exacerbate confusion during PTA, leading to prolonged PTA duration and increased agitation. This study, conducted in a subacute inpatient rehabilitation setting, describes the results of a double-blind, randomized, placebo-controlled trial investigating the efficacy of olanzapine for agitation management during PTA, analyzed as an n-of-1 series. Group comparisons were additionally conducted, examining level of agitation; number of agitated days; agitation at discharge, duration, and depth of PTA; length of hospitalization; cognitive outcome; adverse events; and rescue medication use. Eleven agitated participants in PTA (mean [M] age = 39.82 years, standard deviation [SD] = 20.06; mean time post-injury = 46.09 days, SD = 32.75) received oral olanzapine (n = 5) or placebo (n = 6) for the duration of PTA, beginning at a dose of 5 mg/day and titrated every 3 to 4 days to a maximum dose of 20 mg/day. All participants received recommended environmental management for agitation. A significant decrease in agitation with moderate to very large effect (Tau-U effect size = 0.37-0.86) was observed for three of five participants receiving olanzapine, while no significant reduction in agitation over the PTA period was observed for any participant receiving placebo. Effective olanzapine dose ranged from 5-20 mg. Response to treatment was characterized by lower level of agitation and response to treatment within 3 days. In group analyses, participants receiving olanzapine demonstrated poorer orientation and memory during PTA with large effect size (olanzapine, mean = 9.32, SD = 0.69; placebo, M = 10.68, SD = 0.30; p = .009, d = -2.16), and a trend toward longer PTA duration with large effect size (olanzapine, M = 71.96 days, SD = 20.31; placebo, M = 47.50 days, SD = 11.27; p = 0.072, d = 1.26). No further group comparisons were statistically significant. These results suggest that olanzapine can be effective in reducing agitation during PTA, but not universally so. Importantly, administration of olanzapine during PTA may lead to increased patient confusion, possibly prolonging PTA. When utilizing olanzapine, physicians must therefore balance the possible advantages of agitation management with the possibility that the patient may never respond to the medication and may experience increased confusion, longer PTA and potentially poorer outcomes. Further high-quality research is required to support these findings and the efficacy and outcomes associated with the use of any pharmacological agent for the management of agitation during the PTA period.

Vocational/educational prognosis in adolescents and young adults with acquired brain injury: a nationwide cohort study

OBJECTIVE

To determine prognostic factors for work ability and employment/educational status among young patients referred to outpatient neurorehabilitation clinics after an acquired brain injury.

METHODS

A nationwide cohort study of 471 15-30-year-old patients who attended an interdisciplinary clinical assessment and provided questionnaire data at baseline and after one year. The outcomes were the Work Ability Score (WAS, 0-10 (best)) and employment/educational status after one year. Prognostic performance was analyzed using univariable regression and multivariable Ridge regression in a five-fold cross-validated procedure.

RESULTS

Preinjury, 86% of the patients were employed, while the percentage had decreased to 55% at baseline and 52% at follow-up. The model, which included clinical measures of function, showed moderate prognostic performance with respect to WAS (R2=0.29) and employment/educational status (area under the curve (AUC)=0.77). Glasgow Outcome Scale Extended (R2=0.15, AUC=0.68) and the cognitive subscale of the Functional Independence Measure (R2=0.09, AUC=0.64), along with fatigue measured with the Multidimensional Fatigue Inventory (R2=0.15, AUC=0.60) were the single predictors with the highest predictive performance.

CONCLUSION

Despite generally high scores in motor and cognitive tests, only about half of the patients were employed at baseline and this proportion remained stable. Global disability, cognitive sequelae and fatigue had the highest prognostic performance.

Facebook Experiences of Users With Traumatic Brain Injury: A Think-Aloud Study

BACKGROUND

A critical gap in our knowledge about social media is whether we can alleviate accessibility barriers and challenges for individuals with traumatic brain injury (TBI), to improve their social participation and health. To do this, we need real-time information about these barriers and challenges, to design appropriate aids.

OBJECTIVE

The aim of this study was to characterize the ways people with TBI accessed and used social media websites and understand unique challenges they faced.

METHODS

We invited 8 adults with moderate to severe TBI to log onto their own Facebook page and use it as they regularly would while thinking aloud. Their comments were recorded and transcribed for qualitative analysis. We first analyzed participants' utterances using a priori coding based on a framework proposed by Meshi et al to classify adults' motives for accessing social media. We next used an open coding method to understand the challenges that people with TBI faced while using Facebook. In other words, we analyzed participants' needs for using Facebook and then identified Facebook features that made it challenging for them to meet those needs.

RESULTS

Participants used all categories of codes in the framework by Meshi et al and provided detailed feedback about the Facebook user interface. A priori coding revealed 2 dimensions that characterized participants' Facebook use: whether they were active or passive about posting and self-disclosure on Facebook and their familiarity and fluency in using Facebook. The open coding analysis revealed 6 types of challenges reported by participants with TBI, including difficulty with language production and interpretation, attention and information overload, perceptions of negativity and emotional contagion, insufficient guidance to use Facebook, concerns about web-based scams and frauds, and general accessibility concerns.

CONCLUSIONS

Results showed that individuals with TBI used Facebook for the same reasons typical adults do, suggesting that it can help increase social communication and reduce isolation and loneliness. Participants also identified barriers, and we propose modifications that could improve access for individuals with brain injury. On the basis of identified functions and challenges, we conclude by proposing design ideas for social media support tools that can promote more active use of social media sites by adults with TBI.

Informing the development of an outcome set and banks of items to measure mobility among individuals with acquired brain injury using natural language processing

BACKGROUND

The sheer number of measures evaluating mobility and inconsistencies in terminology make it challenging to extract potential core domains and items. Automating a portion of the data synthesis would allow us to cover a much larger volume of studies and databases in a smaller fraction of the time compared to the usual process. Thus, the objective of this study was to identify a comprehensive outcome set and develop preliminary banks of items of mobility among individuals with acquired brain injury (ABI) using Natural Language Processing (NLP).

METHODS

An umbrella review of 47 reviews evaluating the content of mobility measures among individuals with ABI was conducted. A search was performed on 5 databases between 2000 and 2020. Two independent reviewers retrieved copies of the measures and extracted mobility domains and items. A pre-trained BERT model (state-of-the-art model for NLP) provided vector representations for each sentence. Using the International Classification of Functioning, Disability, and Health Framework (ICF) ontology as a guide for clustering, a k-means algorithm was used to retrieve clusters of similar sentences from their embeddings. The resulting embedding clusters were evaluated using the Silhouette score and fine-tuned according to expert input.

RESULTS

The study identified 246 mobility measures, including 474 domains and 2109 items. Encoding the clusters using the ICF ontology and expert knowledge helped in regrouping the items in a way that is more closely related to mobility terminology. Our best results identified banks of items that were used to create a 24 comprehensive outcome sets of mobility, including Upper Extremity Mobility, Emotional Function, Balance, Motor Control, Self-care, Social Life and Relationships, Cognition, Walking, Postural Transition, Recreation, and Leisure Activities, Activities of Daily Living, Physical Functioning, Communication, Work/Study, Climbing, Sensory Functions, General Health, Fatigue, Functional Independence, Pain, Alcohol and Drugs Use, Transportation, Sleeping, and Finances.

CONCLUSION

The banks of items of mobility domains represent a first step toward establishing a comprehensive outcome set and a common language of mobility to develop the ontology. It enables researchers and healthcare professionals to begin exposing the content of mobility measures as a way to assess mobility comprehensively.

Behavioral intervention approaches for people with disorders of consciousness: a scoping review

PURPOSE

This review was intended to provide an overall picture of work conducted during the last decade to assess the impact of behavioral intervention strategies on people with disorders of consciousness (i.e., comatose state, vegetative state/unresponsive wakefulness, or minimally conscious state). The intervention strategies considered were those not based on music or including music as a component of the intervention package.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist, a scoping review was carried out to identify and provide a synthesis of eligible studies published in English during the 2010-2021 period. Three databases (i.e., PubMed, PsycINFO, and Web of Science) were employed for the literature search.

RESULTS

Forty studies met the inclusion criteria. Those studies were grouped into three categories based on whether they assessed the effects of: (i) verbal stories/messages, (ii) multiple stimulation, and (iii) response-contingent stimulation. Then, a narrative synthesis of the studies of each of the three categories was provided to specify the types of patients involved, the intervention and assessment conditions implemented, and the outcome attained.

CONCLUSIONS

The evidence reported in most of the studies might be considered encouraging and convincing. Even so, it might be very difficult to view the evidence of the various studies cumulatively and make general/conclusive statements due to a number of differences in the intervention conditions applied.Implications for rehabilitationAn informative picture of the studies using behavioral interventions with people with disorders of consciousness is essential to any professional working in the area.Such picture can be highly useful in providing a view of the intervention strategies used for those people, of the variations existing within and across strategies, and of the evidence available.An analysis of the strategies, their implementation and their effects may provide new insights for improving those strategies and eventually increasing their impact.The individuals charged with the implementation process (e.g., family members or nurses) may have a relevant influence on the overall impact of the strategy.

Patient-reported outcome measures as an outcome variable in sports medicine research

Injury prevention and rehabilitation research often address variables that would be considered clinician-oriented outcomes, such as strength, range of motion, laxity, and return-to-sport. While clinician-oriented variables are helpful in describing the physiological recovery from injury, they neglect the patient perspective and aspects of patient-centered care. Variables that capture patient perspective are essential when considering the impact of injury and recovery on the lives of patients. The inclusion of patient-reported outcome measures (PROMs) as dependent variables in sports medicine research, including injury prevention and rehabilitation research, provides a unique perspective regarding the patient's perception of their health status, the effectiveness of treatments, and other information that the patient deems important to their care. Over the last 20 years, there has been a significant increase in the use of PROMs in sports medicine research. The growing body of work gives opportunity to reflect on what has been done and to provide some ideas of how to strengthen the evidence moving forward. This mini-review will discuss ideas for the inclusion of PROMs in sports medicine research, with a focus on critical factors, gaps, and future directions in this area of research. Important elements of research with PROMs, including instrument selection, administration, and interpretation, will be discussed and areas for improvement, consideration, and standardization will be provided.

Reference Values for the Rivermead Post-Concussion Symptoms Questionnaire (RPQ) from General Population Samples in the United Kingdom, Italy, and The Netherlands

After traumatic brain injury (TBI), individuals may experience short- or long-term health burdens, often referred to as post-concussion symptoms (PCS). The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) is one of the commonly used instruments to assess self-reported PCS. To date, no reference values for RPQ have been provided, although they are crucial for clinical practice when evaluating a patient’s health status relative to a comparable healthy population. Therefore, the aim of this study is to provide reference values for the United Kingdom, the Netherlands, and Italy. A total of 11,759 individuals (50.3% women) from representative general population samples participated in an online survey (4646 individuals from the UK, 3564 from the Netherlands, and 3549 from Italy). The factorial structure of the RPQ was examined using confirmatory factor analysis (CFA), and results from the general population samples were compared with those from respective TBI samples recruited within the international CENTER-TBI study using multigroup CFA. Reference values were stratified by sex, health status, age, and education using percentiles. The three-factorial model outperformed the one-factorial structure. The general population samples were largely comparable to the corresponding TBI samples, except for items such as dizziness, vision, and sensory sensitivity, which can be considered more TBI-specific. Because of the significant differences between the general population samples, we provided reference values for the total score and for the somatic, emotional, and cognitive scales for each country separately. The reference values provided can now be used in clinical practice and research. Future studies should obtain stratified reference values for other countries and languages to improve accuracy in the diagnosis and treatment of symptom burden after TBI.

Predicting Clinical Outcomes 7-10 Years after Severe Traumatic Brain Injury: Exploring the Prognostic Utility of the IMPACT Lab Model and Cerebrospinal Fluid UCH-L1 and MAP-2

BACKGROUND

Severe traumatic brain injury (TBI) is a major contributor to disability and mortality in the industrialized world. Outcomes of severe TBI are profoundly heterogeneous, complicating outcome prognostication. Several prognostic models have been validated for acute prediction of 6-month global outcomes following TBI (e.g., morbidity/mortality). In this preliminary observational prognostic study, we assess the utility of the International Mission on Prognosis and Analysis of Clinical Trials in TBI (IMPACT) Lab model in predicting longer term global and cognitive outcomes (7-10 years post injury) and the extent to which cerebrospinal fluid (CSF) biomarkers enhance outcome prediction.

METHODS

Very long-term global outcome was assessed in a total of 59 participants (41 of whom did not survive their injuries) using the Glasgow Outcome Scale-Extended and Disability Rating Scale. More detailed outcome information regarding cognitive functioning in daily life was collected from 18 participants surviving to 7-10 years post injury using the Cognitive Subscale of the Functional Independence Measure. A subset (n = 10) of these participants also completed performance-based cognitive testing (Digit Span Test) by telephone. The IMPACT lab model was applied to determine its prognostic value in relation to very long-term outcomes as well as the additive effects of acute CSF ubiquitin C-terminal hydrolase-L1 (UCH-L1) and microtubule associated protein 2 (MAP-2) concentrations.

RESULTS

The IMPACT lab model discriminated favorable versus unfavorable 7- to 10-year outcome with an area under the receiver operating characteristic curve of 0.80. Higher IMPACT lab model risk scores predicted greater extent of very long-term morbidity (β = 0.488 p = 0.000) as well as reduced cognitive independence (β =  - 0.515, p = 0.034). Acute elevations in UCH-L1 levels were also predictive of lesser independence in cognitive activities in daily life at very long-term follow-up (β = 0.286, p = 0.048). Addition of two CSF biomarkers significantly improved prediction of very long-term neuropsychological performance among survivors, with the overall model (including IMPACT lab score, UCH-L1, and MAP-2) explaining 89.6% of variance in cognitive performance 7-10 years post injury (p = 0.008). Higher acute UCH-L1 concentrations were predictive of poorer cognitive performance (β =  - 0.496, p = 0.029), whereas higher acute MAP-2 concentrations demonstrated a strong cognitive protective effect (β = 0.679, p = 0.010).

CONCLUSIONS

Although preliminary, results suggest that existing prognostic models, including models with incorporation of CSF markers, may be applied to predict outcome of severe TBI years after injury. Continued research is needed examining early predictors of longer-term outcomes following TBI to identify potential targets for clinical trials that could impact long-ranging functional and cognitive outcomes.

Integrating Cognitive Dysfunction Accommodation Strategies into an HIV Prevention Session: A 2-Arm Pilot Feasibility Study

Cognitive dysfunction is prevalent among persons on medication for opioid use disorder (MOUD). This cognitive dysfunction has been shown to reduce HIV treatment engagement and medication adherence. We investigated the impact of integrating specific behavioral strategies into an HIV prevention session to accommodate cognitive dysfunction among people on MOUD. Patients on MOUD (n = 20) were randomized to one of two different HIV prevention conditions. The same HIV risk reduction content was presented to both conditions; however, the experimental condition had accommodation strategies integrated into the session. Participants completed a skills checklist at pre-, post-, and 2-week follow-up to examine the level of HIV risk reduction content learned and utilized over time. Participants in the experimental condition indicated high acceptability (95%) for the accommodation strategies. These participants also demonstrated greater improvement in the ability to properly clean a syringe, from pre- to post- (p < 0.02) and from pre- to follow-up (p < 0.02) when compared to participants in the standard condition. Results from this pilot study indicate that accommodation strategies improved participants’ ability to learn, retain, and utilize risk reduction skills over time. This foundation of research indicates a promising, innovative strategy to increase the ability for persons on MOUD to engage in HIV prevention behaviors.

Comparability of (Post-Concussion) Symptoms across Time in Individuals after Traumatic Brain Injury: Results from the CENTER-TBI Study

Post-concussion symptoms often occur after TBI, persist and cause disabilities. The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) is widely used in this population, but little is known about the comparability of the symptoms over time, i.e., longitudinal measurement invariance (MI). The objectives of this study were to analyze the longitudinal MI of RPQ symptoms from three to twelve months after TBI and to find factors related to RPQ symptoms. The study involved 1023 individuals after TBI who took part in the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study and completed the RPQ at three, six and twelve months post-injury. Longitudinal confirmatory factor analysis showed that the three-factor structure (somatic, emotional and cognitive) remains stable within one year after TBI. Linear mixed models revealed that sex, injury cause and prior psychiatric problems were related to the RPQ three-factor structure as well as to the RPQ total score. The study strengthens evidence for the RPQ’s factorial structure stability within one year after TBI and identifies sex, injury cause and prior psychiatric problems as important factors that may help clinicians to prevent future complications of symptomatology after TBI.

Predicting Global Functional Outcomes Among Post-traumatic Epilepsy Patients After Moderate-to-Severe Traumatic Brain Injury: Development of a Prognostic Model

Objective

The development of post-traumatic epilepsy (PTE) following traumatic brain injury (TBI) is associated with unfavorable functional outcomes, and the global function of PTE patients might change dynamically overtime. Predicting the long-term functional outcomes of patients with PTE may help to develop accurate rehabilitation programs and improve their quality of life. Based on this, the objective of this study is to use clinical data to derive and validate a model for predicting the functional outcomes of patients with PTE after moderate-to-severe TBI.

Methods

This study retrospectively analyzed 721 patients with PTE after moderate-to-severe TBI in the Epilepsy Centre, Beijing Tiantan Hospital, from January 2013 to December 2018. All patients had favorable global function as indicated by the Glasgow Outcome Scale-Extended (GOSE) at the time of their first late post-traumatic seizure (PTS) onset, and the 5-year global function after the first late PTS onset was chosen as the principal outcome of interest. To identify possible predictors for the global functional outcomes, univariate and multivariate logistic regression techniques were used. A prognostic model was established using these identified predictors, the internal validation with the bootstrapping method was performed, and the model was then visualized as a graphical score chart.

Results

The 5-year global functional outcome of 98 (13.59%) patients was unfavorable, and the temporal lobe lesion was found as the strongest predictor of unfavorable outcomes. The final prognostic model also included the following other predictors: gender, age at TBI, multiple injuries, the severity of TBI, and latency of PTE. Discrimination was satisfactory with C-statistic of 0.754 (0.707 – 0.800), the goodness-of-fit test indicated good calibration (P = 0.137), and the C-statistic was 0.726 for internal validation. A graphical score chart was also constructed to provide the probability of an unfavorable 5-year global functional outcomes more readily.

Conclusions

Clearer treatment strategies are essential to help ameliorate the global functional outcomes of patients with PTE. Our proposed prognostic model has significant potential to be used in the clinic for predicting global functional outcomes among patients with PTE after moderate-to-severe TBI.

Behavioral Assessment of Patients with Disorders of Consciousness

Severe brain injury is associated with a period of impaired level of consciousness that can last from days to months and results in chronic impairment. Systematic assessment of level of function in patients with disorders of consciousness (DoC) is critical for diagnosis, prognostication, and evaluation of treatment efficacy. Approximately 40% of patients who are thought to be unconscious based on clinical bedside behavioral assessment demonstrate some signs of consciousness on standardized behavioral assessment. This finding, in addition to a growing body of literature demonstrating the advantages of standardized behavioral assessment of DoC, has led multiple professional societies and clinical guidelines to recommend standardized assessment over routine clinical evaluation of consciousness. Nevertheless, even standardized assessment is susceptible to biases and misdiagnosis, and examiners should consider factors, such as fluctuating arousal and aphasia, that may confound evaluation. We review approaches to behavioral assessment of consciousness, recent clinical guideline recommendations for use of specific measures to evaluate patients with DoC, and strategies for mitigating common biases that may confound the examination.

Tailoring multidimensional outcomes to level of functional recovery after traumatic brain injury

There is increasing emphasis on multi-dimensional outcomes in traumatic brain injury (TBI), but achieving this aim is hampered by a plethora of overlapping assessment tools. There is a clear need for advice on the choice of outcomes and we examine level of functional recovery as a framework to guide selection of assessments. In this cohort study we analysed cross-sectional data from 2604 patients enrolled in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) project. Patients were followed up 6 months after injury and assessed on the Glasgow Outcome Scale-Extended (GOSE), cognitive tests, and patient-reported outcomes. We describe assessment completeness and prevalence of impairment. Relationships between outcomes were visualized using UpSet plots and hierarchical cluster analysis. GOSE categories varied markedly for both completion rates, 34-91% for patient reported outcomes and 9-81% for cognitive tests, and prevalence of impairment, 3-82% for patient reported outcomes and 9-59% for cognitive tests. In complete case samples, the GOSE identified impairment in 59-61%, while the most impaired patient reported outcome was the Short-Form 12 Physical Component Summary (28% overall), and the most impaired cognitive test was Trail Making Test Part A (19% overall). The findings show that degree of disability is a key context of use for cognitive tests and patient reported outcomes. Level of functional recovery provides a guide to the feasibility of different types of assessment and the likelihood of impairment, and can help tailor suitable assessment approaches to individuals and groups.

Independent and Synergistic Associations Between TBI Characteristics and PTSD Symptom Clusters on Cognitive Performance and Postconcussive Symptoms in Iraq and Afghanistan Veterans

OBJECTIVE

The investigators sought to evaluate the independent and interactive associations between mild traumatic brain injury (mTBI) characteristics and posttraumatic stress disorder (PTSD) symptoms with regard to postconcussive symptoms and cognition among treatment-seeking veterans of the U.S. conflicts in Iraq and Afghanistan.

METHODS

Sixty-seven Iraq and Afghanistan veterans who had a history of mTBI and comorbid PTSD were grouped based on injury mechanism (blast versus nonblast) and number of lifetime mTBIs (one to two versus three or more). Independent associations between mTBI characteristics and PTSD symptom clusters were evaluated with regard to cognition and postconcussive symptoms. Follow-up analyses were conducted to determine any interactive associations between TBI characteristics and PTSD symptom clusters.

RESULTS

Higher PTSD symptoms, particularly hyperarousal, were associated with poorer executive functioning and higher postconcussive symptoms. No direct relationships were observed between PTSD symptom clusters and memory or processing speed. The relationship between hyperarousal and processing speed was moderated by lifetime mTBIs, such that those with a history of at least three mTBIs demonstrated a negative association between hyperarousal and processing speed. Blast-related mTBI history was associated with reduced processing speed, compared with non-blast-related mTBI. However, an interaction was observed such that among those with blast-related mTBI history, higher re-experiencing symptoms were associated with poorer processing speed, whereas veterans without history of blast-related mTBI did not demonstrate an association between processing speed and re-experiencing symptoms.

CONCLUSIONS

Higher hyperarousal and re-experiencing symptoms were associated with reduced processing speed among veterans with repetitive and blast-related mTBI history, respectively. PTSD symptoms, specifically hyperarousal, were associated with poorer executive functioning and higher postconcussive symptoms. Limited associations were found between injury characteristics and cognition chronically following mTBI. However, these results support synergistic effects of specific PTSD symptom clusters and TBI characteristics.

Randomized Evaluation of Surgery in Elderly with Traumatic Acute SubDural Hematoma (RESET-ASDH trial): study protocol for a pragmatic randomized controlled trial with multicenter parallel group design

BACKGROUND

The rapidly increasing number of elderly (≥ 65 years old) with TBI is accompanied by substantial medical and economic consequences. An ASDH is the most common injury in elderly with TBI and the surgical versus conservative treatment of this patient group remains an important clinical dilemma. Current BTF guidelines are not based on high-quality evidence and compliance is low, allowing for large international treatment variation. The RESET-ASDH trial is an international multicenter RCT on the (cost-)effectiveness of early neurosurgical hematoma evacuation versus initial conservative treatment in elderly with a t-ASDH METHODS: In total, 300 patients will be recruited from 17 Belgian and Dutch trauma centers. Patients ≥ 65 years with at first presentation a GCS ≥ 9 and a t-ASDH > 10 mm or a t-ASDH < 10 mm and a midline shift > 5 mm, or a GCS < 9 with a traumatic ASDH < 10 mm and a midline shift < 5 mm without extracranial explanation for the comatose state, for whom clinical equipoise exists will be randomized to early surgical hematoma evacuation or initial conservative management with the possibility of delayed secondary surgery. When possible, patients or their legal representatives will be asked for consent before inclusion. When obtaining patient or proxy consent is impossible within the therapeutic time window, patients are enrolled using the deferred consent procedure. Medical-ethical approval was obtained in the Netherlands and Belgium. The choice of neurosurgical techniques will be left to the discretion of the neurosurgeon. Patients will be analyzed according to an intention-to-treat design. The primary endpoint will be functional outcome on the GOS-E after 1 year. Patient recruitment starts in 2022 with the exact timing depending on the current COVID-19 crisis and is expected to end in 2024.

DISCUSSION

The study results will be implemented after publication and presented on international conferences. Depending on the trial results, the current Brain Trauma Foundation guidelines will either be substantiated by high-quality evidence or will have to be altered.

TRIAL REGISTRATION

Nederlands Trial Register (NTR), Trial NL9012 .

CLINICALTRIALS

gov, Trial NCT04648436 .

Longitudinal whole-brain analysis of multi-subject diffusion data in diffuse axonal injury

ABSTRACT Background: Diffuse axonal injury occurs with high acceleration and deceleration forces in traumatic brain injury (TBI). This lesion leads to disarrangement of the neuronal network, which can result in some degree of deficiency. The Extended Glasgow Outcome Scale (GOS-E) is the primary outcome instrument for the evaluation of TBI victims. Diffusion tensor imaging (DTI) assesses white matter (WM) microstructure based on the displacement distribution of water molecules. Objective: To investigate WM microstructure within the first year after TBI using DTI, the patient’s clinical outcomes, and associations. Methods: We scanned 20 moderate and severe TBI victims at 2 months and 1 year after the event. Imaging processing was done with the FMRIB software library; we used the tract-based spatial statistics software yielding fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD) for statistical analyses. We computed the average difference between the two measures across subjects and performed a one-sample t-test and threshold-free cluster enhancement, using a corrected p-value < 0.05. Clinical outcomes were evaluated with the GOS-E. We tested for associations between outcome measures and significant mean FA clusters. Results: Significant clusters of altered FA were identified anatomically using the JHU WM atlas. We found increasing spotted areas of FA with time in the right brain hemisphere and left cerebellum. Extensive regions of increased MD, RD, and AD were observed. Patients presented an excellent overall recovery. Conclusions: There were no associations between FA and outcome scores, but we cannot exclude the existence of a small to moderate association.

Quality of mobility measures among individuals with acquired brain injury: an umbrella review

Background and objective

While several mobility measures exist, there is large variability across measures in how mobility is conceptualized, the source of information and the measurement properties making it challenging to select relevant mobility measures for individuals with acquired brain injury (ABI). Therefore, the objective was to conduct a comprehensive synthesis of existing evidence on the measurement properties, the interpretability and the feasibility of mobility measures from various sources of information (patients, clinicians, technology) using an umbrella review of published systematic reviews among individuals with ABI.

Methods

Ovid MEDLINE, CINHAL, Cochrane Library and EMBASE electronic databases were searched from 2000 to March 2020. Two independent reviewers appraised the methodological quality of the systematic reviews using the Joanna Briggs Institute critical appraisal checklist. Measurement properties and quality of evidence were applied according to COnsensus-based Standards for the Selection of Health Measurement Instrument (COSMIN) guidelines. Mobility measures were categorized using international standards with the international classification of functioning, disability and health (ICF).

Results

Thirty-five systematic reviews were included covering 147 mobility measures, of which 85% were mapped to the ICF Activity and Participation component. Results showed an acceptable overall "sufficient" rating for reliability, construct validity and responsiveness for 132 (90%), 127 (86%) and 76 (52%) of the measures, respectively; however, among these measures, ≤ 25% of the methods for evaluating these properties were rated as ‘high’ quality of evidence. Also, there was limited information that supports measure feasibility and scoring interpretability.

Conclusions

Future systematic reviews should report measures’ content validity to support the use of the measure in clinical care and research. More evaluations of the minimal important difference and floor and ceiling effects are needed to help guide clinical interpretation.

Registration information

International Prospective Register of Systematic Reviews (PROSPERO); ID: CRD42018100068.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-022-03103-4.

Self-Reported Complaints as Prognostic Markers for Outcome After Mild Traumatic Brain Injury in Elderly: A Machine Learning Approach

Self-reported complaints are common after mild traumatic brain injury (mTBI). Particularly in the elderly with mTBI, the pre-injury status might play a relevant role in the recovery process. In most mTBI studies, however, pre-injury complaints are neither analyzed nor are the elderly included. Here, we aimed to identify which individual pre- and post-injury complaints are potential prognostic markers for incomplete recovery (IR) in elderly patients who sustained an mTBI. Since patients report many complaints across several domains that are strongly related, we used an interpretable machine learning (ML) approach to robustly deal with correlated predictors and boost classification performance. Pre- and post-injury levels of 20 individual complaints, as self-reported in the acute phase, were analyzed. We used data from two independent studies separately: UPFRONT study was used for training and validation and ReCONNECT study for independent testing. Functional outcome was assessed with the Glasgow Outcome Scale Extended (GOSE). We dichotomized functional outcome into complete recovery (CR; GOSE = 8) and IR (GOSE ≤ 7). In total 148 elderly with mTBI (median age: 67 years, interquartile range [IQR]: 9 years; UPFRONT: N = 115; ReCONNECT: N = 33) were included in this study. IR was observed in 74 (50%) patients. The classification model (IR vs. CR) achieved a good performance (the area under the receiver operating characteristic curve [ROC-AUC] = 0.80; 95% CI: 0.74-0.86) based on a subset of only 8 out of 40 pre- and post-injury complaints. We identified increased neck pain (p = 0.001) from pre- to post-injury as the strongest predictor of IR, followed by increased irritability (p = 0.011) and increased forgetfulness (p = 0.035) from pre- to post-injury. Our findings indicate that a subset of pre- and post-injury physical, emotional, and cognitive complaints has predictive value for determining long-term functional outcomes in elderly patients with mTBI. Particularly, post-injury neck pain, irritability, and forgetfulness scores were associated with IR and should be assessed early. The application of an ML approach holds promise for application in self-reported questionnaires to predict outcomes after mTBI.

Changes in Outcomes after Discharge from an Acute Hospital in Severe Traumatic Brain Injury

Neurological improvement occurs from the subacute to chronic phases in severe traumatic brain injury. We analyzed factors associated with improved neurological findings in the subacute phase, using data from the Japan Neurotrauma Data Bank (JNTDB). The subjects were 1345 patients registered in the JNTDB (Project 2015). Clinical improvement was evaluated by comparing the Glasgow Outcome Scale (GOS) at discharge and 6 months after injury. Of these patients, 157 with severe disability (SD) on the discharge GOS were examined to evaluate factors associated with neurological improvement in the subacute phase. Cases were defined as those with (group I) and without (group N) improvement: a change from SD at discharge to good recovery (GR) or moderate disability (MD) at 6 months after injury. Patient background, admission findings, treatment, and discharge destination were examined. In all patients, the favorable outcome (GR, MD) rate improved from 30.2% at discharge to 35.7% at 6 months after injury. Of SD cases at discharge, 44.6% had a favorable outcome at 6 months (group I). Patients in group I were significantly younger, and had a significantly lower D-dimer level in initial blood tests and a lower incidence of convulsions. In multivariate analysis, discharge to home was a significant factor associated with an improved outcome. Many SD cases at discharge ultimately showed neurological improvement, and the initial D-dimer level may be a predictor of such improvement. The environment after discharge from an acute care hospital may also contribute to an improved long-term prognosis.