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Bartnik-Olson BL, Alger JR, Babikian T, Harris AD, Holshouser B, Kirov II, Maudsley AA, Thompson PM, Dennis EL, Tate DF, Wilde EA, Lin A. The clinical utility of proton magnetic resonance spectroscopy in traumatic brain injury: recommendations from the ENIGMA MRS working group. Brain Imaging Behav 2021; 15:504-525. [PMID: 32797399 PMCID: PMC7882010 DOI: 10.1007/s11682-020-00330-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Proton (1H) magnetic resonance spectroscopy provides a non-invasive and quantitative measure of brain metabolites. Traumatic brain injury impacts cerebral metabolism and a number of research groups have successfully used this technique as a biomarker of injury and/or outcome in both pediatric and adult TBI populations. However, this technique is underutilized, with studies being performed primarily at centers with access to MR research support. In this paper we present a technical introduction to the acquisition and analysis of in vivo 1H magnetic resonance spectroscopy and review 1H magnetic resonance spectroscopy findings in different injury populations. In addition, we propose a basic 1H magnetic resonance spectroscopy data acquisition scheme (Supplemental Information) that can be added to any imaging protocol, regardless of clinical magnetic resonance platform. We outline a number of considerations for study design as a way of encouraging the use of 1H magnetic resonance spectroscopy in the study of traumatic brain injury, as well as recommendations to improve data harmonization across groups already using this technique.
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Affiliation(s)
| | - Jeffry R Alger
- Departments of Neurology and Radiology, University of California Los Angeles, Los Angeles, CA, USA
- NeuroSpectroScopics LLC, Sherman Oaks, Los Angeles, CA, USA
- Advanced Imaging Research Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Talin Babikian
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, UCLA, Los Angeles, CA, USA
- UCLA Steve Tisch BrainSPORT Program, Los Angeles, CA, USA
| | - Ashley D Harris
- Department of Radiology, University of Calgary, Calgary, Canada
- Child and Adolescent Imaging Research Program, Alberta Children's Hospital Research Institute and the Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Barbara Holshouser
- Department of Radiology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Ivan I Kirov
- Bernard and Irene Schwartz Center for Biomedical Imaging, Center for Advanced Imaging Innovation and Research (CAI2R), Department of Radiology, New York University School of Medicine, New York, NY, USA
| | - Andrew A Maudsley
- Department of Radiology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Paul M Thompson
- Imaging Genetics Center, Stevens Neuroimaging & Informatics Institute, Keck School of Medicine of USC, Marina del Rey, Los Angeles, CA, USA
- Departments of Neurology, Pediatrics, Psychiatry, Radiology, Engineering, and Ophthalmology, USC, Los Angeles, CA, USA
| | - Emily L Dennis
- Imaging Genetics Center, Stevens Neuroimaging & Informatics Institute, Keck School of Medicine of USC, Marina del Rey, Los Angeles, CA, USA
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
- Psychiatry Neuroimaging Laboratory, Brigham & Women's Hospital, Boston, MA, USA
| | - David F Tate
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
- George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, UT, USA
| | - Elisabeth A Wilde
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
- George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, UT, USA
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Alexander Lin
- Center for Clinical Spectroscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Abstract
PURPOSE Traumatic brain injury most commonly affects young adults under the age of 35 and frequently results in reduced quality of life, disability, and death. In long-term survivors, hypopituitarism is a common complication. RESULTS Pituitary dysfunction occurs in approximately 20-40% of patients diagnosed with moderate and severe traumatic brain injury giving rise to growth hormone deficiency, hypogonadism, hypothyroidism, hypocortisolism, and central diabetes insipidus. Varying degrees of hypopituitarism have been identified in patients during both the acute and chronic phase. Anterior pituitary hormone deficiency has been shown to cause morbidity and increase mortality in TBI patients, already encumbered by other complications. Hypopituitarism after childhood traumatic brain injury may cause treatable morbidity in those survivors. Prospective studies indicate that the incidence rate of hypopituitarism may be ten-fold higher than assumed; factors altering reports include case definition, geographic location, variable hospital coding, and lost notes. While the precise pathophysiology of post traumatic hypopituitarism has not yet been elucidated, it has been hypothesized that, apart from the primary mechanical event, secondary insults such as hypotension, hypoxia, increased intracranial pressure, as well as changes in cerebral flow and metabolism may contribute to hypothalamic-pituitary damage. A number of mechanisms have been proposed to clarify the causes of primary mechanical events giving rise to ischemic adenohypophysial infarction and the ensuing development of hypopituitarism. CONCLUSION Future research should focus more on experimental and clinical studies to elucidate the exact mechanisms behind post-traumatic pituitary damage. The use of preventive medical measures to limit possible damage in the pituitary gland and hypothalamic pituitary axis in order to maintain or re-establish near normal physiologic functions are crucial to minimize the effects of TBI.
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Affiliation(s)
- Aydin Sav
- Department of Pathology, Yeditepe University, School of Medicine, Kosuyolu Hospital, Kosuyolu Mahallesi, Koşuyolu Cd. 168, 34718, Kadikoy, Istanbul, Turkey.
| | - Fabio Rotondo
- Department of Laboratory Medicine, Division of Pathology, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Luis V Syro
- Department of Neurosurgery, Hospital Pablo Tobon Uribe and Clinica Medellin, Medellin, Colombia
| | - Carlos A Serna
- Laboratorio de Patologia y Citologia Rodrigo Restrepo, Department of Pathology, Clinica Las Américas, Universidad CES, Medellin, Colombia
| | - Kalman Kovacs
- Department of Laboratory Medicine, Division of Pathology, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
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Brainstem Evoked Potential Indices of Subcortical Auditory Processing After Mild Traumatic Brain Injury. Ear Hear 2018; 38:e200-e214. [PMID: 28319479 DOI: 10.1097/aud.0000000000000411] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The primary aim of this study was to assess subcortical auditory processing in individuals with chronic symptoms after mild traumatic brain injury (mTBI) by measuring auditory brainstem responses (ABRs) to standard click and complex speech stimuli. Consistent with reports in the literature of auditory problems after mTBI (despite normal-hearing thresholds), it was hypothesized that individuals with mTBI would have evidence of impaired neural encoding in the auditory brainstem compared to noninjured controls, as evidenced by delayed latencies and reduced amplitudes of ABR components. We further hypothesized that the speech-evoked ABR would be more sensitive than the click-evoked ABR to group differences because of its complex nature, particularly when recorded in a background noise condition. DESIGN Click- and speech-ABRs were collected in 32 individuals diagnosed with mTBI in the past 3 to 18 months. All mTBI participants were experiencing ongoing injury symptoms for which they were seeking rehabilitation through a brain injury rehabilitation management program. The same data were collected in a group of 32 age- and gender-matched controls with no history of head injury. ABRs were recorded in both left and right ears for all participants in all conditions. Speech-ABRs were collected in both quiet and in a background of continuous 20-talker babble ipsilateral noise. Peak latencies and amplitudes were compared between groups and across subgroups of mTBI participants categorized by their behavioral auditory test performance. RESULTS Click-ABR results were not significantly different between the mTBI and control groups. However, when comparing the control group to only those mTBI subjects with measurably decreased performance on auditory behavioral tests, small differences emerged, including delayed latencies for waves I, III, and V. Similarly, few significant group differences were observed for peak amplitudes and latencies of the speech-ABR when comparing at the whole group level but were again observed between controls and those mTBI subjects with abnormal behavioral auditory test performance. These differences were seen for the onset portions of the speech-ABR waveforms in quiet and were close to significant for the onset wave. Across groups, quiet versus noise comparisons were significant for most speech-ABR measures but the noise condition did not reveal more group differences than speech-ABR in quiet, likely because of variability and overall small amplitudes in this condition for both groups. CONCLUSIONS The outcomes of this study indicate that subcortical neural encoding of auditory information is affected in a significant portion of individuals with long-term problems after mTBI. These subcortical differences appear to relate to performance on tests of auditory processing and perception, even in the absence of significant hearing loss on the audiogram. While confounds of age and slight differences in audiometric thresholds cannot be ruled out, these preliminary results are consistent with the idea that mTBI can result in neuronal changes within the subcortical auditory pathway that appear to relate to functional auditory outcomes. Although further research is needed, clinical audiological evaluation of individuals with ongoing post-mTBI symptoms is warranted for identification of individuals who may benefit from auditory rehabilitation as part of their overall treatment plan.
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Autobiographical and episodic memory deficits in mild traumatic brain injury. Brain Cogn 2017; 111:112-126. [DOI: 10.1016/j.bandc.2016.11.004] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 11/11/2016] [Accepted: 11/14/2016] [Indexed: 11/23/2022]
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Multani N, Goswami R, Khodadadi M, Ebraheem A, Davis KD, Tator CH, Wennberg R, Mikulis DJ, Ezerins L, Tartaglia MC. The association between white-matter tract abnormalities, and neuropsychiatric and cognitive symptoms in retired professional football players with multiple concussions. J Neurol 2016; 263:1332-41. [PMID: 27142715 DOI: 10.1007/s00415-016-8141-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 04/20/2016] [Accepted: 04/22/2016] [Indexed: 02/02/2023]
Abstract
Retired professional athletes, who have suffered repetitive concussions, report symptoms of depression, anxiety, and memory impairment over time. Moreover, recent imaging data suggest chronic white-matter tract deterioration in sport-related concussion. The aim of this study is to evaluate the impact of repetitive concussions in retired professional football players on white-matter tracts, and relate these changes to neuropsychological function. All subjects (18 retired professional football players and 17 healthy controls) underwent imaging, neuropsychological assessment, and reported on concussion-related symptoms. Whole brain tract-based spatial statistics analysis revealed increased axial diffusivity in the right hemisphere of retired players in the (1) superior longitudinal fasciculus (SLF), (2) corticospinal tract, and (3) anterior thalamic radiations, suggesting chronic axonal degeneration in these tracts. Moreover, retired players report significantly higher neuropsychiatric and cognitive symptoms than healthy controls, and worsening of these symptoms since their last concussion. Loss of integrity in the right SLF significantly correlated with participants' visual learning ability. In sum, these results suggest that repetitive concussions in retired professional football players are associated with focal white-matter tract abnormalities that could explain some of the neuropsychiatric symptoms and cognitive deficits experienced by these retired athletes.
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Affiliation(s)
- Namita Multani
- Canadian Sports Concussion Project, Memory Clinic, Toronto Western Hospital, Tanz Centre for Research in Neurodegenerative Disease, 399 Bathurst St., West Wing 5-449, Toronto, ON, M5T 2S8, Canada.,Tanz Centre for Research in Neurodegenerative Diseases, University of Toronto, 60 Leonard Avenue, Toronto, ON, M5T 2S8, Canada.,Division of Neurology, Toronto Western Hospital, Krembil Neuroscience Centre, University Health Network, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada
| | - Ruma Goswami
- Canadian Sports Concussion Project, Memory Clinic, Toronto Western Hospital, Tanz Centre for Research in Neurodegenerative Disease, 399 Bathurst St., West Wing 5-449, Toronto, ON, M5T 2S8, Canada.,Division of Brain, Imaging and Behaviour-Systems Neuroscience, Toronto Western Hospital, Toronto Western Research Institute, University Health Network, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada
| | - Mozhgan Khodadadi
- Canadian Sports Concussion Project, Memory Clinic, Toronto Western Hospital, Tanz Centre for Research in Neurodegenerative Disease, 399 Bathurst St., West Wing 5-449, Toronto, ON, M5T 2S8, Canada
| | - Ahmed Ebraheem
- Canadian Sports Concussion Project, Memory Clinic, Toronto Western Hospital, Tanz Centre for Research in Neurodegenerative Disease, 399 Bathurst St., West Wing 5-449, Toronto, ON, M5T 2S8, Canada
| | - Karen D Davis
- Canadian Sports Concussion Project, Memory Clinic, Toronto Western Hospital, Tanz Centre for Research in Neurodegenerative Disease, 399 Bathurst St., West Wing 5-449, Toronto, ON, M5T 2S8, Canada.,Division of Brain, Imaging and Behaviour-Systems Neuroscience, Toronto Western Hospital, Toronto Western Research Institute, University Health Network, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada.,Institute of Medical Science, University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada.,Department of Surgery, University of Toronto, 149 College Street, Toronto, ON, M5T 1P5, Canada
| | - Charles H Tator
- Canadian Sports Concussion Project, Memory Clinic, Toronto Western Hospital, Tanz Centre for Research in Neurodegenerative Disease, 399 Bathurst St., West Wing 5-449, Toronto, ON, M5T 2S8, Canada.,Division of Brain, Imaging and Behaviour-Systems Neuroscience, Toronto Western Hospital, Toronto Western Research Institute, University Health Network, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada.,Institute of Medical Science, University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada.,Department of Surgery, University of Toronto, 149 College Street, Toronto, ON, M5T 1P5, Canada.,Division of Neurosurgery, Toronto Western Hospital, Krembil Neuroscience Centre, University Health Network, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada
| | - Richard Wennberg
- Canadian Sports Concussion Project, Memory Clinic, Toronto Western Hospital, Tanz Centre for Research in Neurodegenerative Disease, 399 Bathurst St., West Wing 5-449, Toronto, ON, M5T 2S8, Canada.,Division of Neurology, Toronto Western Hospital, Krembil Neuroscience Centre, University Health Network, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada
| | - David J Mikulis
- Canadian Sports Concussion Project, Memory Clinic, Toronto Western Hospital, Tanz Centre for Research in Neurodegenerative Disease, 399 Bathurst St., West Wing 5-449, Toronto, ON, M5T 2S8, Canada.,Division of Brain, Imaging and Behaviour-Systems Neuroscience, Toronto Western Hospital, Toronto Western Research Institute, University Health Network, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada.,Institute of Medical Science, University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada.,Department of Medical Imaging, Toronto Western Hospital, University Health Network, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada
| | - Leo Ezerins
- Canadian Sports Concussion Project, Memory Clinic, Toronto Western Hospital, Tanz Centre for Research in Neurodegenerative Disease, 399 Bathurst St., West Wing 5-449, Toronto, ON, M5T 2S8, Canada
| | - Maria Carmela Tartaglia
- Canadian Sports Concussion Project, Memory Clinic, Toronto Western Hospital, Tanz Centre for Research in Neurodegenerative Disease, 399 Bathurst St., West Wing 5-449, Toronto, ON, M5T 2S8, Canada. .,Tanz Centre for Research in Neurodegenerative Diseases, University of Toronto, 60 Leonard Avenue, Toronto, ON, M5T 2S8, Canada. .,Division of Neurology, Toronto Western Hospital, Krembil Neuroscience Centre, University Health Network, 399 Bathurst St., Toronto, ON, M5T 2S8, Canada.
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Schulte S, Podlog LW, Hamson-Utley JJ, Strathmann FG, Strüder HK. A systematic review of the biomarker S100B: implications for sport-related concussion management. J Athl Train 2015; 49:830-50. [PMID: 25299445 DOI: 10.4085/1062-6050-49.3.33] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Elevated levels of the astroglial protein S100B have been shown to predict sport-related concussion. However, S100B levels within an athlete can vary depending on the type of physical activity (PA) engaged in and the methodologic approach used to measure them. Thus, appropriate reference values in the diagnosis of concussed athletes remain undefined. The purpose of our systematic literature review was to provide an overview of the current literature examining S100B measurement in the context of PA. The overall goal is to improve the use of the biomarker S100B in the context of sport-related concussion management. DATA SOURCES PubMed, SciVerse Scopus, SPORTDiscus, CINAHL, and Cochrane. STUDY SELECTION We selected articles that contained (1) research studies focusing exclusively on humans in which (2) either PA was used as an intervention or the test participants or athletes were involved in PA and (3) S100B was measured as a dependent variable. DATA EXTRACTION We identified 24 articles. Study variations included the mode of PA used as an intervention, sample types, sample-processing procedures, and analytic techniques. DATA SYNTHESIS Given the nonuniformity of the analytical methods used and the data samples collected, as well as differences in the types of PA investigated, we were not able to determine a single consistent reference value of S100B in the context of PA. Thus, a clear distinction between a concussed athlete and a healthy athlete based solely on the existing S100B cutoff value of 0.1 μg/L remains unclear. However, because of its high sensitivity and excellent negative predictive value, S100B measurement seems to have the potential to be a diagnostic adjunct for concussion in sports settings. We recommend that the interpretation of S100B values be based on congruent study designs to ensure measurement reliability and validity.
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Affiliation(s)
- Stefanie Schulte
- Department of Exercise and Sport Science, University of Utah, Salt Lake City
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Cairelli MJ, Fiszman M, Zhang H, Rindflesch TC. Networks of neuroinjury semantic predications to identify biomarkers for mild traumatic brain injury. J Biomed Semantics 2015; 6:25. [PMID: 25992264 PMCID: PMC4436163 DOI: 10.1186/s13326-015-0022-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 04/22/2015] [Indexed: 12/13/2022] Open
Abstract
Objective Mild traumatic brain injury (mTBI) has high prevalence in the military, among athletes, and in the general population worldwide (largely due to falls). Consequences can include a range of neuropsychological disorders. Unfortunately, such neural injury often goes undiagnosed due to the difficulty in identifying symptoms, so the discovery of an effective biomarker would greatly assist diagnosis; however, no single biomarker has been identified. We identify several body substances as potential components of a panel of biomarkers to support the diagnosis of mild traumatic brain injury. Methods Our approach to diagnostic biomarker discovery combines ideas and techniques from systems medicine, natural language processing, and graph theory. We create a molecular interaction network that represents neural injury and is composed of relationships automatically extracted from the literature. We retrieve citations related to neurological injury and extract relationships (semantic predications) that contain potential biomarkers. After linking all relationships together to create a network representing neural injury, we filter the network by relationship frequency and concept connectivity to reduce the set to a manageable size of higher interest substances. Results 99,437 relevant citations yielded 26,441 unique relations. 18,085 of these contained a potential biomarker as subject or object with a total of 6246 unique concepts. After filtering by graph metrics, the set was reduced to 1021 relationships with 49 unique concepts, including 17 potential biomarkers. Conclusion We created a network of relationships containing substances derived from 99,437 citations and filtered using graph metrics to provide a set of 17 potential biomarkers. We discuss the interaction of several of these (glutamate, glucose, and lactate) as the basis for more effective diagnosis than is currently possible. This method provides an opportunity to focus the effort of wet bench research on those substances with the highest potential as biomarkers for mTBI.
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Affiliation(s)
- Michael J Cairelli
- National Institutes of Health, National Library of Medicine, 38A 9N912A, 8600 Rockville Pike, Bethesda, MD 20892 USA
| | - Marcelo Fiszman
- National Institutes of Health, National Library of Medicine, 38A 9N912A, 8600 Rockville Pike, Bethesda, MD 20892 USA
| | - Han Zhang
- Department of Medical Informatics, China Medical University, Shenyang, Liaoning 110001 China
| | - Thomas C Rindflesch
- National Institutes of Health, National Library of Medicine, 38A 9N912A, 8600 Rockville Pike, Bethesda, MD 20892 USA
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Baumgartner L, Schmitt KU. Computer simulations to investigate the consequence of blunt head impact. J Forensic Sci 2014; 59:1191-7. [PMID: 24617824 DOI: 10.1111/1556-4029.12458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 06/05/2013] [Accepted: 06/23/2013] [Indexed: 11/30/2022]
Abstract
Blunt head impact as sustained in falls or punches against the head can result in rupture of bridging veins. Computer simulations were performed to simulate three different types of falls and punches against the head. The relative brain-skull motion was recorded. The falls resulted in impact on the backside of the head, whereas the punches struck the face. The maximum resultant translational and rotational acceleration, the Head Injury Criterion (HIC), and the characteristics of the relative brain-skull motion, as well as the coup and contre-coup regions were determined. The maximum resultant translational acceleration was found to be between 2982 and 3541 m/s² for falls and between 814 and 942 m/s² for punches. The maximum resultant rotational acceleration reached 632-1000 rad/s² for falls and 252-620 rad/s² for punches. The HIC for falls was found to be at least 1357 and at most 130 for punches. The major brain-skull displacement calculated for falls and punches was 6.6 and 4.2 mm, respectively. The results of this study suggest that falls are associated with a higher risk for bridging vein ruptures than punches and that cerebral contusions at the contre-coup side are more serious.
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Affiliation(s)
- Laura Baumgartner
- ETH Zurich, Rämistrasse 101, 8092, Zurich, Switzerland; AGU Zurich, Winkelriedstrasse 27, 8006, Zurich, Switzerland
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Correlation of Fracture Depression Level and Dural Tear in Patients With Depressed Skull Fracture. ACTA ACUST UNITED AC 2014. [DOI: 10.1097/wnq.0b013e31828c7410] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Bigler ED. Neuroimaging biomarkers in mild traumatic brain injury (mTBI). Neuropsychol Rev 2013; 23:169-209. [PMID: 23974873 DOI: 10.1007/s11065-013-9237-2] [Citation(s) in RCA: 102] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Accepted: 08/07/2013] [Indexed: 12/14/2022]
Abstract
Reviewed herein are contemporary neuroimaging methods that detect abnormalities associated with mild traumatic brain injury (mTBI). Despite advances in demonstrating underlying neuropathology in a subset of individuals who sustain mTBI, considerable disagreement persists in neuropsychology about mTBI outcome and metrics for evaluation. This review outlines a thesis for the select use of sensitive neuroimaging methods as potential biomarkers of brain injury recognizing that the majority of individuals who sustain an mTBI recover without neuroimaging signs or neuropsychological sequelae detected with methods currently applied. Magnetic resonance imaging (MRI) provides several measures that could serve as mTBI biomarkers including the detection of hemosiderin and white matter abnormalities, assessment of white matter integrity derived from diffusion tensor imaging (DTI), and quantitative measures that directly assess neuroanatomy. Improved prediction of neuropsychological outcomes in mTBI may be achieved with the use of targeted neuroimaging markers.
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Affiliation(s)
- Erin D Bigler
- Department of Psychology, Brigham Young University, 1001 SWKT, Provo, UT 84602, USA.
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Kirov II, Tal A, Babb JS, Reaume J, Bushnik T, Ashman TA, Flanagan S, Grossman RI, Gonen O. Proton MR spectroscopy correlates diffuse axonal abnormalities with post-concussive symptoms in mild traumatic brain injury. J Neurotrauma 2013; 30:1200-4. [PMID: 23339670 PMCID: PMC3700460 DOI: 10.1089/neu.2012.2696] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
There are no established biomarkers for mild traumatic brain injury (mTBI), in part because post-concussive symptoms (PCS) are subjective and conventional imaging is typically unremarkable. To test whether diffuse axonal abnormalities quantified with three-dimensional (3D) proton magnetic resonance spectroscopic imaging (¹H-MRSI) correlated with patients' PCS, we retrospectively studied 26 mTBI patients (mean Glasgow Coma Scale [GCS] score of 14.7), 18- to 56-year-olds and 13 controls three to 55 days post-injury. All were scanned at 3 Tesla with T1- and T2-weighted MRI and 3D ¹H-MRSI (480 voxels over 360 cm³, ∼30% of the brain). On scan day, patients completed a symptom questionnaire, and those who indicated at least one of the most common subacute mTBI symptoms (headache, dizziness, sleep disturbance, memory deficits, blurred vision) were grouped as PCS-positive. Global gray matter and white matter (GM/WM) absolute concentrations of N-acetylaspartate (NAA), choline (Cho), creatine (Cr) and myo-inositol (mI) in PCS-positive and PCS-negative patients were compared to age- and gender-matched controls using two-way analysis of variance. The results showed that the PCS-negative group (n=11) and controls (n=8) did not differ in any GM or WM metabolite level. The PCS-positive patients (n=15) had lower WM NAA than the controls (n=12; 7.0 ± 0.6 versus 7.9 ± 0.5mM; p=0.0007). Global WM NAA, therefore, showed sensitivity to the TBI sequelae associated with common PCS in patients with mostly normal neuroimaging, as well as GCS scores. This suggests a potential biomarker role in a patient population in which objective measures of injury and symptomatology are currently lacking.
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Affiliation(s)
- Ivan I. Kirov
- Department of Radiology, New York University School of Medicine, New York, New York
| | - Assaf Tal
- Department of Radiology, New York University School of Medicine, New York, New York
| | - James S. Babb
- Department of Radiology, New York University School of Medicine, New York, New York
| | - Joseph Reaume
- Department of Radiology, New York University School of Medicine, New York, New York
| | - Tamara Bushnik
- Rusk Institute of Rehabilitation Medicine, New York University School of Medicine, New York, New York
| | - Teresa A. Ashman
- Rusk Institute of Rehabilitation Medicine, New York University School of Medicine, New York, New York
| | - Steven Flanagan
- Rusk Institute of Rehabilitation Medicine, New York University School of Medicine, New York, New York
| | - Robert I. Grossman
- Department of Radiology, New York University School of Medicine, New York, New York
| | - Oded Gonen
- Department of Radiology, New York University School of Medicine, New York, New York
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Kirov II, Tal A, Babb JS, Lui YW, Grossman RI, Gonen O. Diffuse axonal injury in mild traumatic brain injury: a 3D multivoxel proton MR spectroscopy study. J Neurol 2013; 260:242-52. [PMID: 22886061 PMCID: PMC3729330 DOI: 10.1007/s00415-012-6626-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 06/12/2012] [Accepted: 07/14/2012] [Indexed: 10/28/2022]
Abstract
Since mild traumatic brain injury (mTBI) often leads to neurological symptoms even without clinical MRI findings, our goal was to test whether diffuse axonal injury is quantifiable with multivoxel proton MR spectroscopic imaging ((1)H-MRSI). T1- and T2-weighted MRI images and three-dimensional (1)H-MRSI (480 voxels over 360 cm(3), about 30 % of the brain) were acquired at 3 T from 26 mTBI patients (mean Glasgow Coma Scale score 14.7, 18-56 years old, 3-55 days after injury) and 13 healthy matched contemporaries as controls. The N-acetylaspartate (NAA), choline (Cho), creatine (Cr) and myo-inositol (mI) concentrations and gray-matter/white-matter (GM/WM) and cerebrospinal fluid fractions were obtained in each voxel. Global GM and WM absolute metabolic concentrations were estimated using linear regression, and patients were compared with controls using two-way analysis of variance. In patients, mean NAA, Cr, Cho and mI concentrations in GM (8.4 ± 0.7, 6.9 ± 0.6, 1.3 ± 0.2, 5.5 ± 0.6 mM) and Cr, Cho and mI in WM (4.8 ± 0.5, 1.4 ± 0.2, 4.6 ± 0.7 mM) were not different from the values in controls. The NAA concentrations in WM, however, were significantly lower in patients than in controls (7.2 ± 0.8 vs. 7.7 ± 0.6 mM, p = 0.0125). The Cho and Cr levels in WM of patients were positively correlated with time since mTBI. This (1)H-MRSI approach allowed us to ascertain that early mTBI sequelae are (1) diffuse (not merely local), (2) neuronal (not glial), and (3) in the global WM (not GM). These findings support the hypothesis that, similar to more severe head trauma, mTBI also results in diffuse axonal injury, but that dysfunction rather than cell death dominates shortly after injury.
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Affiliation(s)
- Ivan I Kirov
- Department of Radiology, New York University School of Medicine, 660 First Avenue, 4th Floor, New York, NY 10016, USA
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Fujita M, Wei EP, Povlishock JT. Intensity- and interval-specific repetitive traumatic brain injury can evoke both axonal and microvascular damage. J Neurotrauma 2012; 29:2172-80. [PMID: 22559115 DOI: 10.1089/neu.2012.2357] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In the experimental setting several investigators have recently reported exacerbations of the burden of axonal damage and other neuropathological changes following repetitive traumatic brain injuries (TBI) that were sustained at intervals from hours to days following the initial insult. These same studies also revealed that prolonging the interval between the first and second insult led to a reduction in the burden of neuropathological changes and/or their complete elimination. Although demonstrating the capability of repetitive TBI to evoke increased axonal and other neuropathological changes, these studies did not address the potential for concomitant microvascular dysfunction or damage, although vascular dysfunction has been implicated in the second-impact syndrome. In this study we revisit the issue of repetitive injury in a well-controlled animal model in which the TBI intensity was bracketed from subthreshold to threshold insults, while the duration of the intervals between the injuries varied. Employing cranial windows to assess vascular reactivity and post-mortem amyloid precursor protein (APP) analysis to determine the burden of axonal change, we recognized that subthreshold injuries, even when administered in repeated fashion over a short time frame, evoked neither axonal nor vascular change. However, with an elevation of insult intensity, repetitive injuries administered within 3-h time frames caused dramatic axonal damage and significant vascular dysfunction bordering on a complete loss of vasoreactivity. If, however, the interval between the repetitive injury was extended to 5 h, the burden of axonal change was reduced, as was the overall magnitude of the ensuing vascular dysfunction. With the extension of the interval between injuries to 10 h, neither axonal nor vascular changes were found. Collectively, these studies reaffirm the existence of significant axonal damage following repetitive TBI administered within a relatively short time frame. Additionally, they also demonstrate that these axonal changes parallel changes in the cerebral microcirculation, which also may have adverse consequences for the injured brain.
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Affiliation(s)
- Motoki Fujita
- Department of Anatomy and Neurobiology, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
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Bigler ED, Maxwell WL. Neuropathology of mild traumatic brain injury: relationship to neuroimaging findings. Brain Imaging Behav 2012; 6:108-36. [PMID: 22434552 DOI: 10.1007/s11682-011-9145-0] [Citation(s) in RCA: 207] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Neuroimaging identified abnormalities associated with traumatic brain injury (TBI) are but gross indicators that reflect underlying trauma-induced neuropathology at the cellular level. This review examines how cellular pathology relates to neuroimaging findings with the objective of more closely relating how neuroimaging findings reveal underlying neuropathology. Throughout this review an attempt will be made to relate what is directly known from post-mortem microscopic and gross anatomical studies of TBI of all severity levels to the types of lesions and abnormalities observed in contemporary neuroimaging of TBI, with an emphasis on mild traumatic brain injury (mTBI). However, it is impossible to discuss the neuropathology of mTBI without discussing what occurs with more severe injury and viewing pathological changes on some continuum from the mildest to the most severe. Historical milestones in understanding the neuropathology of mTBI are reviewed along with implications for future directions in the examination of neuroimaging and neuropathological correlates of TBI.
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Affiliation(s)
- Erin D Bigler
- Department of Psychology, Brigham Young University, Provo, UT, USA.
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Tan CO. Defining the characteristic relationship between arterial pressure and cerebral flow. J Appl Physiol (1985) 2012; 113:1194-200. [PMID: 22961266 DOI: 10.1152/japplphysiol.00783.2012] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Reliable assessment of cerebrovascular effectiveness in buffering against pressure fluctuations may have important implications for the timing and the outcome of therapy after adverse cerebrovascular events. Although linear approaches may indicate the presence or absence of cerebral autoregulation, they are inadequate to describe its characteristics and its effectiveness. Establishing a simple yet robust methodology to reliably measure the effectiveness of cerebral autoregulation could provide a tool to guide screening and clinical options to characterize and treat adverse cerebrovascular events associated with alterations in cerebral perfusion. To test the utility of one such methodology, an oscillatory lower body negative pressure of 30-40 mmHg was used at six frequencies from 0.03 to 0.08 Hz in 43 healthy volunteers, and the pressure-flow relation and the effectiveness of autoregulation was quantified using projection pursuit regression. Projection pursuit regression explained the majority of the relationship between pressure and cerebral blood flow fluctuations and revealed its nature consistently across individuals and across separate study days. The nature of this relationship entailed an autoregulatory region wherein slow arterial pressure fluctuations are effectively counterregulated and two passive regions wherein pressure fluctuations resulted in parallel changes in flow. The effectiveness of autoregulation was significantly reduced as pressure fluctuations became faster. These results demonstrate the characteristic relationship between arterial pressure and cerebral blood flow. Furthermore, the methodology utilized in this study provides a tool that can provide unique insight to integrated cerebrovascular control and may allow diagnosis of physiological alterations underlying impaired cerebral autoregulation.
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Affiliation(s)
- Can Ozan Tan
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA 02138, USA.
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Lifshitz J, Lisembee AM. Neurodegeneration in the somatosensory cortex after experimental diffuse brain injury. Brain Struct Funct 2012; 217:49-61. [PMID: 21597967 PMCID: PMC3536493 DOI: 10.1007/s00429-011-0323-z] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Accepted: 04/28/2011] [Indexed: 10/18/2022]
Abstract
Disruption and consequent reorganization of central nervous system circuits following traumatic brain injury may manifest as functional deficits and behavioral morbidities. We previously reported axotomy and neuronal atrophy in the ventral basal (VB) complex of the thalamus, without gross degeneration after experimental diffuse brain injury in adult rats. Pathology in VB coincided with the development of late-onset aberrant behavioral responses to whisker stimulation, which lead to the current hypothesis that neurodegeneration after experimental diffuse brain injury includes the primary somatosensory barrel cortex (S1BF), which receives projection of VB neurons and mediates whisker somatosensation. Over 28 days after midline fluid percussion brain injury, argyrophilic reaction product within superficial layers and layer IV barrels at 1 day progresses into the cortex to subcortical white matter by 7 days, and selective inter-barrel septa and subcortical white matter labeling at 28 days. Cellular consequences were determined by stereological estimates of neuronal nuclear volumes and number. In all cortical layers, neuronal nuclear volumes significantly atrophied by 42-49% at 7 days compared to sham, which marginally attenuated by 28 days. Concomitantly, the number of healthy neurons was reduced by 34-45% at 7 days compared to sham, returning to control levels by 28 days. Progressive neurodegeneration, including argyrophilic reaction product and neuronal nuclear atrophy, indicates injury-induced damage and reorganization of the reciprocal thalamocortical projections that mediate whisker somatosensation. The rodent whisker barrel circuit may serve as a discrete model to evaluate the causes and consequences of circuit reorganization after diffuse brain injury.
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Affiliation(s)
- Jonathan Lifshitz
- Spinal Cord and Brain Injury Research Center, University of Kentucky Chandler Medical Center, Office B463, Biomedical and Biological Sciences Research Building, 741 S. Limestone St, Lexington, KY 40536-0509, USA.
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18
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Len TK, Neary JP. Cerebrovascular pathophysiology following mild traumatic brain injury. Clin Physiol Funct Imaging 2010; 31:85-93. [PMID: 21078064 DOI: 10.1111/j.1475-097x.2010.00990.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Mild traumatic brain injury (mTBI) or sport-induced concussion has recently become a prominent concern not only in the athletic setting (i.e. sports venue) but also in the general population. The majority of research to date has aimed at understanding the neurological and neuropsychological outcomes of injury as well as return-to-play guidelines. Remaining relatively unexamined has been the pathophysiological aspect of mTBI. Recent technological advances including transcranial Doppler ultrasound and near infrared spectroscopy have allowed researchers to examine the systemic effects of mTBI from rest to exercise, and during both asymptomatic and symptomatic conditions. In this review, we focus on the current research available from both human and experimental (animal) studies surrounding the pathophysiology of mTBI. First, the quest for a unified definition of mTBI, its historical development and implications for future research is discussed. Finally, the impact of mTBI on the control and regulation of cerebral blood flow, cerebrovascular reactivity, cerebral oxygenation and neuroautonomic cardiovascular regulation, all of which may be compromised with mTBI, is discussed.
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Affiliation(s)
- T K Len
- Exercise Physiology Laboratory, Faculty of Kinesiology and Health Studies, University of Regina, Regina, SK, Canada
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Friess SH, Ichord RN, Ralston J, Ryall K, Helfaer MA, Smith C, Margulies SS. Repeated traumatic brain injury affects composite cognitive function in piglets. J Neurotrauma 2010; 26:1111-21. [PMID: 19275468 DOI: 10.1089/neu.2008.0845] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Cumulative effects of repetitive mild head injury in the pediatric population are unknown. We have developed a cognitive composite dysfunction score that correlates white matter injury severity in neonatal piglets with neurobehavioral assessments of executive function, memory, learning, and problem solving. Anesthetized 3- to 5-day-old piglets were subjected to single (n = 7), double one day apart (n = 7), and double one week apart (n = 7) moderate (190 rad/s) rapid non-impact axial rotations of the head and compared to instrumented shams (n = 7). Animals experiencing two head rotations one day apart had a significantly higher mortality rate (43%) compared to the other groups and had higher failures rates in visual-based problem solving compared to instrumented shams. White matter injury, assessed by beta-APP staining, was significantly higher in the double one week apart group compared to that with single injury and sham. Worsening performance on cognitive composite score correlated well with increasing severity of white matter axonal injury. In our immature large animal model of TBI, two head rotations produced poorer outcome as assessed by neuropathology and neurobehavioral functional outcomes compared to that with single rotations. More importantly, we have observed an increase in injury severity and mortality when the head rotations occur 24 h apart compared to 7 days apart. These observations have important clinical translation to infants subjected to repeated inflicted head trauma.
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Affiliation(s)
- Stuart H Friess
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Hall KD, Lifshitz J. Diffuse traumatic brain injury initially attenuates and later expands activation of the rat somatosensory whisker circuit concomitant with neuroplastic responses. Brain Res 2010; 1323:161-73. [PMID: 20122903 DOI: 10.1016/j.brainres.2010.01.067] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Revised: 01/22/2010] [Accepted: 01/23/2010] [Indexed: 01/27/2023]
Abstract
Traumatic brain injury can initiate an array of chronic neurological deficits, effecting executive function, language and sensorimotor integration. Mechanical forces produce the diffuse pathology that disrupts neural circuit activation across vulnerable brain regions. The present manuscript explores the hypothesis that the extent of functional activation of brain-injured circuits is a consequence of initial disruption and consequent reorganization. In the rat, enduring sensory sensitivity to whisker stimulation directs regional analysis to the whisker barrel circuit. Adult, male rats were subjected to midline fluid percussion brain or sham injury and evaluated between 1day and 42days post-injury. Whisker somatosensory regions of the cortex and thalamus maintained cellular composition as visualized by Nissl stain. Within the first week post-injury, quantitatively less cFos activation was elicited by whisker stimulation, potentially due to axotomy within and surrounding the whisker circuit as visualized by amyloid precursor protein immunohistochemistry. Over six weeks post-injury, cFos activation after whisker stimulation showed a significant linear correlation with time in the cortex (r(2)=0.545; p=0.015), non-significant correlation in the thalamus (r(2)=0.326) and U-shaped correlation in the dentate gyrus (r(2)=0.831), all eventually exceeding sham levels. Ongoing neuroplastic responses in the cortex are evidenced by accumulating growth associated protein and synaptophysin gene expression. In the thalamus, the delayed restoration of plasticity markers may explain the broad distribution of neuronal activation extending into the striatum and hippocampus with whisker stimulation. The sprouting of diffuse-injured circuits into diffuse-injured tissue likely establishes maladaptive circuits responsible for behavioral morbidity. Therapeutic interventions to promote adaptive circuit restructuring may mitigate post-traumatic morbidity.
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Affiliation(s)
- Kelley D Hall
- Spinal Cord and Brain Injury Research Center, Chandler Medical Center, University of Kentucky, USA
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Abstract
INTRODUCTION Traumatic brain injury is heterogeneous, both in its induction and ensuing neurological sequelae. In this way, medical care depends on accurately identifying the severity of injury-related forces. Clinically, injury severity is determined by a combination of the Glasgow Coma Scale, length of unconsciousness, posttraumatic amnesia, and persistence of neurological sequelae. In the laboratory, injury severity is gauged by the biomechanical forces and the acute suppression of neurological reflexes. The present communication describes and validates the "fencing response" as an overt indicator of injury force magnitude and midbrain localization to aid in injury identification and classification. METHODS Using YouTube, the Internet video database, videos were screened for head injury resulting in unconsciousness and documented for the fencing response. Adult male rats were subjected to midline fluid percussion brain injury at two severities, observed for acute neurological reflexes and the midbrain evaluated histopathologically. RESULTS Tonic posturing (fencing response) has been observed to precede convulsions in sports injuries at the moment of impact, where extension and flexion of opposite arms occurs despite body position or gravity. Of the 35 videos identified by an impact to the head and period of unconsciousness, 66% showed a fencing response at the moment of impact, regardless of the side of impact, without ensuing convulsion. Similarly, diffuse brain-injured rats demonstrate a fencing response upon injury at moderate (1.9 atm, 39/44 animals) but not mild severity (1.1 atm, 0/19 animals). The proximity of the lateral vestibular nucleus to the cerebellar peduncles makes it vulnerable to mechanical forces that initiate a neurochemical storm to elicit the neuromotor response, disrupt the blood-brain barrier, and alter the nuclear volume. CONCLUSIONS Therefore, the fencing response likely indicates neurological disturbance unique from convulsion associated with mechanical forces of moderate magnitude imparted on the midbrain and can assist in guiding medical care after injury.
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Affiliation(s)
- Ario H Hosseini
- Chandler Medical Center, University of Kentucky, Lexington, KY, USA
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Wennberg RA, Cohen HB, Walker SR. Neurologic Injuries in Hockey. Phys Med Rehabil Clin N Am 2009; 20:215-26, x. [DOI: 10.1016/j.pmr.2008.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
Ice hockey is a fast contact sport played on an ice surface enclosed by rigid boards. There is an intrinsic risk for injury in hockey, with many injuries potentially affecting the nervous system. This article provides an overview of neurologic injuries occurring in hockey as reported in the scientific literature. Among all injuries, a small but real risk for catastrophic cervical spinal cord injury and a high incidence of concussion emerge as the two most important neurologic issues.
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