THE LONG-TERM PROGNOSIS OF SEVERE HEAD INJURY

Neurobehavioral sequelae of traumatic brain injury: evaluation and management

Traumatic brain injury (TBI) is a worldwide public health problem. Over the last several decades, improvements in acute care have resulted in higher survival rates. Unfortunately, the majority of survivors of moderate and severe TBI have chronic neurobehavioral sequelae, including cognitive deficits, changes in personality and increased rates of psychiatric illness. These neurobehavioral problems are understandable in the context of the typical profile of regional brain damage associated with trauma. This paper presents an overview of the neurobehavioral sequelae of TBI and outlines issues to consider in the evaluation and management of these challenges.

Psychotic disorder and traumatic brain injury

Traumatic brain injury (TBI) can result in serious and disabling neuropsychiatric disorders, such as cognitive deficits and personality change, as well as severe and chronic psychosis. This review focuses on the relationship between TBI and schizophrenia-like psychosis (SLP) including its epidemiology, diagnostic criteria, clinical presentation, psychopathology, risk factors, and pathophysiology. The relationships between post-traumatic epilepsy and SLP, and brain trauma and schizophrenia, are also discussed. The risk of SLP does increase after TBI. The clinical presentation has considerable overlap with primary schizophrenic disorder, with a prominence of persecutory and other delusions and auditory hallucinations, as well as a lack of negative symptoms. The onset is often gradual, with a subacute or chronic course. More severe and diffuse brain injury, especially of the temporal and frontal lobes, is the most prominent risk factor. Genetic load may also play a role, but presence of epilepsy could be a protective factor. Further large and systematic longitudinal studies are needed.

Quality of Life (QoL) in severely disabled multiple sclerosis patients: comparison of three QoL measures using multidimensional scaling

This study reports a comparison of three quality of life (QoL) measures completed by patients with advanced multiple sclerosis. Multidimensional scaling analysis explored the structure of relationships amongst a general health measure (the Short Form 36--SF 36) and two person-centred measures (the Patient Generated Index--PGI; and the Schedule for the Evaluation of Individual Quality of Life-Direct Weighting version--SEIQoL-DW). Results showed distinct differences both between the two person-centred measures, and when compared against the general health measure, reflecting the different conceptual bases of these measures. The findings suggest that PGI scores closely relate to measures of physical functioning, whereas SEIQoL-DW scores relate more closely to feelings of health and vitality. The implications of these results for selection and development of appropriate QoL scales for the target population are discussed.

A medical/vocational case coordination system for persons with brain injury: an evaluation of employment outcomes

OBJECTIVE

To evaluate initial placement and 1-year employment outcomes of a Medical/Vocational Case Coordination System (MVCCS) for persons with brain injury (BI) that provides: (1) early case identification and coordination, (2) appropriate medical and vocational rehabilitation interventions, (3) work trials, and (4) supported employment interventions including job coaching.

PARTICIPANTS

One hundred fourteen Minnesota residents, ages 18 to 65 years, with acquired BI.

MAIN OUTCOME MEASURES

OUTCOME

Five levels of Vocational Independence Scale (VIS).

PREDICTOR

Preinjury employment status (VIS) and years of education, severity of initial injury, time since injury, current impairment/disability as measured by the Rasch-analyzed Staff Mayo-Portland Adaptability Inventory (MPAI), and impaired self-awareness measured by staff rating and the difference between Staff MPAI and Survivor MPAI.

RESULTS

At placement, 46% in independent work; 25% in transitional placements; 9% in long-term supported employment; 10% in sheltered work; and 10% not placed. At 1-year follow-up (n = 101), 53% in independent work; 19% in transitional placement; 9% in supported work; 6% in sheltered work; and 13% unemployed. Regression analyses showed time since injury and Rasch Staff MPAI predicted VIS at placement; only VIS at placement independently predicted VIS at 1-year follow-up; Rasch Staff MPAI and preinjury education level predicted time to placement.

CONCLUSIONS

The MVCCS optimized vocational outcome after BI. Time since injury and impairment/disability best predicted vocational placement. Level of initial placement best predicted employment status at follow-up. Persons with greater disability required more extended time and more extensive rehabilitation services before placement.

Suicide as an outcome for mental disorders. A meta-analysis

BACKGROUND

Mental disorders have a strong association with suicide. This meta-analysis, or statistical overview, of the literature gives an estimate of the suicide risk of the common mental disorders.

METHOD

We searched the medical literature to find reports on the mortality of mental disorders. English language reports were located on MEDLINE (1966-1993) with the search terms mental disorders', 'brain injury', 'eating disorders', 'epilepsy', 'suicide attempt', 'psychosurgery', with 'mortality' and 'follow-up studies', and from the reference lists of these reports. We abstracted 249 reports with two years or more follow-up and less than 10% loss of subjects, and compared observed numbers of suicides with those expected. A standardised mortality ratio (SMR) was calculated for each disorder.

RESULTS

Of 44 disorders considered, 36 have a significantly raised SMR for suicide, five have a raised SMR which fails to reach significance, one SMR is not raised and for two entries the SMR could not be calculated.

CONCLUSIONS

If these results can be generalised then virtually all mental disorders have an increased risk of suicide excepting mental retardation and dementia. The suicide risk is highest for functional and lowest for organic disorders with substance misuse disorders lying between. However, within these broad groupings the suicide risk varies widely.

Recovery of function following severe traumatic brain injury: a retrospective 10-year follow-up

It has been widely assumed that most of the recovery following severe traumatic brain injury (TBI) occurs within the first 6 months, and that virtually all of the recovery occurs within the first 1-2 years post-injury. In an effort to evaluate the long-term recovery of patients who had sustained severe TBI, we interviewed the relatives and significant others of 20 patients who had sustained TBI at least 5 years earlier, using a modified version of the Portland Adaptability Inventory. Retrospective ratings were collected to evaluate the patients' psychosocial, cognitive, physical, and emotional status prior to their injury, and at 1, 2, 5, and an average of 10.3 years post-injury. The results indicated that TBI patients exhibit significant improvements in their social, cognitive, physical, and emotional functioning after 2 years post-injury regardless of the severity of their initial brain trauma. These data suggest that patients who sustain severe TBI continue to make gradual improvements in their functioning for at least 10 years post-injury. Our findings contradict the widely held assumption that the recovery process ends after 1 or 2 years post-injury.

Cognitive recovery correlates with long-term increases of cerebral perfusion after head injury

Prospective measurements of cerebral blood flow (CBF) and Cognitive Capacity Screening Examination (CCSE) were obtained following head injury among 42 patients for a mean total follow-up interval of 10 years. Clinical data obtained at the time of injury and detailed neurological examinations at each follow-up visit were correlated with serial CBF and CCSE scores. Comparisons of the group of patients who cognitively improved (n = 32) were made with the group that did not (n = 10). Of the total group, 76% showed cognitive improvements for as long as 10 years after injury, with CBF increases toward normal. Predictors for long-term cognitive improvements include: higher initial Glasgow Coma Scales, earlier recovery from coma, absence of signs of brain stem injury, and improvements of cerebral perfusion and autoregulation. Failure to improve correlated with low initial Glasgow Coma Scales, signs of brain stem injury, and persistent impairments of cerebral perfusion.

Head injury, a multivariate study: predicting long-term productivity and independent living outcome

As the second of a two-part research project, this study attempted to build three clinically useful prediction equations; these equations would be used to predict three long-term functional outcomes: productivity status, living arrangement status, number of hours of assistance required per week. There were ten predictor variables used in each analysis. These ten variables belonged to four theoretical classes: pre-injury demographics, pre-injury social characteristics, severity of injury, and post-injury environmental variables. The analytical method used was the General Linear Model of multiple regression, rather than the most often used Stepwise regression procedure. The results indicate that in none of the three prediction equations was more than 28% of the criterion variance accounted for, and only a minority of the predictor variables were significant predictors. It is concluded that, while the equations are of only very limited utility, the theoretical model and the analytical technique will be useful for future investigators.

Unawareness of deficits in neuropsychological syndromes

Damage to different regions of the brain can cause a variety of neuropsychological deficits, including specific disturbances of language, memory, perception and motor function. A significant number of brain-damaged patients are unaware of their deficits, even when they are profound and have debilitating effects on patients' performance. This article reviews clinical observations and experimental investigations concerning unawareness of deficits, considers methodological issues, and critically evaluates different interpretations of the phenomenon. An integrative theoretical framework is proposed to account for unawareness of deficits in diverse neuropsychological syndromes. Possible directions for future research are outlined.

Choice (CRT) and simple reaction times (SRT) compared in laboratory technicians: factors influencing reaction times and a predictive model

Choice reaction time (CRT) and simple reaction time (SRT) tests were administered to 151 female histology laboratory technicians to determine if occupational exposure to organic solvents and formaldehyde delayed either or both. The relationships between CRT and SRT latencies were evaluated using different testers, sequences of administration, and microcomputers. Formaldehyde exposure, cigarette smoking history, ethnicity, and alveolar CO levels did not significantly influence CRT and SRT. However, slightly different protocols did significantly affect SRT. A linear model demonstrated that logSRT (LSRT) and LogCRT (LCRT) were longer with increasing age, promising further clinical applications. It is concluded that both CRT and SRT measure some overlapping and some different neurologic pathways. Reaction times in large "normal" populations are needed to compare with groups exposed to potential neurotoxins.

Psychosocial sequelae of head injury--anatomy of a relationship

The nature and extent of psychological and social disability following head injury remain issues of considerable practical and theoretical interest. Practical because of the size of the problem and the resulting burden of care; theoretical because head injury should provide a powerful model for an improved understanding of the relationships between cerebral disorder and psychological impairment.

Return to work after severe head injury

This paper reports attempts of a series of head-injured people to regain employment. Return to work after a severe head injury is generally considered to be a function of age, severity of injury, and nature of disability. The results showed that it was the opportunity to go back to the previous job, the provision of a work trial or easier work, and a lengthy period of support that were the more important factors. This demonstrates the importance of working to provide an environment that will help the individual learn to make adaptations and accommodate his or her disabilities.

Late outcome of very severe blunt head trauma: a 10-15 year second follow-up

Forty patients with very severe blunt head trauma (post-traumatic amnesia greater than or equal to 1 month) were initially examined at an average of 4.5 months after the injury. The patients were visited in their homes 2.5 years and 10-15 years after the accident and questionnaires were presented to patients, relatives and/or staff. Though physical impairment, dysarthria and defects of memory remained severe in many cases, the psychosocial sequelae presented the most serious problems. Permanent changes in personality and emotion were reported in two thirds and were especially frequent among the youngest patients. The worse overall outcome was seen in cases with severe brainstem involvement or anterior lesions or both. In spite of the great frequency of deficits long-term improvement of functional state was common and several regained at least some work capacity.

Methodological problems in assessing psychosocial recovery following severe head injury

A number of specific methodological issues have arisen in studies of the social, emotional, and behavioural sequelae of head injury. The accounts given by patients and relatives may differ: Patients may lack insight, and relatives--who are often under considerable stress--may themselves give distorted accounts. Moreover, the sequelae of head injury may not all be specific to brain injury but may include effects common to other forms of traumatic injury: The use of control groups may help disentangle specific and non-specific effects.

Post-concussional symptoms, financial compensation and outcome of severe blunt head injury

Two groups, each of 21 cases of severe blunt head injury, were compared. Patients in one group were pursuing claims for financial compensation while patients in the other were not. Patients were assessed on cognitive tests, and both patients and relatives were interviewed at 3, 6 and 12 months after injury. There were few differences between claimants and non-claimants: post-concussional symptoms were common in both, cognitive performance was equal, and the reports given by relatives of changes in the patients were very similar. However, the reports given by patients themselves differed with claimants reporting slightly more symptoms than non-claimants.

Return to work after head injury: a review of post-war studies

The literature on occupational resettlement after head injury is confounded by varying standards of clinical severity and social outcome. A comparison of eleven key studies in the light of the authors' own research yielded a success rate ranging from 50 to 99 per cent, but this was based on superficial evidence. A more searching enquiry is needed, using objective methods and avoiding the technical inadequacies of most previous work. This would be unlikely to challenge the importance of age and length of post-traumatic amnesia as determinants of return to work, but should lead to a better understanding of other factors such as previous occupational status, cognitive deficits and personality changes.

Pediatric coma: prognosis and outcome

A review of 40 previously comatose children identified significant degrees of disability 10 months after the insult. Of all the antecedent factors assessed, duration of coma correlated most highly with outcome, especially in relation to language and intellectual spheres. The literature reveals heterogeneous approaches to the study of sequelae of pediatric coma, and thus disparate results: a more uniform approach is needed to the study of the nature and prognosis of pediatric coma.

Psychiatric sequelae of head injury

The psychiatric problems which may arise following head injury are common, occurring in from 10-77% of cases. The behaviours manifest often impede the progress of treatment causing frustration to the staff, and continuing distress to the patient. To assist in their understanding, I will present the sorts of problems which may arise, with reference to the course of the symptoms and behaviour and to their management.

Late recovery from head injury: case report and review

Some problems of prognosis in patients with head injury are reviewed, and a case of late and unexpected recovery from post-traumatic dementia presented. The possible mechanism of recovery is discussed with particular reference to normal pressure hydrocephalus.

Amnesia following severe head injury

This report concerns some aspects of the problem of establishing valid and reliable criteria for post-traumatic amnesia, and of relating this to other cognitive functions in the post-injury period. Of specific interest are the variability of the duration of retrograde and anterograde amnesia on attempts at repeated assessment, and the relationship between the time of return of full orientation and the end of the period of anterograde amnesia. A prospective study was undertaken of sixty consecutive patients who had suffered severe head injuries and had been admitted to the neurosurgical service of the Winnipeg General Hospital. The object of this study was to obtain information regarding organic, psychological and social indices of the future clinical course.

Influence of site of impact on cognitive impairment persisting long after severe closed head injury

The cognitive abilities of right-handed men who had sustained a severe closed head injury between 10 and 20 years earlier were studied. Results showed that a right-sided impact produced greater deficits than a left-sided impact in both verbal and non-verbal skills. The results are interpreted as reflecting left hemisphere damage due to contrecoup injury. Some evidence that a left frontal impact was apt to result in defective visual-spatial functioning is presented. These observations accord with some theories on the mechanics of head injury and with observations on the predictability of sites of cerebral contusion in brain injury uncomplicated by dural penetration, intracranial infection, or cerebral infarction. The roles of the duration of post-traumatic amnesia, the level of neurological responsiveness at the time of admission to hospital, and the age at which the injury was sustained are also discussed.

The psychiatric sequelae of head injury: a review

The review deals mainly with the more chronic psychiatric sequelae of head injury. The constellation of factors—psychological, social, and organic—which may contribute to enduring disability are discussed. Principal areas of disability are then considered in detail—namely, intellectual impairments, change of personality, psychotic illness, and neurotic disorders.

Brain damage in relation to psychiatric disability after head injury

The extent to which psychiatric disability after head injury depends upon the brain damage which has occurred remains a problem of considerable practical and theoretical interest. In 1904 Adolf Meyer saw the need for caution in approaching this question since there was “no direct measure of the damage of a concussion”; similarly in 1945 Denny-Brown saw that the most serious obstacles to better understanding still lay in the difficulty of obtaining a reliable estimate of the severity of injury to the brain and in the impossibility of differentiating clinically between simple skull fracture, laceration or contusion of the brain.