Head injury

A Criteria to Reduce Interhospital Transfer of Traumatic Brain Injuries in Greater East Texas

BACKGROUND

Traumatic brain injury (TBI) due to single-level falls (SLF) are frequent and often require interhospital transfer. This retrospective cohort study aimed to assess the safety of a criteria for non-transfer among a subset of TBI patients who could be observed at their local hospital, vs mandatory transfer to a level 1 trauma center (L1TC).

METHODS

We conducted a 7-year review of patients with TBI due to SLF at a rural L1TC. Patients were classified as transfer/non-transfer according to the Brain Injuries in Greater East Texas (BIGTEX) criteria. The primary outcome measure was the occurrence of a critical event defined as deteriorating repeat head computed tomography (CT) scan or neurological status, neurosurgical intervention, or death.

RESULTS

Of the 689 included patients, 63 (9.1%) were classified as non-transfer. Although there were 4 cases with a neurological change and one with a head CT change among the non-transfer group, there were no neurosurgical procedures or deaths. The Cox Proportional Hazard model showed a near 3-fold increased risk of experiencing a critical event if classified as a non-transfer. The multivariable regression model showed patients with an Abbreviated Injury Scale (AIS) of 3 was twice as likely to experience a critical event, with an AIS of 4, three times, and 3 times more likely to be classified to transfer.

DISCUSSION

The BIGTEX criteria identify a subset of patients who can safely be observed at their local hospital. To confirm the safety and efficacy of this transfer criteria recommendation, a prospective study is warranted.

Evaluation of an Elastomeric Honeycomb Bicycle Helmet Design to Mitigate Head Kinematics in Oblique Impacts

Head impacts in bicycle accidents are typically oblique to the impact surface and transmit both normal and tangential forces to the head, causing linear and rotational head kinematics, respectively. Traditional expanded polystyrene (EPS) foam bicycle helmets are effective at preventing many head injuries, especially skull fractures and severe traumatic brain injuries (TBIs) (primarily from normal contact forces). However, the incidence of concussion from collisions (primarily from rotational head motion) remains high, indicating need for enhanced protection. An elastomeric honeycomb helmet design is proposed herein as an alternative to EPS foam to improve TBI protection and be potentially reusable for multiple impacts, and tested using a twin-wire drop tower. Small-scale normal and oblique impact tests showed honeycomb had lower oblique strength than EPS foam, beneficial for diffuse TBI protection by permitting greater shear deformation and had the potential to be reusable. Honeycomb helmets were developed based on the geometry of an existing EPS foam helmet, prototypes were three-dimensional-printed with thermoplastic polyurethane and full-scale flat and oblique drop tests were performed. In flat impacts, honeycomb helmets resulted in a 34% higher peak linear acceleration and 7% lower head injury criteria (HIC15) than EPS foam helmets. In oblique tests, honeycomb helmets resulted in a 30% lower HIC15 and 40% lower peak rotational acceleration compared to EPS foam helmets. This new helmet design has the potential to reduce the risk of TBI in a bicycle accident, and as such, reduce its social and economic burden. Also, the honeycomb design showed potential to be effective for repetitive impact events without the need for replacement, offering benefits to consumers.

Hospital Admissions Associated With Head and Neck Injuries From Olympic-style Sports and Activities Between 2010 and 2022

The objective of this study was to evaluate which Olympic-style sports and activities are most likely to result in hospitalizations relating to head and neck injuries. This was a cross-sectional study using the National Electronic Injury Surveillance System (NEISS) database. Subjects with head and neck injuries from selected Olympic-style sports and activities between 2010 and 2022 were included. Independent variables were demographics and injury characteristics (injury location and sport). The primary outcome variable was hospitalization (yes/no). Survey-weighted descriptive, bivariate, and logistic regression statistics were computed to measure the association between demographic/injury variables and hospitalization. There were 175,995 subjects (national estimate, 5,922,584) meeting inclusion criteria. After adjusting for demographic and injury characteristics, head injuries (odds ratio [OR] = 2.17; 95% CI, 1.83-2.56; P<0.001) demonstrated higher odds of hospitalization compared with facial injuries. Injuries from cycling (OR = 2.52; 95% CI, 2.16-2.95; P<0.001), mountain biking (OR = 2.56; 95% CI, 1.80-3.65; P<0.001), and horseback riding (OR = 4.01; 95% CI, 2.76-5.83; P<0.001) demonstrated higher odds of hospitalization relative to baseball injuries. In conclusion, head and neck injuries associated with high velocity Olympic-style sports and activities such as cycling, mountain biking, and horseback riding had the highest odds of hospitalization.

Communication and Psychosocial Outcomes 2-Years After Severe Traumatic Brain Injury: Development of a Prognostic Model

OBJECTIVE

To examine predictive factors underlying communication and psychosocial outcomes at 2 years post-injury. Prognosis of communication and psychosocial outcomes after severe traumatic brain injury (TBI) is largely unknown yet is relevant for clinical service provision, resource allocation, and managing patient and family expectations for recovery.

DESIGN

A prospective longitudinal inception design was employed with assessments at 3 months, 6 months, and 2 years.

PARTICIPANTS

The cohort included 57 participants with severe TBI (N=57).

SETTING

Subacute and post-acute rehabilitation.

MAIN OUTCOME MEASURES

Preinjury/injury measures included age, sex, education years, Glasgow Coma Scale, and PTA. The 3-month and 6-month data points included speech, language, and communication measures across the ICF domains and measures of cognition. The 2-year outcome measures included conversation, perceived communication skills, and psychosocial functioning. Predictors were examined using multiple regression.

INTERVENTIONS

Not applicable.

RESULTS

The cognitive and communication measures at 6 months significantly predicted conversation measures at 2 years and psychosocial functioning as reported by others at 2 years. At 6 months, 69% of participants presented with a cognitive-communication disorder (Functional Assessment of Verbal Reasoning and Executive Strategies [FAVRES]). The unique variance accounted for by the FAVRES measure was 7% for conversation measures and 9% for psychosocial functioning. Psychosocial functioning at 2 years was also predicted by pre-injury/injury factors and 3-month communication measures. Pre-injury education level was a unique predictor, accounting for 17% of the variance, and processing speed/memory at 3 months uniquely accounted for 14% of the variance.

CONCLUSION

Cognitive-communication skills at 6 months are a potent predictor of persisting communication challenges and poor psychosocial outcomes up to 2 years after a severe TBI. Findings emphasize the importance of addressing modifiable cognitive and communication outcomes variables during the first 2 years after severe TBI to maximize functional patient outcomes.

Differentiating Use of Facial Expression between Individuals with and without Traumatic Brain Injury Using Affectiva Software: A Pilot Study

This study investigated the feasibility of using an automated facial coding engine, Affectiva (integrated in iMotions, version 8.2), for evaluating facial expression after traumatic brain injury (TBI). An observational cross-sectional study was conducted based on facial expression data from videos of participants with TBI and control participants. The aims were to compare TBI and control groups, and identify confounding factors affecting the data analysis. Video samples of two narrative tasks (personal event and story retell) from ten participants with severe TBI and ten control participants without TBI were analyzed using Affectiva. Automated data on participants' engagement, smile and brow furrow were compared statistically between and within groups. Qualitative notes for each sample were also recorded. Affectiva detected a higher percentage of time of engagement for TBI participants than for control participants on both tasks. There was also a higher percentage of time of smiling for TBI participants in one task. Within groups, there were no significant differences between the two narrative tasks. Affectiva provides standardized data about facial expression and may be sensitive to detecting change in the use of facial expression after TBI. This study also identified factors to avoid during videorecording to ensure high quality samples for future research.

Pattern and In-Hospital Mortality of Thoracoabdominal Injuries Associated with Motor Vehicle Accident-Related Head Injury: a Single-Center Retrospective Study

Aim

To determine the pattern and in-hospital mortality of thoracoabdominal injuries associated with head injuries (HI) due to motor vehicle accidents. Settings and Design. A single-center retrospective study in a tertiary care hospital, level 1 trauma center in the southern region of Saudi Arabia.

Methods and Materials

Descriptive analysis was conducted to evaluate sex, age, types of head injury, associated thoracoabdominal injuries, particular admission day, duration of hospital stay, and discharge category, and associations between different variables and outcomes were analyzed.

Results

The cohort had a mean age of 26.9 ± 15.8 years, with a predominance of men (86.9%). Thoracoabdominal injuries were present in 6.8% of MVA-related HI, and 14.3% of victims expired during their hospital stay, mostly within the first 10 days. All expired patients had posttraumatic brain lesions. Moreover, there was a significant association between intensive care unit (ICU) admission and poor prognosis.

Conclusions

Existence of posttraumatic brain lesions and requirement of ICU admission are significant variables affecting outcomes in patients with motor vehicle-associated HI with concomitant thoracoabdominal trauma in this study. Patients who survived the first 10 days after trauma seemed to have a better prognosis. More efforts are needed to reduce the health burden of this lethal injury.

Testing a Model of Resilience in Family Members of Relatives with Traumatic Brain Injury vs Spinal Cord Injury: Multigroup Analysis

OBJECTIVE

To test a model comprising explanatory (neurologic impairment, coping, personality) and mediating (resilience, self-efficacy, hope, social support) variables on psychological adjustment and burden among family caregivers of individuals with traumatic brain injury (TBI) vs spinal cord injury (SCI).

DESIGN

Structural equation modeling with multigroup analysis.

SETTING

Six rehabilitation centers across New South Wales and Queensland, Australia.

PARTICIPANTS

A total of 181 family members (N=181; 131 TBI, 50 SCI).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Connor-Davidson Resilience Scale, Eysenck Personality Questionnaire, Ways of Coping Questionnaire, General Self-Efficacy Scale, Herth Hope Scale, Medical Outcome Study Social Support Survey; and 4 measures of psychological adjustment including: Caregiver Burden Scale, Medical Outcomes Survey Short Form-36 (SF-36), General Health Questionnaire-28, and Positive and Negative Affect Scale.

RESULTS

The model for the aggregated sample demonstrated a very good model fit (χ²=47.42, df=39, ρ=0.167, normed fit index=.962, incremental fit index=.993, Tucker-Lewis index=.985, comparative fit index=.993, root-mean-squared error of approximation=.035). Multi-group analysis found significant commonalities in the pattern of relationships among variables across the 2 groups. In the only differences found, neuroticism was significantly more influential on burden in family members supporting individuals with TBI than family members of individuals with SCI. Furthermore, problem-focused coping was statistically more influential on positive affect in family members of individuals with TBI when compared with family members of individuals with SCI.

CONCLUSIONS

The study found significant similarities in the patterns of resilience and psychological adjustment among family caregivers of individuals with TBI and SCI.

The experience of families following traumatic brain injury in adult populations: A meta-synthesis of narrative structures

BACKGROUND

Traumatic brain injury has a significant effect on uninjured family members. Typically, this has been examined with a focus on psychopathological outcomes including stress, depression and anxiety. However, in recent years there has been increasing interest in the subjective experiences of families post-injury leading to a plethora of qualitative studies. Therefore, an in-depth examination and synthesis of this literature is now relevant and timely.

OBJECTIVE

To examine the subjective experiences of families following traumatic brain injury in adult populations in the sub/post-acute period through the synthesis of original qualitative research.

DESIGN

This paper presents a meta-synthesis using Thomas and Harden's framework of 'thematic synthesis' rooted in a critical realist philosophy.

DATA SOURCES

In July 2019 five electronic databases, were searched for the terms 'traumatic brain injury', 'family' and 'qualitative'. Studies were included if the primary research reported qualitative data about the subjective experiences of family members of adults with traumatic brain injury and had been published in a peer reviewed journal. Studies with mixed brain injury samples, child or adolescent traumatic brain injury or disorders of consciousness were excluded. Hand searching and citation searches were also completed.

REVIEW METHODS

Two reviewers screened titles, abstracts and full text and reached consensus through critical discussion. Thirty papers were finally agreed for inclusion in this review. Each study was then assessed for relevance, resonance and rigour using the Critical Appraisal Skills Programme (CASP) tool. Line by line coding of the findings in each paper was conducted as the basis for a thematic analysis and synthesis.

RESULTS

Descriptive themes were identified followed later by analytical themes. This final stage was informed by a narrative lens and from these, eight narrative functions belonging to four dimensions were identified from the subjective experiences of families post-traumatic brain injury. Specifically, these were: (1) Displacing and Anchoring; (2) Rupturing and Stabilising; (3) Isolating and Connecting; (4) Harming and Healing.

CONCLUSIONS

The interpretation of the narrative functions revealed the substantial existential work involved in negotiating lives, maintaining family system equilibrium and moving forward. As such, family members have their own unique narrative needs. Despite contemporary service models built around the injured person, service providers are well placed to support families in this everyday narrative work through actively attending to narrative structures and understanding the implications of these for family experience. The study protocol was registered with PROSPERO (International prospective register of systematic reviews) in July 2018 (Registration number: CRD42018085824). Tweetable abstract: This synthesis showed the immense and invisible work required for family members to maintain family system equilibrium and negotiate their lives post-TBI.

Does Curved Walking Sharpen the Assessment of Gait Disorders? An Instrumented Approach Based on Wearable Inertial Sensors

Gait and balance assessment in the clinical context mainly focuses on straight walking. Despite that curved trajectories and turning are commonly faced in our everyday life and represent a challenge for people with gait disorders. The adoption of curvilinear trajectories in the rehabilitation practice could have important implications for the definition of protocols tailored on individual’s needs. The aim of this study was to contribute toward the quantitative characterization of straight versus curved walking using an ecological approach and focusing on healthy and neurological populations. Twenty healthy adults (control group (CG)) and 20 patients with Traumatic Brain Injury (TBI) (9 severe, sTBI-S, and 11 very severe, sTBI-VS) performed a 10 m and a Figure-of-8 Walk Test while wearing four inertial sensors that were located on both tibiae, sternum and pelvis. Spatiotemporal and gait quality indices that were related to locomotion stability, symmetry, and smoothness were obtained. The results show that spatiotemporal, stability, and symmetry-related gait patterns are challenged by curved walking both in healthy subjects and sTBI-S, whereas no difference was displayed for sTBI-VS. The use of straight walking alone to assess gait disorders is thus discouraged, particularly in patients with good walking abilities, in favor of the adoption of complementary tests that were also based on curved paths.

Burden and Preparedness amongst Informal Caregivers of Adults with Moderate to Severe Traumatic Brain Injury

This study examined the patterns of informal (unpaid) caregiving provided to people after moderate to severe traumatic brain injury (TBI), explore the self-reported burden and preparedness for the caregiving role, and identify factors predictive of caregiver burden and preparedness. A cross-sectional cohort design was used. Informal caregivers completed the Demand and Difficulty subscales of the Caregiving Burden Scale; and the Mutuality, Preparedness, and Global Strain subscales of the Family Care Inventory. Chi-square tests and logistic regression were used to examine the relationships between caregiver and care recipient variables and preparedness for caregiving. Twenty-nine informal caregivers who reported data on themselves and people with a moderate to severe TBI were recruited (referred to as a dyad). Most caregivers were female (n = 21, 72%), lived with the care recipient (n = 20, 69%), and reported high levels of burden on both scales. While most caregivers (n = 21, 72%) felt “pretty well” or “very well” prepared for caregiving, they were least prepared to get help or information from the health system, and to deal with the stress of caregiving. No significant relationships or predictors for caregiver burden or preparedness were identified. While caregivers reported the provision of care as both highly difficult and demanding, further research is required to better understand the reasons for the variability in caregiver experience, and ultimately how to best prepare caregivers for this long-term role.

Craniectomy size for subdural haematomas and the impact on brain shift and outcomes

BACKGROUND

Midline shift in trauma relates to the severity of head injury. Large craniectomies are thought to help resolve brain shift but can be associated with higher rates of morbidity. This study explores the relationship between craniectomy size and subtemporal decompression for acute subdural haematomas with the resolution of brain compression and outcomes. No systematic study correlating these measures has been reported.

METHOD

A retrospective study of all adult cases of acute subdural haematomas that presented to a Major Trauma Centre and underwent a primary decompressive craniectomy between June 2008 and August 2013. Data collection included patient demographics and presentation, imaging findings and outcomes. All imaging metrics were measured by two independent trained assessors. Compression was measured as midline shift, brainstem shift and cisternal effacement.

RESULTS

Thirty-six patients with mean age of 36.1 ± 12.5 (range 16-62) were included, with a median follow-up of 23.5 months (range 2.2-109.6). The median craniectomy size was 88.7 cm² and the median subtemporal decompression was 15.0 mm. There was significant post-operative resolution of shift as measured by midline shift, brainstem shift and cisternal effacement score (all p < .00001). There was no mortality, and the majority of patients made a good recovery with 82.8% having a Modified Rankin Score of 2 or less. There was no association between craniectomy size or subtemporal decompression and any markers of brain shift or outcome (all R² < 0.05).

CONCLUSIONS

This study suggests that there is no clear relationship between craniectomy size or extent of subtemporal decompression and resolution of brain shift or outcome. Further studies are needed to assess the relative efficacy of large craniectomies and the role of subtemporal decompression.

Gait Quality Assessment in Survivors from Severe Traumatic Brain Injury: An Instrumented Approach Based on Inertial Sensors

Despite existing evidence that gait disorders are a common consequence of severe traumatic brain injury (sTBI), the literature describing gait instability in sTBI survivors is scant. Thus, the present study aims at quantifying gait patterns in sTBI through wearable inertial sensors and investigating the association of sensor-based gait quality indices with the scores of commonly administered clinical scales. Twenty healthy adults (control group, CG) and 20 people who suffered from a sTBI were recruited. The Berg balance scale, community balance and mobility scale, and dynamic gait index (DGI) were administered to sTBI participants, who were further divided into two subgroups, severe and very severe, according to their score in the DGI. Participants performed the 10 m walk, the Figure-of-8 walk, and the Fukuda stepping tests, while wearing five inertial sensors. Significant differences were found among the three groups, discriminating not only between CG and sTBI, but also for walking ability levels. Several indices displayed a significant correlation with clinical scales scores, especially in the 10 m walking and Figure-of-8 walk tests. Results show that the use of wearable sensors allows the obtainment of quantitative information about a patient’s gait disorders and discrimination between different levels of walking abilities, supporting the rehabilitative staff in designing tailored therapeutic interventions.

Length of post-traumatic amnesia and its prediction of neuropsychological outcome following severe to extremely severe traumatic brain injury in a litigating sample

Primary Objective: The aim of the current study was to examine the relationship between duration of post-traumatic amnesia (PTA) and neuropsychological outcome at one or more years following severe to extremely severe traumatic brain injury (TBI) in a litigating sample. Research Design: Retrospective study design, using data collected from 2010 to 2017. Methods and Procedures: Data from 41 cases obtained from a private medicolegal neuropsychological database was examined. The database comprised information pertaining to TBI etiology, TBI severity parameters, demographic variables, neuropsychological test results and scores on psychological questionnaires. PTA duration was examined as a continuous variable. All cases that demonstrated non-credible effort were excluded. Main Outcomes and Results: Continuous PTA duration was not found to be a significant predictor of cognitive impairment across domains of verbal intellect, non-verbal intellect, working memory, information processing speed, immediate memory, delayed memory, and executive functioning. Conclusions: The predictive relationship between duration of PTA and cognitive impairment that has been reported in non-litigating populations did not exist in a litigating TBI sample. Findings illustrate the importance of investigating the relationships between injury variables and cognitive outcome in a population undergoing litigation, to provide better understanding of outcome in this subgroup of patients with TBI.

External causes of death after severe traumatic brain injury in a multicentre inception cohort: clinical description and risk factors

Objective: To characterize the clinical profile of patients dying from external causes (EC) following severe traumatic brain injury (TBI). Design and Methods: Data from 2545 patients forming the NSW-BIRP inception cohort discharged from post-acute inpatient rehabilitation between 1 July 1990 and 1 October 2007 were retrospectively reviewed. Standardized mortality ratios (SMRs) were calculated for EC sub-categories. Demographic, clinical and rehabilitation service factors were compared between deaths from EC, deaths from other causes (OC), and non-deceased. Clinical profiles of EC sub-categories were analysed descriptively. Results: Overall, patients with TBI were 5.2x more likely to die from EC relative to the general population. Risk of death was elevated in all EC sub-categories examined, with the largest risks relating to other accidental threats to breathing (SMR = 33.0; 95%CI = 13.79-60.45) and falls (SMR = 14.3; 95%CI = 5.01-28.39). The EC group were younger, more likely to have pre-injury psychiatric histories, less severe injuries, greater functional independence, and die earlier than the OC group. There was considerable heterogeneity in the clinical profiles of patients dying from different EC sub-categories. Conclusions: EC constitutes one of the largest causes of mortality following TBI in patients surviving beyond the post-acute phase. Potential implications for risk modification and prevention of premature and avoidable deaths are discussed.

Is computed tomography of the head justified in patients with minor head trauma presenting with Glasgow Coma Scale 15/15?

Background

In keeping with radiology departments in tertiary referral hospitals in developing countries offering computed tomography (CT) head scan services, the radiology department at Groote Schuur Hospital (GSH) in the Western Cape of South Africa undertakes several such scans annually. Of these scans, many are undertaken for post-trauma patients with minor head injury (MHI). While there is agreement that MHI patients with Glasgow Coma Scale (GCS) scores of 13–14/15 may well benefit, there is doubt as to the clinical utility of routine CT head scanning in MHI patients with GCS scores of 15/15.

Objectives

This retrospective descriptive study of patient records was undertaken to determine the frequency and clinical significance of any abnormalities found on CT head scans of 460 patients with MHI and GCS scores of 15/15, scanned at GSH between 2012 and 2014.

Method

Ethical clearance was obtained and the records of 460 MHI patients with GCS scores of 15/15, loss of consciousness (LOC) and amnesia who underwent CT head scanning at GSH between 2012 and 2014 were then retrieved from the Philips picture archiving and communication system (PACS). Patient records, containing illegible referral forms or technically inadequate CT head scans, were excluded from the study. Patients’ biographical, clinical and CT head scan data were entered into sequentially numbered data collection forms. These data were tabulated and summed as percentage distributions. Patients’ CT head scan findings were reviewed and classified as either showing normal or abnormal features. Abnormalities detected on CT head scans were classified as being either clinically significant or clinically non-significant.

Results

Referral forms and CT scan reports were obtained for 460 MHI patients from a sample of 497 patients, calculated by using the equation for estimating a single proportion from a large sample (precision 1.5%). The sample obtained yielded an acceptable response rate of 460/497 (92.6%). Of 460 (100%) scan reports, 320 (69.6%) showed no abnormality, while 140 (30.4%) showed abnormality. Of the 140 abnormal scans, 107 (23.3%) showed clinically non-significant abnormality, while 33 (7.2%) revealed clinically significant abnormality. Twenty-two (4.8%) of these clinically significant scans showed brain contusion and 11(2.4%) showed skull fracture. No subdural or extradural haematoma, shift or herniation were reported and none of the 33 patients whose CT scans showed clinically significant abnormality underwent urgent neurosurgical intervention.

Conclusion

Of the 460 CT head scans performed at GSH for MHI with LOC but normal GCS between 2012 and 2014, none required urgent neurosurgical intervention. This is in accordance with the 2012 Kimberley Hospital Rule (KHR), a management protocol which indicates that CT head scanning in patients with MHI and GCS scores of 15/15 can safely be delayed for 8 h. An audit of the records of patients excluded from this study coupled with an analysis of data from other Western Cape hospital CT head scan databases could help ensure that this scarce resource is used cost-beneficially for all head-injured patients in the Western Cape catchment area.

Does magnesium sulfate have a role in the management of severe traumatic brain injury in civilian and military populations? A systematic review and meta-analysis

INTRODUCTION

Traumatic brain injury (TBI) is a significant cause of combat morbidity. Currently, the medical management of TBI is limited to supportive critical care. Magnesium sulfate has been studied as a potentially beneficial therapeutic agent.

METHODS

A systematic review and meta-analysis was undertaken, examining the role of magnesium in the management of severe TBI in adults. The primary outcome of the study was all-cause mortality, with secondary outcomes of Glasgow Outcome Score (GOS) and GCS. EMBASE, MEDLINE, CINAHL, WHO Trial Registry and the Cochrane Library database were systematically searched, with data included until 1 February 2017. Inclusion criteria were: human study; aged >13 years; randomised controlled trial; severe TBI. Exclusion criteria were: data collected prior to 1 January 2002; magnesium commenced >24 hours postinjury; magnesium therapy for <24 hours. Statistical analysis was conducted using Stata (V.13.1).

RESULTS

The pooled results of six studies found all-cause mortality not to be significantly different in the treatment group (RR 0.84, 95% CI 0.54 to 1.33; P=0.46) with an I² value of >70%. With regard to the secondary outcomes, no significant difference in GOS scores between treatment and control was demonstrated. GCS showed a significant improvement in the treatment group.

CONCLUSIONS

The meta-analysis found a lack of evidence for magnesium pharmacotherapy in severe TBI, although the data were noted to be conflicting and significantly heterogeneous. Further study is recommended to ascertain whether a therapeutic window exists for magnesium in severe TBI.

Prognostic Value of S-100β Protein for Prediction of Post-Concussion Symptoms after a Mild Traumatic Brain Injury: Systematic Review and Meta-Analysis

This systematic review and meta-analysis aimed to determine the prognostic value of S-100β protein to identify patients with post-concussion symptoms after a mild traumatic brain injury (mTBI). A search strategy was submitted to seven databases from their inception to October 2016. Individual patient data were requested. Cohort studies evaluating the association between S-100β protein level and post-concussion symptoms assessed at least seven days after the mTBI were considered. Outcomes were dichotomized as persistent (≥3 months) or early (≥7 days <3 months). Our search strategy yielded 23,298 citations of which 29 studies including between seven and 223 patients (n = 2505) were included. Post-concussion syndrome (PCS) (16 studies) and neuropsychological symptoms (9 studies) were the most frequently assessed outcomes. The odds of having persistent PCS (odds ratio [OR] 0.62, 95% confidence interval [CI]: 0.34-1.12, p = 0.11, I² 0% [n = five studies]) in patients with an elevated S-100β protein serum level were not significantly different from those of patients with normal values while the odds of having early PCS (OR 1.67, 95% CI: 0.98-2.85, p = 0.06, I² 38% [n = five studies]) were close to statistical significance. Similarly, having an elevated S-100β protein serum level was not associated with the odds of returning to work at six months (OR 2.31, 95% CI: 0.50-10.64, p = 0.28, I² 22% [n = two studies]). Overall risk of bias was considered moderate. Results suggest that the prognostic biomarker S-100β protein has a low clinical value to identify patients at risk of persistent post-concussion symptoms. Variability in injury to S-100ß protein sample time, mTBI populations, and outcomes assessed could potentially explain the lack of association and needs further evaluation.

Case study: Head injury

This study is presented to encourage recognition of the contribution mental health practitioners can make to the care of head-injured people.

Diagnostic and Prognostic Capability of Newer Magnetic Resonance Imaging Brain Sequences in Diffuse Axonal Injury Patient

Objectives:

Diffuse axonal injury is one of the major causes of unconsciousness, profound neurologic deficits and persistent vegetative state after head trauma. In recent years, MR imaging has been gaining popularity as an adjunctive imaging method in patients with DAI. Our study aims to assess the relative diagnostic and prognostic capability of various MRI sequences.

Patients and Methods:

Retrospective observational study done in 1 year duration on 30 DAI patients. Clinical assessment done with GCS at admission and GOS at 6 month. MRI Brain FLAIR, DWI, T2*GRE AND SWI sequences taken. DAI grade were evaluated for different MRI sequences. Prognosis was correlated to total number of lesion/locations and DAI grade of patients. Statistical analysis was done using SPSS Statistical software (ver.20.0.0) and XL-Stat and ANOVA one way test, post hoc test (Turkey test) and Chi square test.

Result:

We studied 30 male patients, mean age 32.57±8.72 ranges. The commonest mode of injury is RTA-80%, fall-16% followed by assault-3.33%. Out of 30 patients, 17 patients (56.67%) had GCS <=8, 13 patients (43.33%) had GCS between 9 and 12 and no patient had a GCS score between 13 and 15. The mean GCS score was 8.47±1.50. At a 6 month follow up, out of a total of 30 patients, 2 patients (6.66%) expired (GOS-1), 3 patients (10%) remained in persistent vegetative state (GOS-2), 11 patients (36.67%) and 10 patients (33.33%) were found to be severely (GOS-3) and moderately (GOS-4) disabled respectively and 4 patients (13.33%) showed good recovery (GOS-5). Mean GOS is 3.37+/-1.06. Newer imaging -SWI able to detects lesion better (diagnosis of DAI) as compared to other older sequences like FLAIR,DWI,T2*GRE. But no statistically significant found between total number of lesion/locations to the outcome and also newer imaging do not change the grade of DAI patients.

Conclusion:

Although advanced imaging in head injury, SWI helps in diagnosing the diffuse axonal injury more efficiently than other imaging sequences, but it is the grade of patients at admission that predicts the outcome best.

Navigating Employment Pathways and Supports Following Brain Injury in Australia: Client Perspectives

This study investigated the vocational rehabilitation experiences of 29 clients, up to 14 years post brain injury. Data obtained from participant interviews were thematically analysed by employment pathway (‘return to pre-injury employment’, ‘job seeking’ and ‘not worked since injury’). A total of nine themes were identified. Across all pathways, participants identified the importance of working, impact of injury and their own determination. The content for the remaining themes (understanding, adjustment, access, support, disclosure of injury, intervention) varied by pathway, reflecting the differing perspectives arising from integrating back into a familiar workplace versus seeking new employment. In conclusion, programme approaches to vocational rehabilitation need to be tailored to the individual circumstances, opportunities and support needs of people with brain injury pursuing these different pathways.

Social Disinhibition: Piloting a New Clinical Measure in Individuals with Traumatic Brain Injury

Social disinhibition difficulties are common following traumatic brain injury (TBI). However, clinically sensitive tools to objectively assess the difficulties are lacking. This study aimed to pilot a new clinical measure of social disinhibition, the social disinhibition task (SDT). Whether social disinhibition is dependent on the type of social information judgements required and whether disinhibited responses can be adjusted with additional guidance were also examined. Participants were 31 adults (25 Male) with moderate-to-severe TBI and 22 adult (17 Male) healthy control participants. Participants viewed scenes of complex social situations and were asked to describe a character in them (Part A), describe a character while inhibiting inappropriate or negative responses (Part B), and describe a character while not only inhibiting negative responses, but also providing positive responses (Part C). One-half of the items contained a faux pas requiring participants to make inferences about a character's mental state. TBI and control participants responded similarly to Part A, although control participants responded less positively than TBI participants in the faux pas items. TBI participants were significantly impaired on Part B indicating they experienced difficulties in inhibiting automatic responding. TBI participants were however able to adjust their responding in Part C so that they respond similarly to the control participants. Between group differences were not detected in reaction time. Overall, the SDT appears to be suitable to detect social inhibition difficulties in clinical settings and provides a new direction for remediation of the difficulties in individuals with TBI.

Brain Injury as the Result of Violence: A Systematic Scoping Review

This scoping review investigated risk factors, impacts, outcomes, and service implications of violence-related traumatic brain injury (TBI) for individuals and their informal caregivers. A systematic search (Web of Science, PubMed, PsycInfo, ProQuest, Medline, Informit; 1990-2015) identified 17 studies meeting the inclusion and exclusion criteria. Violence was the cause of between 3% and 26% of all TBIs. Males, a non-White racial background, preinjury unemployment, and preinjury substance abuse problems all elevated the risk for sustaining a violence-related TBI compared to other-cause TBI. However, few differences were observed in 12 months postinjury outcomes. No studies investigated the impact of violence-related TBI on informal caregivers.

Contemporary Perspectives on Social Work in Acquired Brain Injury: An Introduction

This special issue of the Journal of Social Work in Disability and Rehabilitation, "Contemporary Perspectives on Social Work in Acquired Brain Injury," has been initiated and coordinated by the International Network of Social Workers in Acquired Brain Injury (INSWABI). In introducing the issue, some space is allocated for providing definitions of traumatic brain injury (TBI) and acquired brain injury (ABI), outlining the epidemiology and global costs, and detailing the impairments and psychosocial impacts for both the person sustaining the injury and his or her family. Finally, an outline of the articles contributing to this special issue are detailed, followed by a brief discussion about the role of the INSWABI network in promoting best practice in social work within this specialty area.

Swallowing Disorders in Severe Brain Injury in the Arousal Phase

The objective of this study was to determine the clinical characteristics of swallowing disorders in severe brain injury in the arousal phase after coma. Between December 1, 2013 and June 30, 2014, eleven patients with severe acquired brain injury who were admitted to rehabilitation center (Male 81.8 %; 40.7 ± 14.6 years) were included in the study. Evaluation of swallowing included a functional examination, clinical functional swallowing test, and naso-endoscopic swallowing test. All patients had swallowing disorders at admission. The first functional swallowing test showed oral (77.8 %) and pharyngeal (66.7 %) food bolus transport disorders; and alterations in airway protection mechanisms (80 %). Swallowing test under endoscopic control showed a disorder in swallowing coordination in 55.6 % of patients tested. Seven (63.6 %) patients resumed oral feeding within an average of 6 weeks after admission to rehabilitation center and 14 weeks after acquired brain injury. Six (85.7 %) of these seven patients continued to require modified solid and liquid textures. Swallowing disorders are a major concern in severe brain injury in the arousal phase. Early bedside assessment of swallowing is essential for detection of swallowing disorders to propose appropriate medical rehabilitation care to these patients in a state of altered consciousness.

Arterial Spin Labeling Perfusion Study in the Patients with Subacute Mild Traumatic Brain Injury

Background

This study uses a MRI technique, three-dimension pulse continuous arterial spin labeling (3D-PCASL), to measure the patient’s cerebral blood flow (CBF) at the subacute stage of mild traumatic brain injury (MTBI) in order to analyze the relationship between cerebral blood flow and neurocognitive deficits.

Objective

To provide the relationship between cortical CBF and neuropsychological dysfunction for the subacute MTBI patients.

Methods

After MTBI, perfusion MR imaging technique (3D-PCASL) measures the CBF of MTBI patients (n = 23) within 1 month and that of normal controls (n = 22) to determine the quantity and location of perfusion defect. The correlation between CBF abnormalities and cognitive deficits was elucidated by combining the results of the neuropsychological tests of the patients.

Result

We observed a substantial reduction in CBF in the bilateral frontal and left occipital cortex as compared with the normal persons. In addition, there were correlation between post concussive symptoms (including dizziness and simulator sickness) and CBF in the hypoperfused areas. The more severe symptom was correlated with higher CBF in bilateral frontal and left occipital lobes.

Conclusion

First, this study determined that despite no significant abnormality detected on conventional CT and MRI studies, hypoperfusion was observed in MTBI group using 3D-PCASL technique in subacute stage, which suggested that this approach may increase sensitivity to MTBI. Second, the correlation between CBF and the severity of post concussive symptoms suggested that changes in cerebral hemodynamics may play a role in pathophysiology underlies the symptoms.

Reducing head computed tomography after mild traumatic brain injury: Screening value of clinical findings and S100B protein levels

PRIMARY OBJECTIVE

The present prospective study was performed to investigate whether primary clinical findings and serum S100B concentrations at 3 and 6 hours post-trauma can contribute to the selection of patients for an initial computed tomography (CT) scanning.

RESEARCH DESIGN AND METHODS

S100B was measured in serum samples obtained at 3 and 6 hours after the injury. Adjusted odds ratios (OR) and 95% confidence interval (CI) associated with demographics and clinical predictors of positive CT scan were calculated. Sensitivity, specificity, negative and positive predictive values were also calculated for S100B levels.

MAIN OUTCOMES AND RESULTS

It was found that the presence of loss of consciousness (OR = 2.3; 95% CI = 1.00-4.01; p = 0.008) and post-traumatic vomiting ≥ 2 episodes (OR = 1.8; 95% CI = 1.08-3.29; p = 0.019) are factors associated with positive CT scan. In this study the best cut-off point of 0.115 µg L(-1) for 3-hour S100B has sensitivity of 94.9% (95% CI = 86.8-98.3) with specificity of 35.4% (95% CI = 25.2-47.0) to predict intracranial injury on CT scanning. The corresponding results for 6-hour S100B > 0.210 µg L(-1) were 98.7% (95% CI = 92.1-99.9) for sensitivity and 39.2% (95% CI = 28.6-50.8) for specificity.

CONCLUSIONS

Serum S100B measurement along with clinical evaluation of patients with mild traumatic brain injury has promising screening value to support selection of patients for CT scanning.

Deficits in comprehension of speech acts after TBI: The role of theory of mind and executive function

Theory of mind (ToM) is critical to effective communication following traumatic brain injury (TBI) however, whether impairments are specific to social cognition, or reflective of executive demands is unclear. This study examined whether ToM impairments are predicted by executive function difficulties using everyday conversation tasks. Twenty-five individuals with severe-TBI were compared to 25 healthy controls on low- and high-ToM tasks across four conditions: (1) low cognitive load, (2) high flexibility, (3) high working memory (WM) and (4) high inhibition. TBI individuals were impaired on high-ToM tasks in the WM condition. When the WM demands of the task were controlled, the impairments were no longer apparent. TBI individuals were not impaired on high-ToM tasks in the inhibition and flexibility conditions, suggesting these tasks may not have been sufficiently demanding of ToM abilities. The results suggest that ToM impairments in everyday communication may arise due to WM demands, in individuals with TBI.

Development of a finite element head model for the study of impact head injury

This study is aimed at developing a high quality, validated finite element (FE) human head model for traumatic brain injuries (TBI) prediction and prevention during vehicle collisions. The geometry of the FE model was based on computed tomography (CT) and magnetic resonance imaging (MRI) scans of a volunteer close to the anthropometry of a 50th percentile male. The material and structural properties were selected based on a synthesis of current knowledge of the constitutive models for each tissue. The cerebrospinal fluid (CSF) was simulated explicitly as a hydrostatic fluid by using a surface-based fluid modeling method. The model was validated in the loading condition observed in frontal impact vehicle collision. These validations include the intracranial pressure (ICP), brain motion, impact force and intracranial acceleration response, maximum von Mises stress in the brain, and maximum principal stress in the skull. Overall results obtained in the validation indicated improved biofidelity relative to previous FE models, and the change in the maximum von Mises in the brain is mainly caused by the improvement of the CSF simulation. The model may be used for improving the current injury criteria of the brain and anthropometric test devices.

Challenging Behaviours, Co-morbidities, Service Utilisation and Service Access among Community-dwelling Adults with Severe Traumatic Brain Injury: A Multicentre Study

Objective: To examine patterns, predictors and unmet needs of service utilisation and access to mental health and/or drug and alcohol services among community-dwelling adults with severe traumatic brain injury, and compare those who displayed challenging behaviours with those not displaying challenging behaviour.

Design: Retrospective multicentre study.

Subjects: All active clients (n= 507) of the New South Wales (NSW) Brain Injury Rehabilitation Program (BIRP) community rehabilitation teams.

Methods: Clinician-rated data were collected on client challenging behaviours, mental health and functional status, service utilisation and unmet needs. Between-groups analyses (challenging behaviour versus no challenging behaviours) were conducted to examine patterns of service utilisation and unmet needs. Predictors for service utilisation were tested by multiple linear regression.

Results: Challenging behaviours were associated with higher use of BIRP and non-BIRP services and greater levels of unmet needs. Challenging behaviour was an independent predictor of higher levels of service utilisation, in conjunction with pre- and post-injury mental health and drug and alcohol co-morbidities and geographic location. Only 15.3% of the 111 clients with challenging behaviours and co-morbid drug and alcohol problems accessed a drug and alcohol service, while another 32.4% had unmet needs for such services.

Conclusion: Challenging behaviours make an independent contribution to increased levels of service utilisation after severe traumatic brain injury.

Diagnosis and treatment of an obsessive-compulsive disorder following traumatic brain injury: a single case and review of the literature

A 27-year-old patient with traumatic brain injury and neuropsychiatric symptoms fitting the obsessive-compulsive disorder was investigated. Brain CT-scan revealed left temporal and bilateral fronto-basal parenchymal contusions. Main Outcome Measure was the Yale-Brown Obsessive Compulsive Scale at pre- and post-treatment and at 6 months follow-up. The combination of pharmacotherapy and psychotherapy resulted in lower intensity and frequency of symptoms. Our case illustrates the importance of a detailed diagnostic procedure in order to provide appropriate therapeutic interventions. Further studies are needed to guide the clinician in determining which patients are likely to benefit from a psychotherapeutic intervention in combination with pharmacotherapy.

Use of the King's Outcome Scale for Childhood Head Injury in the evaluation of outcome in childhood traumatic brain injury

OBJECTIVE

To examine the inter-rater reliability of The King's Outcome Scale for Childhood Head Injury (KOSCHI) with clinicians of varying experience in paediatric traumatic brain injury (TBI); and to examine change in outcome during long-term follow-up of children following traumatic brain injury (TBI) using KOSCHI.

METHOD

Retrospective assessment of detailed clinic reports of 97 children followed-up by a tertiary specialist paediatric brain injury service. Investigators were blinded to each other's scores.

RESULTS

Inter-rater reliability was substantial (weighted kappa 0.71) and similar for investigators of varying experience. KOSCHI outcome was strongly associated with markers of injury severity (p = 0.028). In longitudinal follow-up, KOSCHI score worsened in 7 (23%) children who were injured under 8 years but in no older children (p = 0.02).

CONCLUSION

KOSCHI has high inter-rater reliability for investigators of different experience. Long-term KOSCHI outcome is associated with injury severity. Some young children may develop worse disability over time.

Paediatric head injury admissions over a 10-year period in a regional neurosurgical unit

Traumatic brain injury is a leading cause of death and disability in childhood. A retrospective study of all paediatric head injuries admitted to the neurosurgical unit for the West of Scotland over a 10-year period was performed to assess the impact of the National Institute for Health and Clinical Excellence head injury guidelines on the admission rate and to determine the associated risk factors, causes, severity and outcomes of these injuries. There were 564 admissions between 1998 and 2007. The median age at presentation was nine years and two months. There was no change in the admission rate, injury mechanism or severity of head injury admitted over the period studied. A relationship was observed between the Scottish Index of Multiple Deprivation Score and the incidence of head injury ( P = 0.05). Alcohol was reported as a causative factor in only a small number of cases, and moderate to severe head injuries were more commonly identified as a result of road traffic accidents.

Comparative approach to understanding traumatic injury in the immature, postnatal brain of domestic animals

Traumatic brain injury (TBI) is a frequent occurrence in veterinary medicine, but the mechanisms leading to brain damage after a head impact are incompletely understood, particularly in the postnatal immature and still developing nervous system. This paper reviews neurotrauma studies, largely in paediatric humans and experimental animal models, in order to outline the pathophysiological and biomechanical events likely to be operative in head trauma involving domestic animal species in the postnatal period, as there is almost no other information available in the veterinary literature. Predicting the outcome of TBI is particularly difficult at this developmental time, in large part because recovery is influenced by the stage of brain maturation and neuroplasticity. An important part of the clinical management of TBI is the differentiation of primary brain damage, which occurs at the moment of head impact and is largely refractory to treatment, from the cascade of secondary events, which evolve over time and are potentially preventable and amenable to therapeutic intervention. An understanding of the causes and consequences of secondary brain damage such as hypoxia-ischaemia, brain swelling, elevated intracranial pressure, and infection is critical to limiting the resulting brain injury.

Validation of the Abbreviated Westmead Post-traumatic Amnesia Scale: a brief measure to identify acute cognitive impairment in mild traumatic brain injury

OBJECTIVE

To validate the use of the Abbreviated Westmead Post-traumatic Amnesia Scale (A-WPTAS) in the assessment of acute cognitive impairment in mild traumatic brain injury (mTBI).

METHODS

Data previously collected from 82 mTBI and 88 control participants using the Revised Westmead Post-traumatic Amnesia Scale (R-WPTAS) was converted to A-WPTAS scores and pass/fail classifications were calculated for both scales.

RESULTS

The proportion of failures on the R-WPTAS and the A-WPTAS did not differ and a similar number of mTBIs were classified on each. For mTBIs the relationship between the independent memory test and a pass/fail classification was the same for both scales. Bivariate logistic regressions revealed that mTBIs, relative to controls, were around 8 times more likely to fail the assessment (R-WPTAS: 95% CI: 3.70-18.87; A-WPTAS: 95% CI: 3.70-20.14). As verbal learning improved the likelihood of failure was reduced. Greater education was associated with a decreased likelihood of failure. The relationship between education and a fail performance was not sustained when education was adjusted for the effect of age, prior mTBI, blood alcohol level, injury status, verbal learning, and morphine administration.

CONCLUSIONS

The A-WPTAS is a valid measure. The A-WPTAS may reduce the risk of failing to classify patients with mTBI by identifying and documenting acute cognitive impairment.