Cognitive dysfunction in young men following head injury in childhood and adolescence: a population study

Social Determinants of Health and Health Equity in the Diagnosis and Management of Pediatric Mild Traumatic Brain Injury: A Content Analysis of Research Underlying Clinical Guidelines

We conducted a content analysis of the literature underlying the Centers for Disease Control and Prevention (CDC) Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children (i.e., the "Guideline") to determine the extent to which social determinants of health (SDoH) were examined or addressed. The systematic review forming the basis for the Guideline included 37 studies addressing diagnosis, prognosis, and treatment/rehabilitation. We examined those studies to identify SDoH domains derived from the U.S. Department of Health and Human Services' Healthy People 2020 and 2030 websites. No study explicitly mentioned "social determinants of health," by name, and few studies addressed SDoH domains as a primary focus (ranging from 0% to 27% of studies across SDoH domains). The most frequently represented SDoH domains, described in an inferential or a descriptive manner, were Education Access and Quality (29.7% of studies), Social and Community Context (27.0% of studies), and Economic Stability (21.6% of studies). Health Care Access (13.5% of studies) was less well represented and no studies (0%) examined Neighborhood and Built Environment. In terms of the CDC clinical questions, SDoH were only examined as predictors of outcome (prognosis) and no studies examined SDoH in relation to diagnosis or treatment/rehabilitation. The Guideline includes some commentary on health literacy and socioeconomic status. Overall, social determinants of health are largely unrepresented as important or meaningful variables influencing the Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children, or in the studies that informed the Guideline.

Neurocognitive Outcomes and Their Diffusion Tensor Imaging Correlates in Children With Mild Traumatic Brain Injury

This study aimed to assess the neurocognitive outcomes and their diffusion tensor imaging correlates in children (aged 6-16 years) with mild traumatic brain injury. This prospective analysis included 74 children with mild traumatic brain injury (52 boys; mean age: 9.5 [±2.7] years). Wechsler Intelligence Scale for Children-Indian adaptation (WISC-IV), Child Behavior Checklist, and Children's Sleep Habits Questionnaire were administered for 57 cases (at 3 months postinjury) and 51 controls of similar age. The findings of diffusion tensor imaging (done within 7 days of injury) were correlated with various WISC-IV indices. The presenting features at the time of injury were loss of consciousness (53%), confusion or disorientation (47%), and post-traumatic amnesia (10%). Other features in the acute phase included drowsiness (86%), headache (78%), balance problems (62%), nausea (47%), fatigue (45%), vomiting (35%), nasal or ear bleed (12%), sensitivity to sound and light (12%), etc. At 3 months postinjury, the children with mild traumatic brain injury performed poorly in terms of Intelligence Quotient, perceptual reasoning index, and processing speed index as compared to controls. Based on the Child Behavior Checklist, 17% of children with mild traumatic brain injury had internalizing behavioral problems in comparison with 4% of controls. Prevalence of poor sleepers in the mild traumatic brain injury cohort and controls was 12.3% and 2% respectively. Headache, reduced attention span, and fatigue were common postconcussion symptoms. There was a positive correlation between right uncinate fasciculus fractional anisotropy and verbal comprehension index (r = 0.32; P < .05).

[Current possibilities of complex diagnosis and treatment of the consequences of traumatic brain injury]

Article is devoted to topical issues of complex diagnosis and treatment of the consequences of traumatic brain injury (TBI) in children, adolescents and adults. Craniocerebral trauma is one of the most important problems of modern neurology, due to the high frequency and severity of disability. In recent years, there has been a steady increase in effects of TBI, a significant part of which are asthenic, autonomic, cognitive, emotional and motor disorders. Factors affecting the severity of the consequences of TBI are: the severity of the injury, the age, at which the injury occurred, the time elapsed since the injury, the localization of the lesion. After mild TBI, the structure of cognitive impairment is dominated by memory and attention disorders (75%), visual-motor coordination, as well as asthenic disorders (88%), chronic headaches (95%). After moderate and severe TBI, there are more pronounced impairment of cognitive and motor functions accompanied by pathological neurological symptoms in 94-100% of children, which leads to difficulties in learning, self-service and has a negative impact on social adaptation. The article describes in detail the modern methods of complex diagnosis, as well as pathogenetically justified methods of drug therapy of cognitive disorders in patients with the consequences of TBI. The high efficacy of the modern cytoprotective drug Cytoflavin in the treatment of the effects of TBI is shown.

Diagnosis and Management of Mild Traumatic Brain Injury in Children: A Systematic Review

Importance

In recent years, there has been an exponential increase in the research guiding pediatric mild traumatic brain injury (mTBI) clinical management, in large part because of heightened concerns about the consequences of mTBI, also known as concussion, in children. The CDC National Center for Injury Prevention and Control's (NCIPC) Board of Scientific Counselors (BSC), a federal advisory committee, established the Pediatric Mild TBI Guideline workgroup to complete this systematic review summarizing the first 25 years of literature in this field of study.

Objective

To conduct a systematic review of the pediatric mTBI literature to serve as the foundation for an evidence-based guideline with clinical recommendations associated with the diagnosis and management of pediatric mTBI.

Evidence Review

Using a modified Delphi process, the authors selected 6 clinical questions on diagnosis, prognosis, and management or treatment of pediatric mTBI. Two consecutive searches were conducted on PubMed, Embase, ERIC, CINAHL, and SportDiscus. The first included the dates January 1, 1990, to November 30, 2012, and an updated search included December 1, 2012, to July 31, 2015. The initial search was completed from December 2012 to January 2013; the updated search, from July 2015 to August 2015. Two authors worked in pairs to abstract study characteristics independently for each article selected for inclusion. A third author adjudicated disagreements. The risk of bias in each study was determined using the American Academy of Neurology Classification of Evidence Scheme. Conclusion statements were developed regarding the evidence within each clinical question, and a level of confidence in the evidence was assigned to each conclusion using a modified GRADE methodology. Data analysis was completed from October 2014 to May 2015 for the initial search and from November 2015 to April 2016 for the updated search.

Findings

Validated tools are available to assist clinicians in the diagnosis and management of pediatric mTBI. A significant body of research exists to identify features that are associated with more serious TBI-associated intracranial injury, delayed recovery from mTBI, and long-term sequelae. However, high-quality studies of treatments meant to improve mTBI outcomes are currently lacking.

Conclusions and Relevance

This systematic review was used to develop an evidence-based clinical guideline for the diagnosis and management of pediatric mTBI. While an increasing amount of research provides clinically useful information, this systematic review identified key gaps in diagnosis, prognosis, and management.

Effects of concussions on visually guided motor actions: A literature review

Athletes must be able to successfully navigate the soccer pitch or hockey rink to win the game, requiring maximal cognitive resources to successfully compete. Concussions potentially deplete these resources, and the long-term impact of concussions on an individual's goal-directed visually guided behavior continues to elude the scientific community. While the acute effects on cognition and the motor system have been elucidated elsewhere, long-term effects on performance have been less clear. Additionally, most investigations into long-term postinjury motor behaviors have focused on balance and gait, with little focus on functional upper extremity movements. These arm movements require both cognitive and motor functions to successfully complete the task, such as visually guided reaching, and have received little attention. This review examines the current state of the literature to date on the long-term effects of concussions on cognitive and motor deficits affecting visuomotor behavior.

Age at injury is associated with the long-term cognitive outcome of traumatic brain injuries

INTRODUCTION

The association between age at injury (AAI) and long-term cognitive outcome of traumatic brain injuries (TBI) is debatable.

METHODS

Eligible participants with a history of TBI from Alzheimer's Disease Neuroimaging Initiative were divided into a childhood TBI (cTBI) group (the AAI ≤ 21 years old) and an adult TBI (aTBI) group (the AAI > 21 years old).

RESULTS

The cTBI group has a higher Everyday Cognition total score than the aTBI group. All perceived cognitive functions are worse for the cTBI group than for the aTBI group except memory. By contrast, the cTBI group has higher assessment scores on either the Boston Naming Test or Rey Auditory Verbal Learning Test than the aTBI group.

DISCUSSION

The AAI is associated with the long-term cognitive outcomes in older adults with a history of TBI.

Acute brain trauma

In the 20th century, the complications of head injuries were controlled but not eliminated. The wars of the 21st century turned attention to blast, the instant of impact and the primary injury of concussion. Computer calculations have established that in the first 5 milliseconds after the impact, four independent injuries on the brain are inflicted: 1) impact and its shockwave, 2) deceleration, 3) rotation and 4) skull deformity with vibration (or resonance). The recovery, pathology and symptoms after acute brain trauma have always been something of a puzzle. The variability of these four modes of injury, along with a variable reserve of neurones, explains some of this problem.

Pediatric shopping-cart-related injuries treated in US emergency departments, 1990-2011

This study investigates the effect of the 2004 US shopping cart safety standard on shopping-cart-related injuries among children younger than 15 years of age by retrospectively analyzing data from the National Electronic Injury Surveillance System. An estimated 530 494 children younger than 15 years were treated in US emergency departments for shopping-cart-related injuries from 1990 to 2011, averaging 24 113 children annually. The most commonly injured body region was the head (78.1%). The annual concussion/closed head injury rate per 10 000 children increased significantly (P < .001) by 213.3% from 0.64 in 1990 to 2.02 in 2011. Although a shopping cart safety standard was implemented in the United States in 2004, the overall number and rate of injuries associated with shopping carts have not decreased. In fact, the number and rate of concussions/closed head injuries have continued to climb. Increased prevention efforts are needed to address these injuries among children.

Health-related quality of life among people with epilepsy with mild seizure-related head injuries

Seizure-related head injury (SRHI) is an under-recognized condition frequently experienced by people with epilepsy (PWE). The purpose of this study is to investigate the potential impact of SRHI on health-related quality of life (HRQOL) among PWE receiving care in a tertiary epilepsy center. Consecutive adult PWE receiving care at the Baylor Comprehensive Epilepsy Center (BCEC) were recruited for the study. After their informed consent was obtained, patients were administered the QOLIE-31 to measure HRQOL and the NDDI-E to screen for depression. Simple linear regression was used to identify clinical variables associated with HRQOL and that included SRHI obtained systematically at each clinic visit. Data were also compared between the SRHI and non-SRHI groups. Participants included 172 subjects. Recurrent mild SRHI occurred in 50 (29%) subjects. Factors with a negative effect on HRQOL included depression (slope=-19.99 [95% CI -25.16, -14.81]; p<.0001), recurrent SRHI (-17.02 [-22.35, -11.69]; p<.0001), past SRHI (-13.46 [-18.43, -8.48]; p<.0001), and seizure frequency (-0.17 [-0.26, -0.07]; p=0.001) on univariate analysis. With stepwise multiple regression, depression and recurrent SRHI significantly impacted HRQOL with slopes (95% CI; p-value) of (-17.53 [-22.34, -12.73]; p<.0001) and (-14.03 [-18.78, -9.28]; p<.0001), respectively. Patient-derived HRQOL is negatively associated with depression and recurrent SRHI, independently. There has been a justifiable increased awareness of the potential effects of head injuries among healthy individuals. Our data suggest that head injuries can certainly be detrimental among PWE, and greater efforts should be made to recognize and formulate prevention strategies for SRHI.

Cognitive ability and educational level in relation to concussion: a population study of young men

OBJECTIVES

To investigate the association of concussion with cognitive ability (CA) and educational level (EL).

DESIGN

Epidemiological-cross-linkage of national computer registers.

SETTING

Denmark.

PARTICIPANTS

130 420 young men appearing before the Danish draft board during the period 2006-2010.

PRIMARY AND SECONDARY OUTCOME MEASURES

CA test scores, EL and occurrence of concussion during the period 2004-2009, treated either in an A&E unit or upon admission to a hospital ward.

RESULTS

The 3067 men who had suffered a concussion had lower CAs (mean=96.5, SD=15, 95% CI 95.0 to 97.0) than the total cohort and they were lower for 1452 who were admitted to a hospital ward (mean CA=95.8, SD=15, 95% CI 95.1 to 96.6) than for 1615 who were treated only at an A&E unit (mean CA=97.1, SD=15, 95% CI 96.3 to 98.0). Multiple logistic regressions revealed that the effects for EL were stronger than those for CA. Among 127 353 men not sustaining a concussion, 48% attended a 'gymnasium' (sixth-form college), among men treated for a concussion at an A&E unit, this falls to 36% and among men hospitalised for a concussion to 30%. Transfer to a gymnasium, if it happens, almost invariably does so before the 18th birthday. Among 701 men suffering a concussion and admitted to a hospital department after this date, only 26% (n=182) were previously transferred to a gymnasium. Among the 804 men treated at an A&E unit after their 18th birthday, 33% (n=265) had done so. These two percentages are significantly below the corresponding non-concussed population (48%).

CONCLUSIONS

Taken together, the results suggest that lower CA and, in particular, lower EL are risk factors for sustaining a concussion, the risk increasing with the severity of the injury.

Consequences of repeated blood-brain barrier disruption in football players

The acknowledgement of risks for traumatic brain injury in American football players has prompted studies for sideline concussion diagnosis and testing for neurological deficits. While concussions are recognized etiological factors for a spectrum of neurological sequelae, the consequences of sub-concussive events are unclear. We tested the hypothesis that blood-brain barrier disruption (BBBD) and the accompanying surge of the astrocytic protein S100B in blood may cause an immune response associated with production of auto-antibodies. We also wished to determine whether these events result in disrupted white matter on diffusion tensor imaging (DT) scans. Players from three college football teams were enrolled (total of 67 volunteers). None of the players experienced a concussion. Blood samples were collected before and after games (n = 57); the number of head hits in all players was monitored by movie review and post-game interviews. S100B serum levels and auto-antibodies against S100B were measured and correlated by direct and reverse immunoassays (n = 15 players; 5 games). A subset of players underwent DTI scans pre- and post-season and after a 6-month interval (n = 10). Cognitive and functional assessments were also performed. After a game, transient BBB damage measured by serum S100B was detected only in players experiencing the greatest number of sub-concussive head hits. Elevated levels of auto-antibodies against S100B were elevated only after repeated sub-concussive events characterized by BBBD. Serum levels of S100B auto-antibodies also predicted persistence of MRI-DTI abnormalities which in turn correlated with cognitive changes. Even in the absence of concussion, football players may experience repeated BBBD and serum surges of the potential auto-antigen S100B. The correlation of serum S100B, auto-antibodies and DTI changes support a link between repeated BBBD and future risk for cognitive changes.

Double Concussions and Cognitive Dysfunction: A Population Study of Young Men

Aims: To determine whether double concussions can result in longer-lasting cognitive dysfunctioning than a single concussion and/or whether cognitive dysfunction is a greater risk factor for double concussions than for a single concussion.

Method: Through a national hospitalisation database, 2753 men were found who, at ages between infancy and early adulthood, had, on two separate occasions, been briefly hospitalised after a concussion. This cohort was compared with a previously obtained and comparable sample of men who had suffered a single concussion. From Draft Board records a dichotomised index was obtained indicating whether or not they had performed at or above a cut-off total score on a cognitive screening test involving four timed subtests, below cut-off being considered as dysfunctional.

Findings: For all age groups, double concussions were associated with higher rates of cognitive dysfunction than single concussions. This was especially true where the concussion(s) had occurred after cognitive testing [odds ratio = 2.53, 95% confidence interval (CI) = 1.92–3.36]. Where double concussions had occurred before cognitive testing but after age 12, cognitive dysfunction was more prevalent when the interval between concussions was less than 1 month than at longer intervals (odds ratio = 3.91, 95%CI = 1.14–13.34). It is concluded that cognitive dysfunction in young men is a risk factor for repeat concussions; at the same time cognitive dysfunction can also be a long-term consequence of two concussions occurring in close temporal proximity.

Sports-related concussions

During the past decade, awareness of concussions has exploded as both the media and the medical literature have given more focus to this common problem. Concussions after recreational activities, especially athletics, are a frequent complaint in the emergency department. In the past few years, care of these patients has been simplified as grading systems and classifications have been abandoned. However, questions remain as to the best way to rehabilitate these patients to avoid long-term sequelae, especially in children and adolescents. The purpose of this review is to discuss the demographic characteristics, the pathophysiology, definition, clinical characteristics, and management of concussions in children and adolescents.

Do recurrent seizure-related head injuries affect seizures in people with epilepsy?

Seizure-related head injuries (SRHIs) are among the most commonly encountered injuries in people with epilepsy (PWE). Whether head injury has an effect on preexisting epilepsy is not known. The purpose of this study was to systematically assess for any possible effects of SRHIs on seizure frequency and seizure semiology over a 2-year period. We identified 204 patients who have been followed at the Baylor Comprehensive Epilepsy Center from 2008 to 2010. SRHI occurred in 18.1% of the cohort. Most injuries (91%) were classified as mild. Though seizure frequency varied following head injury, overall seizure frequency was not significantly impacted by presence or absence of SRHI over the 2-year study period. Changes in seizure semiology were not observed in those with SRHIs. Although mild SRHI is common among PWE, it does not appear to have an effect on seizure characteristics over a relatively short period.

Recurrent seizure-related injuries in people with epilepsy at a tertiary epilepsy center: a 2-year longitudinal study

Though seizure-related injuries (SRIs) among people with epilepsy (PWE) have recently gained much attention in the literature, most studies are retrospective and data are gathered indirectly through questionnaires or medical record documentation. We investigated SRIs and their associated risks in PWE attending a tertiary care center with direct and systematic inquiries during routine clinic follow-up visits over a 2-year period (N = 306). Past SRIs occurred in 54% of all patients, and 24% experienced recurrent SRIs during the study period. On multiple regression analyses, past SRI was associated with tonic-clonic seizures (TCSs) (3.2, 95% CI = 1.7-5.8) and cognitive handicap (4.3, 95% CI 1.5-16.1), and recurrent SRI was associated with TCSs (3.5, 95% CI = 1.6-7.9). Most recurrent SRIs (72%) involved head injury. SRIs are common when assessed systematically in a tertiary care setting, and TCSs represent a risk factor for recurrent SRIs. The potential clinical impact of recurrent SRIs on PWE requires further study.

The Danish draft board's intelligence test, Børge Priens Prøve: psychometric properties and research applications through 50 years

For over 50 years the Danish draft board has used the same test, Børge Priens Prøve (BPP) for cognitive abilities, involving four paper-and-pencil subtests, to assess suitability for conscription. The potential availability of test scores has been an invaluable resource for research into factors relating to intelligence. In this article the circumstances of the original development of the test are briefly presented, followed by a description of the four subtests and the conditions of testing, scoring and result registration. Over forty studies are identified, including some unpublished, which have explored the psychometric properties of the BPP and have shown the relationships between intelligence as measured by the BPP and a wide range of biological, social and health-related factors.

Neuropsychological dysfunction following repeat concussions in jockeys

BACKGROUND

Single and repeat concussions have a high prevalence in sport. However, there is limited research into longterm risks associated with single and repeat concussions.

OBJECTIVES

To determine the effects of single and repeat historical concussions on the neuropsychological functioning and neurological reports of licensed jockeys.

METHODS

Six hundred and ninety eight licensed jockeys in the UK were assessed for neurological and neuropsychological symptoms of concussion at least three months after potential episodes.

RESULTS

Jockeys reporting multiple historical injuries versus a single injury showed reliable decrements on a measure of response inhibition and, to a less robust degree, on divided attention. Younger adults showed greater vulnerability.

CONCLUSIONS

Repeated concussion is associated with reliable decrements in cognitive performance--even after a three month window for recent recovery.