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Background: Complaints of persistent cognitive deficits following mild head trauma are often uncorroborated by structural brain imaging and neuropsychological examination.Objective: To investigate, using positron emission tomography (PET), the in vivo changes in regional cerebral uptake of 2-[(18)F]fluoro-2-deoxy-D-glucose (FDG) and regional cerebral blood flow (rCBF) in patients with persistent symptoms following mild head trauma.Methods: Five patients with mild head trauma and five age and education matched healthy controls were imaged using FDG-PET to measure differences in resting regional cerebral glucose metabolism. Oxygen-15 labelled water (H(2)(15)O)-PET was also used to measure group differences in rCBF changes during a spatial working memory task. In addition, neuropsychological testing and self report of dysexecutive function and post-concussion symptoms were acquired to characterise the sample.Results: There was no difference between patients and controls in normalised regional cerebral FDG uptake in the resting state in frontal and temporal regions selected a priori. However, during the spatial working memory task, patients had a smaller increase in rCBF than controls in the right prefrontal cortex.Conclusions: Persistent post-concussive symptoms may not be associated with resting state hypometabolism. A cognitive challenge may be necessary to detect cerebral changes associated with mild head trauma. [ABSTRACT FROM AUTHOR]

Objectives: Increases in the extracellular concentration of the excitatory amino acids glutamate and aspartate during cerebral ischaemia in patients are well recognised. Less emphasis has been placed on the concentrations of the inhibitory amino acid neurotransmitters, notably gamma-amino-butyric acid (GABA), despite evidence from animal studies that GABA may act as a neuroprotectant in models of ischaemia. The objective of this study was to investigate the concentrations of various excitatory, inhibitory and non-transmitter amino acids under basal conditions and during periods of cerebral ischaemia in patients with head injury or a subarachnoid haemorrhage.Methods: Cerebral microdialysis was established in 12 patients with head injury (n=7) or subarachnoid haemorrhage (n=5). Analysis was performed using high performance liquid chromatography for a total of 19 (excitatory, inhibitory and non-transmitter) amino acids. Patients were monitored in neurointensive care or during aneurysm clipping.Results: During stable periods of monitoring the concentrations of amino acids were relatively constant enabling basal values to be established. In six patients, cerebral ischaemia was associated with increases (up to 1350 fold) in the concentration of GABA, in addition to the glutamate and aspartate. Parallel increases in the concentration of glutamate and GABA were found (r=0.71, p<0.005).Conclusions: The results suggest that, in the human brain, acute cerebral ischaemia is not accompanied by an imbalance between excitatory and inhibitory amino acids, but by an increase in all neurotransmitter amino acids. These findings concur with the animal models of ischaemia and raise the possibility of an endogenous GABA mediated neuroprotective mechanism in humans. [ABSTRACT FROM AUTHOR]

Objective: To assess neuropsychiatric sequelae 1 year after minor head injury in a cross sectional study using home interviews with patients and their relatives at 1 year after head injury.Methods: The study cohort included 148 adults who were admitted to hospital after a minor head injury between 1 July 1994 and 30 June 1995 and showed clinical or radiological evidence of brain injury. Main outcome measures used in the study were the Glasgow outcome scale, Edinburgh rehabilitation status scale, Barthel index, clinical interview schedule-revised, mini mental state examination, and assessment of symptoms of postconcussional syndrome.Results: At one year follow up, four (2.9%) patients had a severe disability, 35 (25.5%) had a moderate disability, and 95 (69.3%) had no disability according to the Glasgow outcome scale. A slightly higher proportion (33.3%, n=45) showed disability according to the Edinburgh rehabilitation status scale. Thirty one patients (23.1%) scored <24 in the mini mental state examination. These were mostly patients over the age of 65. Twenty three patients (17.2%) were diagnosed as psychiatric cases according to the clinical interview schedule-revised scale. Seventy four (55.2%) patients showed one of the symptoms of postconcussional syndrome. The most commonly shown neurobehavioural problems were irritability (30%), sleep disturbance (29%), and impatience (27%).Conclusion: One year after a minor head injury, a substantial proportion of patients showed neuropsychiatric sequelae. [ABSTRACT FROM AUTHOR]

Objectives: The validity of memory and concentration complaints that are often reported after a whiplash trauma is controversial. The prevalence of malingering or underperformance in post-whiplash patients, and its impact on their cognitive test results were studied.Methods: The Amsterdam short term memory (ASTM) test, a recently developed malingering test, was used as well as a series of conventional memory and concentration tests. The study sample was a highly selected group of patients, who were examined either as part of a litigation procedure (n=36) or in the normal routine of an outpatient clinic (n=72).Results: The prevalence of underperformance, as defined by a positive score on the malingering test, was 61% (95% CI: 45-77) in the context of litigation, and 29% (95% CI: 18-40) in the outpatient clinic (p=0.003). Furthermore, the scores on the memory and concentration test of malingering post-whiplash patients (n=43) and non-malingering post-whiplash patients (n=65) were compared with the scores of patients with closed head injury (n=20) and normal controls (n=46). The malingering post-whiplash patients scored as low as the patients with closed head injury on most tests.Conclusions: The prevalence of malingering or cognitive underperformance in late post-whiplash patients is substantial, particularly in litigation contexts. It is not warranted to explain the mild cognitive disorders of whiplash patients in terms of brain damage, as some authors have done. The cognitive complaints of non-malingering post-whiplash patients are more likely a result of chronic pain, chronic fatigue, or depression. [ABSTRACT FROM AUTHOR]

Neuroimaging with single photon emission computed tomography (SPECT) using the cerebral blood flow tracer 99Tc(m)-HMPAO has been used to study acute functional alterations after head injury and residual abnormalities at six month follow up in 32 patients. Comparison has been made with anatomical abnormalities defined acutely with CT and on follow up with MRI. SPECT showed slightly more abnormalities than CT in the acute phase (49 regions of abnormally low tracer uptake on SPECT and 45 lesions on CT). Twenty two of the acute SPECT abnormalities were in normal regions on CT. At follow up MRI showed more abnormalities than SPECT (30 on SPECT and 48 on MRI). Ten of the SPECT deficits were in regions with normal MRI. Comparison of the intensity of late and early SPECT deficits showed that only four early deficits deteriorated whereas 28 improved. Only five of 27 lesions seen on both acute SPECT and CT resolved compared with 16 of 22 lesions seen on SPECT but not on CT. Regions of abnormally high tracer uptake were detected in the acute stage in five of the patients. No high focal uptake was evident on follow up. Ten patients with a residual SPECT abnormality and eight with residual MRI lesions were graded clinically in the upper band of good recovery. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the Medical Disability Society's 1988 recommendation that "every patient attending hospital after a head injury should be registered and offered an outpatient follow up appointment" by determining whether offering a routine follow up service to patients presenting to hospital with a head injury of any severity affects outcome six months later.Design: A randomised controlled trial design with masked assessment of outcome.Setting: A mixed rural and urban health district with a population of about 560000.Patients: 1156 consecutive patients resident in Oxfordshire aged between 16 and 65 years presenting over 13 months to accident and emergency departments or admitted to hospital and diagnosed as having a head injury of any severity, including those with other injuries.Interventions: Patients were registered and randomised to one of two groups. Both groups continued to receive the standard service offered by the hospitals. The early follow up group were approached at 7-10 days after injury and offered additional information, advice, support, and further intervention as needed. All randomised patients were approached for follow up assessment six months after injury by independent clinicians blind to their group.Main Outcome Measures: Validated questionnaires were used to elicit ratings of post-concussion symptoms (the Rivermead postconcussion symptoms questionnaire), and changes in work, relationships, leisure, social, and domestic activities (the Rivermead head injury follow up questionnaire).Results: The two groups were comparable at randomisation. Data was obtained at six months on 226 of 577 "control" patients and 252 of 579 "trial" patients (59% were lost to follow up). There were no significant differences overall between the trial and control groups at follow up, but subgroup analysis of the patients with moderate or severe head injuries (posttraumatic amnesia > or = one hour, or admitted to hospital), showed that those in the early intervention group had significantly fewer difficulties with everyday activities (P = 0.03).Conclusions: The results from the 41% of patients followed up do not support the recommendation of offering a routine follow up to all patients with head injury, but they do suggest that routine follow up is most likely to be beneficial to patients with moderate or severe head injuries. Some of those with less severe injuries do continue to experience difficulties and need access to services. A further trial is under way to test these conclusions. [ABSTRACT FROM AUTHOR]

Records of coma and post-traumatic amnesia (PTA) were collected for a group of 38 patients with closed head injury. The results confirmed earlier studies indicating that patients may have short or negligible coma but report prolonged PTA. Comparison of eight patients with prolonged PTA (> 7 days) and short coma (< 6 hours) with the rest of the group on MRI in the acute stage showed that these patients had significantly more extensive hemispheric damage. In the group as a whole both coma and PTA were related to the number of areas in central brain structures in which lesions were detected, but only PTA was significantly related to the number of hemispheric areas in which lesions were found. It is concluded that although both coma and PTA are related to brain damage they reflect disparate patterns of lesions. Assessment of PTA can thus provide additional information concerning severity of injury. [ABSTRACT FROM AUTHOR]

The purpose of the 23 year follow up study was to determine the relationship between trauma variables including measures of head injury and very long-term sequelae. The study included 159 individuals with a mean age 31.40 years, of whom approximately 90% were admitted to hospital with a mild head injury during childhood (mean age 7.96). Extent of head injury was determined by unconsciousness, neurological status, skull fracture, EEG, post-traumatic seizures and a composite measure. The composite measure of neurological variables was the best predictor of long-term outcome. In addition, IQ recorded in the post-acute phase was a reliable predictor of long-term outcome. Of the sample, 32.7% reported physical complaints and 17.6% reported current psychological/psychiatric problems unrelated to the head injury. Subjective sequelae (physical, intellectual and emotional) specified as due to the head injury were reported by 31% of the sample, and the sequelae were found to be related to the extent of the head injury and initial IQ. There were no discernible relationships between attribute variables including premorbid status and age with subjective sequelae. There were, however, significant relationships between subjective sequelae and objective, psychosocial measures of adaptation including educational lag, unemployment, current psychological/psychiatric problems and relationships with family members. Finally, there appeared to be continuity of complaints elicited during the five year follow up of the original project and current sequelae. The severity of the head injury was identified as the primary contributory factor in the reconstitution process and in the prediction of long term outcomes. [ABSTRACT FROM AUTHOR]

Thirty six patients (31 male, 5 female) who had suffered severe closed head injury were re-examined at an average of 39.3 (SD 12.8, range 7-66) months after the injury. Behavioural symptoms were measured using the Giessen test. The relatives' reports were used for data analysis to ensure that results were valid. The neurophysical impairment subscale of the Glasgow assessment schedule was completed by two neurologists, and the number connection test was completed by each patient. The adjective mood scale was completed by each relative. All patients were investigated by single photon emission computerised tomography (SPECT). Exploratory factor analysis using the principal components method was carried out separately for SPECT results and psychological measures and correlations were sought between the resulting factors. Factor analysis of the data from the Giessen test identified social isolation, disinhibition, and aggressive behaviour as major components of post-traumatic personality changes; it indicates that these behavioural features are independent of the level of neurological and neuropsychological impairment, which loaded on a single independent factor. Relatives' psychic health seemed to be relatively resistant to physical and cognitive disability and was mainly affected by disinhibitive behaviour. The highest correlation was between frontal flow indices and disinhibitive behaviour (p less than 0.01): the severity of disinhibition increased with lower frontal flow rates. There was a significant but somewhat weaker correlation (p less than 0.05) between flow indices of the left cerebral hemisphere and social isolation. Low flow values of the right brain regions were related to aggressive behaviour (p less than 0.05). Neurological and cognitive impairment correlated negatively with the thalamus; worse neurological and cognitive performance indicate by raised scores on the neurophysical scale and on the number connection test was associated with low thalamic flow values. The results support the importance of lesion location in the production of post traumatic behavioural disorders. [ABSTRACT FROM AUTHOR]

Fifty patients who sustained mild to moderate closed head injury (CHI) underwent a CT scan, MRI, and neurobehavioural testing. At baseline 40 patients had intracranial hyperintensities detected by MRI which predominated in the frontal and temporal regions, whereas 10 patients had lesions detected by CT. Neurobehavioural data obtained during the first admission to hospital disclosed no distinctive pattern in subgroups of patients characterised by lesions confined to the frontal, temporal, or frontotemporal regions, whereas all three groups exhibited pervasive deficits in relation to normal control subjects. The size of extraparenchymal lesion was significantly related to the initial Glasgow Coma Scale score, whereas this relation was not present in parenchymal lesions. One and three month follow up MRI findings showed substantial resolution of lesion while neuropsychological data reflected impressive recovery. The follow up data disclosed a trend from pervasive deficits to more specific impairments which were inconsistently related to the site of brain lesion. These results corroborate and extend previous findings, indicating that intracranial lesions detected by MRI are present in most patients hospitalised after mild to moderate CHI. Individual differences in the relation between site of lesion and the pattern of neuropsychological findings, which persist over one to three months after mild to moderate CHI, remain unexplained. [ABSTRACT FROM AUTHOR]

A scheme to quantitate the clinical neurological status of the seriously head-injured patient has been devised. The neurological parameters used to quantify the degree of injury are based on neurological functions which have previously been accepted as indicators of the severity of the head injury. A numerical value is assigned to each parameter with emphasis on defining the level of consciousness. The accrued point total of each examination represents the neurological status of the patient at that time. Mean values and standard error from the means are determined from repeated examinations during a single 24 hour period, and are plotted against days after injury. From this graph a line which represents the rate of clinical recovery is determined by least squares analysis. General intensive care nurses were trained to score patients independently; their determinations were found to be in statistical agreement with scores derived from examinations by the attending physicians. The data presented highlight the effects of hypoxaemia in impeding the rate of neurological recovery from a serious head injury. This simple clinical analytical scheme for the quantitative assessment of patients with head injury permits evaluation of the efficacy of various modes of therapy in altering the rate of recovery. [ABSTRACT FROM AUTHOR]

Ranking of head injuries by severity is an essential part of clinical management, of prognosis, of treatment trials, and of legal assessment for compensation. Various methods of assessing severity are reviewed. No one scale is appropriate for all types of injury, or in all circumstances. A check list is provided which should enable every injury to be assessed; its use would facilitate comparison between individual cases of head injury, and between reports from different studies. [ABSTRACT FROM AUTHOR]

Computerized midline echoencephalography was developed in order to make the determination of the midline more objective. In a group study involving the neurosurgical clinics in Berlin, Erlangen, and Munich, a total of 1,889 patients with various intracranial diseases was examined by this method. An exact analysis of the results obtained is presented: 18 percent were unsatisfactory. [ABSTRACT FROM AUTHOR]

The objective of this study was to analyse the temporal course of the jugular venous-arterial gradient of S-100B protein after severe head injury and the correlation between the absolute concentrations of serum S-100B protein and outcome, CT findings, and clinical variables. Fifteen patients were included in this pilot study. All patients were treated according to a standard therapy protocol targeted to maintain cerebral perfusion pressure. The serum concentration of S-100 protein was measured daily for five consecutive days after injury by a monoclonal two site immunoluminometric assay. Nine patients showed favourable and six unfavourable outcome after 6 months with a mortality rate of 33% (five patients). The mean gradient between jugular venous and arterial blood was 8.2% (p<0.05). Patients showing an unfavourable outcome had significantly higher jugular venous or arterial S-100 values compared with those with a favourable outcome (jugular venous S-100B 2.78 microg/l v 1.22 microg/l, p<0.05; arterial S-100B 2.48 microg/l v 1.19 microg/l, p<0.05). All patients with an initial or secondary increase in S-100B value of >2 microg/l were found to have an unfavourable outcome. S-100B was found to be an independent predictor of outcome after severe head injury. The persisting increase of S-100B for three to five days even in patients with favourable outcome and no signs of secondary insults might reflect continuing damage to the blood-brain barrier or ongoing glial cell death. [ABSTRACT FROM AUTHOR]