Search

Background: Severe traumatic brain injury is a leading cause of morbidity and mortality among young people around the world. Prehospital care focuses on the prevention and treatment of secondary brain injury and commonly includes tracheal intubation after induction of general anesthesia. The choice of induction agent in this setting is controversial. This study therefore investigated the association between the chosen induction medication etomidate versus S(+)-ketamine and the 30-day mortality in patients with severe traumatic brain injury who received prehospital airway management in the Netherlands., Methods: This study is a retrospective analysis of the prospectively collected observational data of the Brain Injury: Prehospital Registry of Outcomes, Treatments and Epidemiology of Cerebral Trauma (BRAIN-PROTECT) cohort study. Patients with suspected severe traumatic brain injury who were transported to a participating trauma center and who received etomidate or S(+)-ketamine for prehospital induction of anesthesia for advanced airway management were included. Statistical analyses were performed with multivariable logistic regression and inverse probability of treatment weighting analysis., Results: In total, 1,457 patients were eligible for analysis. No significant association between the administered induction medication and 30-day mortality was observed in unadjusted analyses (32.9% mortality for etomidate versus 33.8% mortality for S(+)-ketamine; P = 0.716; odds ratio, 1.04; 95% CI, 0.83 to 1.32; P = 0.711), as well as after adjustment for potential confounders (odds ratio, 1.08; 95% CI, 0.67 to 1.73; P = 0.765; and risk difference 0.017; 95% CI, -0.051 to 0.084; P = 0.686). Likewise, in planned subgroup analyses for patients with confirmed traumatic brain injury and patients with isolated traumatic brain injury, no significant differences were found. Consistent results were found after multiple imputations of missing data., Conclusions: The analysis found no evidence for an association between the use of etomidate or S(+)-ketamine as an anesthetic agent for intubation in patients with traumatic brain injury and mortality after 30 days in the prehospital setting, suggesting that the choice of induction agent may not influence the patient mortality rate in this population., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Anesthesiologists.)

Objective: To develop new diagnostic criteria for mild traumatic brain injury (TBI) that are appropriate for use across the lifespan and in sports, civilian trauma, and military settings., Design: Rapid evidence reviews on 12 clinical questions and Delphi method for expert consensus., Participants: The Mild Traumatic Brain Injury Task Force of the American Congress of Rehabilitation Medicine Brain Injury Special Interest Group convened a Working Group of 17 members and an external interdisciplinary expert panel of 32 clinician-scientists. Public stakeholder feedback was analyzed from 68 individuals and 23 organizations., Results: The first 2 Delphi votes asked the expert panel to rate their agreement with both the diagnostic criteria for mild TBI and the supporting evidence statements. In the first round, 10 of 12 evidence statements reached consensus agreement. Revised evidence statements underwent a second round of expert panel voting, where consensus was achieved for all. For the diagnostic criteria, the final agreement rate, after the third vote, was 90.7%. Public stakeholder feedback was incorporated into the diagnostic criteria revision prior to the third expert panel vote. A terminology question was added to the third round of Delphi voting, where 30 of 32 (93.8%) expert panel members agreed that 'the diagnostic label 'concussion' may be used interchangeably with 'mild TBI' when neuroimaging is normal or not clinically indicated.', Conclusions: New diagnostic criteria for mild TBI were developed through an evidence review and expert consensus process. Having unified diagnostic criteria for mild TBI can improve the quality and consistency of mild TBI research and clinical care., (Copyright © 2023 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: Severe traumatic brain injury is a leading cause of mortality and morbidity, and these patients are frequently intubated in the prehospital setting. Cerebral perfusion and intracranial pressure are influenced by the arterial partial pressure of CO 2 and derangements might induce further brain damage. We investigated which lower and upper limits of prehospital end-tidal CO 2 levels are associated with increased mortality in patients with severe traumatic brain injury., Methods: The BRAIN-PROTECT study is an observational multicenter study. Patients with severe traumatic brain injury, treated by Dutch Helicopter Emergency Medical Services between February 2012 and December 2017, were included. Follow-up continued for 1 year after inclusion. End-tidal CO 2 levels were measured during prehospital care and their association with 30-day mortality was analyzed with multivariable logistic regression., Results: A total of 1776 patients were eligible for analysis. An L-shaped association between end-tidal CO 2 levels and 30-day mortality was observed (p = 0.01), with a sharp increase in mortality with values below 35 mmHg. End-tidal CO 2 values between 35 and 45 mmHg were associated with better survival rates compared to < 35 mmHg. No association between hypercapnia and mortality was observed. The odds ratio for the association between hypocapnia (< 35 mmHg) and mortality was 1.89 (95% CI 1.53-2.34, p < 0.001) and for hypercapnia (≥ 45 mmHg) 0.83 (0.62-1.11, p = 0.212)., Conclusion: A safe zone of 35-45 mmHg for end-tidal CO 2 guidance seems reasonable during prehospital care. Particularly, end-tidal partial pressures of less than 35 mmHg were associated with a significantly increased mortality., (© 2023. The Author(s).)

Purpose: Mild traumatic brain injury (TBI) is one of the most common causes of morbidity worldwide. Patients at risk of unfavourable outcome may benefit from additional attention and help but identification of these patients necessitates the development of diagnostic methods to assess indices of brain injury at an early stage. The aim of this overview is to highlight studies that reflect the growing scientific attention to the early diagnosis and prognostication of mild TBI., Recent Findings: The value of serum biomarkers for the diagnosis of TBI severity has been acknowledged in recent studies. The diagnostic and prognostic utility of several biomarkers of brain injury, such as glial fibrillary acidic protein, and of inflammation, such as interleukin (IL)-6 and IL-10, holds promise for application in daily clinical practice in a point-of-care platform. Besides head CT imaging, early advanced MRI brain imaging has been reported as a tool for assessment of injury severity and prognostication. The introduction of direct oral anticoagulants (DOACs) has raised new challenges for the treatment of intracranial traumatic haemorrhage at the Emergency Department., Summary: Promising findings of new diagnostic markers of brain injury severity highlight the potential prognostic value of serum biomarkers and early MRI imaging. The accurate assessment of patients at risk of incomplete recovery after mTBI will enhance more timely and individualized treatment., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Behavioral changes are common after acquired brain injury (ABI) and may be caused by social cognition impairments. We investigated whether impaired emotion recognition, specifically Negative Emotion Recognition (NER) and Anger Misattribution (AM), after ABI was related to behavioral problems, so-called Behaviors of Concern (BoC)., Method: The study included 139 participants with ABI and 129 healthy controls. BoC was measured using four scales of the Brock Adaptive Functioning Questionnaire (BAFQ): Impulsivity, Aggression, Social Monitoring, and Empathy. Both self-ratings and informant ratings of BoC were obtained. Emotion recognition was measured with the Ekman 60 Faces Test (FEEST). A NER score was composed of the summed scores on Anger, Disgust, Fear, and Sadness. An AM score was composed of the number of facial expressions wrongly recognized as Anger., Results: Total FEEST scores in ABI participants were significantly worse than in healthy controls. The effect size is moderate. Informants rated significantly more problems in Social Monitoring and Empathy than participants. Effect sizes were small. Scores on FEEST total, NER, and AM were significantly correlated to informant ratings of Social Monitoring. Correlations were weak to moderate., Conclusions: Worse NER and more profound AM were related to more informant-rated problems in social monitoring. In addition, informants rated more problems in social monitoring and empathy than participants. This strongly suggests problems in self-awareness in ABI participants. Consequently, social cognition tests and informant ratings should be used in clinical practice to improve the detection and treatment of BoC after ABI.

Background/objective: Current severe traumatic brain injury (TBI) outcome prediction models calculate the chance of unfavourable outcome after 6 months based on parameters measured at admission. We aimed to improve current models with the addition of continuously measured neuromonitoring data within the first 24 h after intensive care unit neuromonitoring., Methods: Forty-five severe TBI patients with intracranial pressure/cerebral perfusion pressure monitoring from two teaching hospitals covering the period May 2012 to January 2019 were analysed. Fourteen high-frequency physiological parameters were selected over multiple time periods after the start of neuromonitoring (0-6 h, 0-12 h, 0-18 h, 0-24 h). Besides systemic physiological parameters and extended Corticosteroid Randomisation after Significant Head Injury (CRASH) score, we added estimates of (dynamic) cerebral volume, cerebral compliance and cerebrovascular pressure reactivity indices to the model. A logistic regression model was trained for each time period on selected parameters to predict outcome after 6 months. The parameters were selected using forward feature selection. Each model was validated by leave-one-out cross-validation., Results: A logistic regression model using CRASH as the sole parameter resulted in an area under the curve (AUC) of 0.76. For each time period, an increased AUC was found using up to 5 additional parameters. The highest AUC (0.90) was found for the 0-6 h period using 5 parameters that describe mean arterial blood pressure and physiological cerebral indices., Conclusions: Current TBI outcome prediction models can be improved by the addition of neuromonitoring bedside parameters measured continuously within the first 24 h after the start of neuromonitoring. As these factors might be modifiable by treatment during the admission, testing in a larger (multicenter) data set is warranted.

Objective: Post-concussion syndrome (PCS) occurs following mild traumatic brain injury (mTBI). Patients with mTBI are often assessed using self-report instruments that rely on perception of current symptoms compared to how they felt and functioned pre-injury. The objective was to examine reliability of patients' post-injury reporting of their pre-injury symptoms., Methods: We included two control groups (trauma patients without brain injury history and healthy controls) who were recruited at an outpatient surgical clinic and among the working and social environment of the researchers, respectively. The Head Injury Symptom Checklist (HISC) was used to assess pre-injury and current symptoms at four time points post injury. We included 836 patients with mTBIs, 191 trauma patients without brain injury history, and 100 healthy controls., Results: Patients with mTBI reported significantly more pre-injury symptoms than both control groups ( p < .001). Forty-five percent of patients with mTBI were inconsistent in their pre-injury ratings across four assessments. Patients with post-injury PCS reported much greater pre-injury symptoms and were more often inconsistent., Conclusion: Accurately assessing PCS by comparing pre with post-injury complaints is difficult, and may have implications for diagnosis when using self-report instruments. Therefore, post-injury PCS diagnosis should be interpreted with caution and PCS should ideally be examined using clinical examination.

Various guidelines for minor head injury focus on patients with a Glasgow Coma Scale (GCS) score of 13-15 and loss of consciousness (LOC) or post-traumatic amnesia (PTA), while clinical management for patients without LOC or PTA is often unclear. We aimed to investigate the effect of presence and absence of LOC or PTA on intracranial complications in minor head injury. A prospective multi-center cohort study of all patients with blunt head injury and GCS score of 15 was conducted at six Dutch centers between 2015 and 2017. Five centers used the national guideline and one center used a local guideline-both based on the CT in Head Injury Patients (CHIP) prediction model-to identify patients in need of a computed tomography (CT) scan. We studied the presence of traumatic findings and neurosurgical interventions in patients with and without LOC or PTA. In addition, we assessed the association of LOC and PTA with traumatic findings with logistic regression analysis and the additional predictive value of LOC and PTA compared with other risk factors in the CHIP model. Of 3914 patients, 2249 (58%) experienced neither LOC nor PTA and in 305 (8%) LOC and PTA was unknown. Traumatic findings were present in 153 of 1360 patients (11%) with LOC or PTA and in 67 of 2249 patients (3%) without LOC and PTA. Five patients without LOC and PTA had potential neurosurgical lesions and one patient underwent a neurosurgical intervention. LOC and PTA were strongly associated with traumatic findings on CT, with adjusted odds ratios of 2.9 (95% confidence interval [CI] 2.2-3.8) and 3.5 (95% CI 2.7-4.6), respectively. To conclude, patients who had minor head injury with neither LOC nor PTA are at risk of intracranial complications. Clinical guidelines should include clinical management for patients without LOC and PTA, and they should include LOC and PTA as separate risk factors rather than as diagnostic selection criteria.

- After introduction of the Dutch guideline for 'Care for patients with minor head/brain injury' (LTH guideline) in 2010, the number of CT scans has increased. Some of these scans were for patients with only trivial trauma and may not have been necessary.- In addition, since this guideline was implemented, there have been changes in the use of anticoagulants and platelet aggregation inhibitors. Non-vitamin-K-dependent oral anticoagulants (NOACs) and platelet aggregation inhibitors, or combinations of these, are prescribed more often.- These two factors have led the Netherlands Society of Neurology to initiate a request for modification of the LTH guideline for adults in two ways: (a) identification of minimal or trivial trauma for which no CT scan is required and (b) inclusion of NOACs and platelet aggregation inhibitors, or combinations of these, in the guideline.

The majority of patients with traumatic brain injury (TBI) sustain a mild injury (mTBI). One out of 4 patients experiences persistent complaints, despite their often normal neuropsychological test results and the absence of structural brain damage on conventional neuroimaging. Susceptibility to develop persistent complaints is thought to be affected by interindividual differences in adaptation, which can also be influenced by preinjury psychological factors. Coping is a key construct of adaptation and refers to strategies to deal with new situations and serious life events. An important element of coping is the ability to regulate emotions and stress. The prefrontal cortex is a crucial area in this regulation process, given that it exerts a top-down influence on the amygdala and other subcortical structures involved in emotion processing. However, little is known about the role of the prefrontal cortex and associated brain networks in emotion regulation and adaptation post-mTBI. Especially, the influence of prefrontal dysfunction on development of persistent postconcussive complaints is poorly understood. In this article, we aim to integrate findings from functional and structural MRI studies on this topic. Alterations within the default mode, executive and salience network have been found in relation to complaints post-mTBI. Dysfunction of the medial prefrontal cortex may impair network dynamics for emotion regulation and adaptation post-mTBI, resulting in persistent post-concussive complaints.

Behavioral problems are serious consequences of moderate to severe traumatic brain injury (TBI) and have a negative impact on outcome. There may be two types: neurobehavioral problems, manifesting as inadequate social behavior resulting from prefrontal system damage, and affective behavioral problems, resulting from emotional distress as a reaction to the brain injury. In the present study we investigated whether these two types of behavioral problems, as indicated by proxies, could be distinguished in a group of chronic TBI patients and whether early indicators of prefrontal damage on imaging could predict long-term neurobehavioral problems. Computed tomography (CT) imaging data on admission were used to identify frontal lesions. Three hundred twenty-three moderate to severe TBI survivors received 2 to 16 years post-trauma an aftercare survey with seven questions asking for changes in behavior and affect, presented both to patients and their proxies. One hundred eighty-six patients (59%) answered the behavioral questions; 42% had frontal lesions on CT. Ordinal common factor analysis on proxy scores yielded two factors, with behavior and affective items clearly separated and the anger item mediocre related to both factors. Three scales were created: Behavior, Affective and Anger. Frontal patients scored significantly higher on the Behavior and Anger scales. Logistic regression analysis showed a fourfold increase of long-term neurobehavioral problems in patients with frontal lesions. Long-term neurobehavioral problems were significantly correlated to one-year outcome and return to work in the long term. We conclude that in patients with moderate to severe TBI neurobehavioral and affective problems can be distinguished. Early CT frontal abnormalities predict long-term neurobehavioral problems, but not affective problems.

Primary Objective: To determine the pathways of care within the first year after traumatic brain injury (TBI) and to explore whether provided care is related to residual impairments., Research Design: Retrospective study of 343 patients with moderate and severe TBI admitted to a Level-1 trauma centre., Methods and Procedures: Discharge destinations from hospital to home and frequency of outpatient visits were determined. Outcome was defined 1 year after injury by the Extended Glasgow Outcome Scale and Return to Work., Results: Most (94%) patients had returned home 1-year after injury despite cognitive (76%), behavioural (67%) and physical (55%) impairments. One in four patients was severely disabled and 32% had resumed work on a previous level. Two-thirds of all patients went home as secondary discharge destination and 50% needed inpatient rehabilitation. Almost half of patients needed outpatient care, mostly for behavioural and cognitive impairments. One in 10 patients consulted a psychiatrist, with 55% unfavourable outcome. Of those patients initially discharged to home without follow-up, eventually 10% needed outpatient rehabilitation., Conclusions: One-year after injury most patients had returned home with residual impairments and frequent medical consultations. This finding warrants further investigation to define appropriate aftercare by various medical specialists aimed at long-term community integration.

Functional imaging includes imaging techniques that provide information about the metabolic and hemodynamic status of the brain. Most commonly applied functional imaging techniques in patients with traumatic brain injury (TBI) include magnetic resonance spectroscopy (MRS), single photon emission computed tomography (SPECT), positron emission tomography (PET) and perfusion CT (PCT). These imaging modalities are used to determine the extent of injury, to provide information for the prediction of outcome, and to assess evidence of cerebral ischemia. In TBI, secondary brain damage mainly comprises ischemia and is present in more than 80% of fatal cases with traumatic brain injury (Graham et al., 1989; Bouma et al., 1991; Coles et al., 2004). In particular, while SPECT measures cerebral perfusion and MRS determines metabolism, PET is able to assess both perfusion and cerebral metabolism. This chapter will describe the application of these techniques in traumatic brain injury separately for the major groups of severity comprising the mild and moderate to severe group. The application in TBI and potential difficulties of each technique is described. The use of imaging techniques in children will be separately outlined., (© 2015 Elsevier B.V. All rights reserved.)

In a subgroup of patients with mild traumatic brain injury (TBI) residual symptoms, interfering with outcome and return to work, are found. With neuropsychological assessment cognitive deficits can be demonstrated although the pathological underpinnings of these cognitive deficits are not fully understood. As the admission computed tomography (CT) often is normal, perfusion CT imaging may be a useful indicator of brain dysfunction in the acute phase after injury in these patients. In the present study, directly after admission perfusion CT imaging was performed in mild TBI patients with follow-up neuropsychological assessment in those with complaints and a normal non-contrast CT. Neuropsychological tests comprised the 15 Words test Immediate Recall, Trailmaking test part B, Zoo Map test and the FEEST, which were dichotomized into normal and abnormal. Perfusion CT results of patients with normal neuropsychological test scores were compared to those with abnormal test scores. In total eighteen patients were included. Those with an abnormal score on the Zoo Map test had a significant lower CBV in the right frontal and the bilateral parieto-temporal white matter. Patients with an abnormal score on the FEEST had a significant higher MTT in the bilateral frontal white matter and a significant decreased CBF in the left parieto-temporal grey matter. No significant relation between the perfusion CT parameters and the 15 Words test and the Trailmaking test part B was present. In conclusion, impairments in executive functioning and emotion perception assessed with neuropsychological tests during follow up were related to differences in cerebral perfusion at admission in mild TBI. The pathophysiological concept of these findings is discussed., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Introduction: Prehospital guidelines advise advanced life support in all patients with severe traumatic brain injury (TBI). In the Netherlands, it is recommended that prehospital advanced life support is particularly provided by a physician-based helicopter emergency medical service (P-HEMS) in addition to paramedic care (EMS). Previous studies have however shown that a substantial part of severe TBI patients is exclusively treated by an EMS team. In order to better understand this phenomenon, we evaluated P-HEMS deployment characteristics in severe TBI in a multicenter setting., Methods: The database included patient demographics, prehospital and injury severity parameters and determinants of EMS or EMS/P-HEMS dispatch in 334 patients with severe TBI admitted to level 1 trauma centres in the Netherlands., Results: P-HEMS was deployed in 62% of patients with severe TBI. Patients treated by the P-HEMS had a higher injury severity score (29 (20-38)) vs. (25 (16-30); P<0.001), more frequently required blood product transfusions (41% vs. 29%; P=0.03) and recurrently suffered from TBI with extracranial injuries (33% vs. 6%; P<0.001) than patients solely treated by an EMS. The prehospital endotracheal intubation rate was higher in the P-HEMS group in isolated TBI (93% vs. 19%; P<0.001) or TBI with extracranial injuries (96% vs. 43%; P<0.001) compared to the EMS group. In the EMS group, more patients were secondary referred to a level 1 trauma centre (32% vs. 4%; P<0.001 vs. P-HEMS). Despite higher injury severity levels in P-HEMS patients, 6-month mortality rates were similar among groups, irrespective of the presence of extracranial injuries in addition to TBI. Deployment of P-HEMS estimated 52% and 72% (P<0.001) in urban and rural regions, respectively, with comparable endotracheal intubation rates among regions., Conclusions: This study shows that a physician-based HEMS was more frequently deployed in patients with severe TBI in the presence of extracranial injuries, and in rural trauma regions. Treatment of severe TBI patients by a paramedic EMS only was associated with a higher incidence of secondary referrals to a level I trauma centre. Our data support adjustment of local prehospital guidelines for patients with severe TBI to the geographical context., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: With this study we aimed to design validated outcome prediction models in moderate and severe traumatic brain injury (TBI) using demographic, clinical, and radiological parameters., Methods: Seven hundred consecutive moderate or severe TBI patients were included in this observational prospective cohort study. After inclusion, clinical data were collected, initial head computed tomography (CT) scans were rated, and at 6 months outcome was determined using the extended Glasgow Outcome Scale. Multivariate binary logistic regression analysis was applied to evaluate the association between potential predictors and three different outcome endpoints. The prognostic models that resulted were externally validated in a national Dutch TBI cohort., Results: In line with previous literature we identified age, pupil responses, Glasgow Coma Scale score and the occurrence of a hypotensive episode post-injury as predictors. Furthermore, several CT characteristics were associated with outcome; the aspect of the ambient cisterns being the most powerful. After external validation using Receiver Operating Characteristic (ROC) analysis our prediction models demonstrated adequate discriminative values, quantified by the area under the ROC curve, of 0.86 for death versus survival and 0.83 for unfavorable versus favorable outcome. Discriminative power was less for unfavorable outcome in survivors: 0.69., Conclusions: Outcome prediction in moderate and severe TBI might be improved using the models that were designed in this study. However, conventional demographic, clinical and CT variables proved insufficient to predict disability in surviving patients. The information that can be derived from our prediction rules is important for the selection and stratification of patients recruited into clinical TBI trials.

Traumatic brain injury (TBI) is a leading cause of disability, specifically among younger adults. Behavioral changes are common after moderate to severe TBI and have adverse consequences for social and vocational functioning. It is hypothesized that deficits in social cognition, including facial affect recognition, might underlie these behavioral changes. Measurement of behavioral deficits is complicated, because the rating scales used rely on subjective judgement, often lack specificity and many patients provide unrealistically positive reports of their functioning due to impaired self-awareness. Accordingly, it is important to find performance based tests that allow objective and early identification of these problems. In the present study 51 moderate to severe TBI patients in the sub-acute and chronic stage were assessed with a test for emotion recognition (FEEST) and a questionnaire for behavioral problems (DEX) with a self and proxy rated version. Patients performed worse on the total score and on the negative emotion subscores of the FEEST than a matched group of 31 healthy controls. Patients also exhibited significantly more behavioral problems on both the DEX self and proxy rated version, but proxy ratings revealed more severe problems. No significant correlation was found between FEEST scores and DEX self ratings. However, impaired emotion recognition in the patients, and in particular of Sadness and Anger, was significantly correlated with behavioral problems as rated by proxies and with impaired self-awareness. This is the first study to find these associations, strengthening the proposed recognition of social signals as a condition for adequate social functioning. Hence, deficits in emotion recognition can be conceived as markers for behavioral problems and lack of insight in TBI patients. This finding is also of clinical importance since, unlike behavioral problems, emotion recognition can be objectively measured early after injury, allowing for early detection and treatment of these problems.

Background: A subgroup of patients with mild traumatic brain injury (TBI) experiences residual symptoms interfering with their return to work. The pathophysiological substrate of the suboptimal outcome in these patients is a source of debate., Objective: To provide greater insight into the pathophysiological mechanisms of mild TBI., Methods: Diffusion tensor imaging (DTI) was performed during follow-up of 18 patients with mild TBI and compared with healthy control subjects. DTI data of the patient group were also compared with perfusion CT imaging in the acute phase of injury., Results: In patients with mild TBI, a trend was observed for a decreased fractional anisotropy (FA) in widespread bilateral frontal white matter areas with increased mean diffusivity (MD) in the parieto-temporal regions, compared to healthy control subjects. Cerebral blood volume (CBV) correlated significantly with FA in several white matter tracts including the corpus callosum, the internal capsule, the inferior fronto-occipital fascicle, the corticospinal tract, the superior and the inferior longitudinal fascicle., Conclusion: In mild TBI with normal conventional imaging significant associations between cerebral perfusion in the acute phase of injury and DTI analyses in the chronic phase of injury were discerned. The pathophysiological concept of these findings is being outlined.

Objectives: To investigate the relation of postconcussive complaints, anxiety, and depression with vocational outcome in patients with traumatic brain injury (TBI) of various severities and to assess sex differences., Design: A prospective cross-sectional cohort study., Setting: Level I trauma center., Participants: Adults (N=242) with TBI of various severity., Interventions: Not applicable., Main Outcome Measures: Extended Glasgow Outcome Scale, return to work (RTW), Head Injury Symptom Checklist, and Hospital Anxiety and Depression Scale., Results: In 67% of the patients, complaints were present; 22% were anxious, and 18% were depressed. The frequency of complaints increased significantly with injury severity, in contrast to anxiety and depression. Frequencies of patients with anxiety and depression (9% and 5%) were lower with complete RTW than with incomplete RTW (42% and 37%; P<.001). Patients with minor TBI with complaints were more anxious (50% vs 27%; P<.05) and depressed (46% vs 23%; P<.05) compared with patients with other severity categories and patients with incomplete RTW (67% vs 36% and 60% vs 30%, respectively). A higher percentage of women with minor TBI were depressed (45% vs 13%; P=.01) and had incomplete RTW (50% vs 18%; P<.05) compared with men. Multiple regression analysis showed that injury severity, complaints, anxiety, and depression were all predictive of RTW (explained variance 45%). In all severity categories, anxiety and depression were predictive of RTW, complaints, and sex only for minor TBI., Conclusions: Anxiety and depression are related to vocational outcome after TBI, with a different profile in the minor TBI category, partly due to sex differences., (Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Several prognostic models to predict outcome in traumatic brain injury (TBI) have been developed, but few are externally validated. We aimed to validate the International Mission on Prognosis and Analysis of Clinical Trials in TBI (IMPACT) prognostic models in a recent unselected patient cohort and to assess the additional prognostic value of extracranial injury., Methods: The Prospective Observational COhort Neurotrauma (POCON) registry contains 508 patients with moderate or severe TBI, who were admitted in 2008 and 2009 to five trauma centers in the Netherlands. We predicted the probability of mortality and unfavorable outcome at 6 months after injury with the IMPACT prognostic models. We studied discrimination (area under the curve [AUC]) and calibration. We added the extracranial component of the Injury Severity Score (ISS) to the models and calculated the increase in AUC., Results: The IMPACT models had an adequate discrimination in the POCON registry, with AUCs in the external validation between 0.85 and 0.90 for mortality and between 0.82 and 0.87 for unfavorable outcome. Observed outcomes agreed well with predicted outcomes. Adding extracranial injury slightly improved predictions in the overall population (unfavorable outcome: AUC increase of 0.002, p = 0.02; mortality: AUC increase of 0.000, p = 0.37) but more clearly in patients with moderate TBI (unfavorable outcome: AUC increase of 0.008, p < 0.01, mortality: AUC increase of 0.012, p = 0.02) and patients with minor computed tomographic result abnormalities (unfavorable outcome: AUC increase of 0.013, p < 0.01; mortality: AUC increase of 0.001, p = 0.08)., Conclusion: The IMPACT models performed well in a recent series of TBI patients. We found some additional impact of extracranial injury on outcome, specifically in patients with less severe TBI or minor computed tomographic result abnormalities., Level of Evidence: Epidemiologic/prognostic study.

Deficits in emotion recognition, a crucial aspect of social cognition, are common after serious brain injury, as are executive deficits. Since social cognition and executive function are considered to be separate constructs, our first aim was to examine the presence of emotion recognition problems in brain injury patients with dysexecutive problems. We studied 65 brain injury patients of mixed aetiology participating in a randomised controlled trial evaluating the effects of a multifaceted treatment for executive dysfunction (Spikman, Boelen, Lamberts, Brouwer, & Fasotti, 2010 ) and 84 matched controls with a test for emotion recognition. Results showed that, in patients with acquired brain injury exhibiting executive deficits, emotion recognition deficits are also present. Male patients are more impaired than female patients, irrespective of aetiology. Our second aim was to investigate whether emotion recognition problems negatively predict the results of the treatment programme. Pre-treatment emotion recognition performance significantly predicted resumption of roles in daily life (Role Resumption List; RRL) and performance on an ecologically valid test for everyday executive functioning (Executive Secretarial Task; EST) post-treatment and, in addition, interfered negatively with treatment condition. Moreover, worse pre-treatment emotion recognition skills affect the learning of compensatory strategies for executive dysfunction negatively, whereas pre-treatment dysexecutive deficits do not.

Introduction: Prehospital care by physician-based helicopter emergency medical services (P-HEMS) may prolong total prehospital run time. This has raised an issue of debate about the benefits of these services in traumatic brain injury (TBI). We therefore investigated the effects of P-HEMS dispatch on prehospital run time and outcome in severe TBI., Methods: Prehospital run times of 497 patients with severe TBI who were solely treated by a paramedic EMS (n = 125) or an EMS/P-HEMS combination (n = 372) were retrospectively analyzed. Other study parameters included the injury severity score (ISS), Glasgow Coma Scale (GCS), prehospital endotracheal intubation and predicted and observed outcome rates., Results: Patients who received P-HEMS care were younger and had higher ISS values than solely EMS-treated patients (10%; P = 0.04). The overall prehospital run time was 74 ± 54 min, with similar out-of-hospital times for EMS and P-HEMS treated patients. Prehospital endotracheal intubation was more frequently performed in the P-HEMS group (88%) than in the EMS group (35%; P<0.001). The prehospital run time for intubated patients was similar for P-HEMS (66 (51-80)min) and EMS-treated patients (59 (41-88 min). Unexpectedly, mortality probability scores and observed outcome scores were less favourable for EMS-treated patients when compared to patients treated by P-HEMS., Conclusion: P-HEMS dispatch does not increase prehospital run times in severe TBI, while it assures prehospital intubation of TBI patients by a well-trained physician. Our data however suggest that a subgroup of the most severely injured patients received prehospital care by an EMS, while international guidelines recommend advanced life support by a physician-based EMS in these cases., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objective: To determine adherence to Brain Trauma Foundation guidelines for intracranial pressure monitoring after severe traumatic brain injury, to investigate if characteristics of patients treated according to guidelines (ICP+) differ from those who were not (ICP-), and whether guideline compliance is related to 6-month outcome., Design: Observational multicenter study., Patients: Consecutive severe traumatic brain injury patients (≥16 yrs, n = 265) meeting criteria for intracranial pressure monitoring., Measurements and Main Results: Data on demographics, injury severity, computed tomography findings, and patient management were registered. The Glasgow Outcome Scale Extended was dichotomized into death (Glasgow Outcome Scale Extended = 1) and unfavorable outcome (Glasgow Outcome Scale Extended 1-4). Guideline compliance was 46%. Differences between the monitored and nonmonitored patients included a younger age (median 44 vs. 53 yrs), more abnormal pupillary reactions (52% vs. 32%), and more intracranial pathology (subarachnoid hemorrhage 62% vs. 44%; intraparenchymal lesions 65% vs. 46%) in the ICP+ group. Patients with a total intracranial lesion volume of ~150 mL and a midline shift of ~12 mm were most likely to receive an intracranial pressure monitor and probabilities decreased with smaller and larger lesions and shifts. Furthermore, compliance was low in patients with no (Traumatic Coma Databank score I -10%) visible intracranial pathology. Differences in case-mix resulted in higher a priori probabilities of dying (median 0.51 vs. 0.35, p < .001) and unfavorable outcome (median 0.79 vs. 0.63, p < .001) in the ICP+ group. After correction for baseline and clinical characteristics with a propensity score, intracranial pressure monitoring guideline compliance was not associated with mortality (odds ratio 0.93, 95% confidence interval 0.47-1.85, p = .83) nor with unfavorable outcome (odds ratio 1.81, 95% confidence interval 0.88-3.73, p = .11)., Conclusions: Guideline noncompliance was most prominent in patients with minor or very large computed tomography abnormalities. Intracranial pressure monitoring was not associated with 6-month outcome, but multiple baseline differences between monitored and nonmonitored patients underline the complex nature of examining the effect of intracranial pressure monitoring in observational studies.

Objective: The biomarkers glial fibrillary acid protein (GFAP) and S100B are increasingly used as prognostic tools in severe traumatic brain injury (TBI). Data for mild TBI are scarce. This study aims to analyze the predictive value of GFAP and S100B for outcome in mild TBI and the relation with imaging., Methods: In 94 patients biomarkers were determined directly after admission. Collected data included injury severity, patient characteristics, admission CT, and MRI 3 months postinjury. Six months postinjury outcome was determined with Glasgow Outcome Scale Extended (GOSE) and return to work (RTW)., Results: Mean GFAP was 0.25 μg/L (SD 1.08) and S100B 0.54 μg/L (SD 1.18). In 63% GFAP was not discernible. GFAP was increased in patients with an abnormal CT (1.20 μg/L, SD 2.65) compared to normal CT (0.05 μg/L, SD 0.17, p < 0.05). Also in patients with axonal injury on MRI GFAP was higher (0.65 μg/L, SD 0.91 vs 0.07 μg/L, SD 0.2, p < 0.05). GFAP was increased in patients with incomplete RTW compared to complete RTW (0.69 μg/L, SD 2.11 vs 0.12 μg/L, SD 0.38, p < 0.05). S100B was not related to outcome or imaging studies. In multivariate analysis GFAP was not predictive for outcome determined by GOSE and RTW., Conclusions: A relation between GFAP with imaging studies and outcome (determined by RTW) was found in contrast to S100B. As the positive predictive value of GFAP is limited in this category of TBI patients, this biomarker is not suitable for prediction of individual patient outcome.

This prospective multicenter study investigated the association of the course of coagulation abnormalities with initial computed tomography (CT) characteristics and outcome in patients with isolated traumatic brain injury (TBI). Patient demographics, coagulation parameters, CT characteristics, and outcome data of moderate and severe TBI patients without major extracranial injuries were prospectively collected. Coagulopathy was defined as absent, early but temporary, delayed, or early and sustained. Delayed/sustained coagulopathy was associated with a higher incidence of disturbed pupillary responses (40% versus 27%; p<0.001) and higher Traumatic Coma Data Bank (TCDB) CT classification (5 (2-5) versus 2 (1-5); p=0.003) than in patients without or with early, but short-lasting coagulopathy. The initial CT of patients with delayed/sustained coagulopathy more frequently showed intracranial hemorrhage and signs of raised intracranial pressure (ICP) compared to patients with early coagulopathy only. This was paralleled by higher in-hospital mortality rates (51% versus 33%; p<0.05), and poorer 6-month functional outcome in patients with delayed/sustained coagulopathy. The relative risk for in-hospital mortality was particularly related to disturbed pupillary responses (OR 8.19; 95% CI 3.15,21.32; p<0.001), early, short-lasting coagulopathy (OR 6.70; 95% CI 1.74,25.78; p=0.006), or delayed/sustained coagulopathy (OR 5.25; 95% CI 2.06,13.40; p=0.001). Delayed/sustained coagulopathy is more frequently associated with CT abnormalities and unfavorable outcome at 6 months after TBI than early, short-lasting coagulopathy. Our finding that not only the mere presence but also the time course of coagulopathy holds predictive value for patient outcome underlines the importance of systematic hemostatic monitoring over time in TBI.

Impairments in social behavior are frequently found in moderate to severe traumatic brain injury (TBI) patients and are associated with an unfavorable outcome with regard to return to work and social reintegration. Neuropsychological tests measuring aspects of social cognition are thought to be sensitive to these problems. However, little is known about the effect of general cognitive problems on these tests, nor about their sensitivity to injury severity and frontal lesions. In the present study 28 chronic TBI patients with a moderate to severe TBI were assessed with tests for social cognition (emotion recognition, Theory of Mind, and empathy), and for general, non-social cognition (memory, mental speed, attention, and executive function). The patients performed significantly worse than healthy controls on all measures, with the highest effect size for the emotion recognition test, the Facial Expressions of Emotion-Stimuli and Tests (FEEST). Correlation analyses yielded no significant (partial) correlations between social and non-social cognition tests. Consequently, poor performance on social cognition tests was not due to general cognitive deficits. In addition, the emotion recognition test was the only measure that was significantly related to post-traumatic amnesia (PTA) duration, Glasgow Coma Scale (GCS) score, and the presence of prefrontal lesions. Hence, we conclude that social cognition tests are a valuable supplement to a standard neuropsychological examination, and we strongly recommend the incorporation of measurements of social cognition in clinical practice. Preferably, a broader range of social cognition tests would be applied, since our study demonstrated that each of the measures represents a unique aspect of social cognition, but if capacity is limited, at least a test for emotion recognition should be included.

Changes in the demographics, approach, and treatment of traumatic brain injury (TBI) patients require regular evaluation of epidemiological profiles, injury severity classification, and outcomes. This prospective multicenter study provides detailed information on TBI-related variables of 508 moderate-to-severe TBI patients. Variability in epidemiology and outcome is examined by comparing our cohort with previous multicenter studies. Additionally, the relation between outcome and injury severity classification assessed at different time points is studied. Based on the emergency department Glasgow Coma Scale (GCS), 339 patients were classified as having severe and 129 as having moderate TBI. In 15%, the diagnosis differed when the accident scene GCS was used for classification. In-hospital mortality was higher if severe TBI was diagnosed at both time points (44%) compared to moderate TBI at one or both time points (7-15%, p<0.001). Furthermore, 14% changed diagnosis when a threshold (≥6 h) for impaired consciousness was used as a criterion for severe TBI: In-hospital mortality was<5% when impaired consciousness lasted for<6 h. This suggests that combining multiple clinical assessments and using a threshold for impaired consciousness may improve the classification of injury severity and prediction of outcome. Compared to earlier multicenter studies, our cohort demonstrates a different case mix that includes a higher age (mean=47.3 years), more diffuse (Traumatic Coma Databank [TCDB] I-II) injuries (58%), and more major extracranial injuries (40%), with relatively high 6 month mortality rates for both severe (46%) and moderate (21%) TBI. Our results confirm that TBI epidemiology and injury patterns have changed in recent years whereas case fatality rates remain high.

Introduction: Traumatic cervical artery dissection (TCAD) is a relative infrequent complication of traumatic brain injury (TBI). Since TCAD is associated with morbidity in a considerable percentage of patients, it is important to obtain clues for recognising TCAD in this category of patients., Methods: Retrospective case-cohort study in severe TBI patients., Results: Five patients with traumatic cervical artery dissection after severe TBI, leading to ischemic strokes, are described. Secondary deterioration to coma was present in four out of five patients during admission. The diagnosis of TCAD was delayed in most cases because the secondary deterioration was often attributed to multisystem problems related to trauma patients, i.e. shock or hypoxia or medication effects. Local clinical symptoms and signs suggestive of TCAD are difficult to detect in this patient group. In all patients, the CT-scan on admission demonstrated no abnormalities. A follow-up scan at day 2 revealed that in all patients abnormalities in the vascular territories had evolved., Conclusion: With this case-cohort study we underline the importance of considering TCAD in severe TBI patients and emphasise the role for standard follow-up brain imaging. Also possible treatment consequences are discussed., ((c) 2010 Elsevier B.V. All rights reserved.)

Objective: To evaluate the cognitive and behavioral disturbances related to return to work (RTW) in patients with traumatic brain injury (TBI) with the application of a differentiated outcome scale., Design: Longitudinal cohort study., Setting: Level I trauma center., Participants: Adults (N=434) with TBI of various severity., Interventions: Not applicable., Main Outcome Measures: Extended Glasgow Outcome Scale (GOS-E), Differentiated Outcome Scale (DOS), and RTW., Results: Patients encountered problems in the physical (40%), cognitive (62%), behavioral (55%), and social domains (49%) of the DOS, with higher frequency related to severity of injury. Even those with mild TBI experienced cognitive (43%) and behavioral problems (33%). Patients with good recovery (58%) according to the GOS-E experienced problems in 1 or more domains of the DOS. Half the patients were able to resume previous vocational activities completely, although 1 in 3 experienced cognitive or behavioral problems. Using multivariate logistic regression analysis, the cognitive (odds ratio [OR], 10.548; confidence interval [CI], 5.99-18.67), behavioral (OR, 2.648; CI, 1.63-4.29), and physical domains (OR, 2.763; CI, 1.60-4.78) were significant (P<.01) predictors of RTW. For subcategories of TBI, the cognitive domain was predictive for RTW in those with moderate and severe TBI, whereas both the cognitive and behavioral domains were predictive for RTW in those with mild TBI., Conclusions: With application of a more detailed outcome scale, cognitive and behavioral impairments interfering with RTW were present in a substantial part of patients with TBI in the chronic phase after injury. More research is needed exploring the cognitive and behavioral outcome in different categories of injury severity separately.

In patients with moderate to severe traumatic brain injury (TBI), impairments of self-awareness are frequently found and associated with worse functional outcome and poor compliance with rehabilitation. The aim of this study was to investigate whether indications of impaired self-awareness could be found in TBI patients with frontal lesions and executive function deficits. Twenty-two TBI patients with focal frontal injuries were compared to 29 TBI patients without focal frontal injuries visible on neuroimaging. No differences were found on several outcome measures, including the Glasgow Outcome Scale-Extended (GOS-E), the Differential Outcome Scale (DOS), and return to work (RTW), although the frontal injury patients were more severely injured as indicated by the Glasgow Coma Scale (GCS) and duration of post-traumatic amnesia (PTA), and had impaired performance on a neuropsychological test of executive functioning. Even more so, the frontal injury group had a significantly lower score on the Sickness Impact Profile (SIP), indicating that they had fewer complaints than the patients without frontal injury, and scored significantly higher on the percentage of recovery (PoR) score, which expresses the extent of recovery as a percentage of their previous level of functioning. In contrast to the non-frontal-injury group, their PoR scores were not related to RTW, reflecting an erroneous perception of their actual working status. The positive results on these different outcome measures, which are partly or entirely self-reported, were seen as an indication of an impaired self-evaluative ability in the frontal injury patients. To determine outcome in a patient with frontal injuries and executive dysfunction, the judgment of several relevant other persons in the patient's life (e.g., partners, therapists, and employers) of the patient's daily life functioning should be sought.

Background: One of the predictive factors of outcome in traumatic brain injury is high intracranial pressure (ICP). Recently, the time course of ICP has been described but few data are available on the relation of these ICP profiles and outcome. The aim of this study is to investigate the relation of the time course of ICP with CT-findings and outcome., Methods: Retrospective analysis of prospectively collected data of 246 patients with traumatic brain injury admitted to the neurosurgical intensive care unit., Results: Early rise in ICP (within the first 2 days) was present in 32%, an intermediate rise (between days 3 and 5) in 34% and a late rise (after day 5) in 34% of patients. Half of the patients with a normal opening pressure (76%) developed intermediate or late ICP rise profiles. More mass lesions and sub/epidural hematomas were present in the late rise group. Patients with a late ICP rise required significant more intensive treatment (65% vs. 37 and 33%) when compared to the early and intermediate rise groups. In multiple regression analysis both ICP profiles and extracranial hematomas were related to outcome. With late ICP rise more unfavorable outcome (46 vs. 17%, P < 0.001) was seen although one in four patients showed a favorable outcome., Conclusion: During ICP monitoring different ICP profiles are present over time. These profiles are related to CT-characteristics and outcome. The importance of early and late monitoring of ICP is underlined.

Introduction: Trauma patients in an unresponsive state upon presentation to the Emergency Department have a poor prognosis. Rapid assessment of injuries combined with life-preserving therapy is required but defining the optimal strategy can be complicated when multiple organ systems are involved. This study analysed various categories of trauma patients with a Glasgow Coma Scale (GCS) of 3 on admission and evaluated the relation between injuries, clinical condition, treatment and outcome., Patients and Methods: A retrospective cohort-study, performed at a level 1 Trauma Center from 2002 to 2005. Trauma patients of all ages with GCS of 3 (without sedation) and Injury Severity Score (ISS) > or = 16 were included. The collected patient data comprised data on demographics, mechanism of injury, physiological condition on admission, diagnosis, ISS, treatment, admission to Intensive Care Unit, complications and outcome., Results: Ninety-seven patients were included and divided into three groups based on the pathology that caused the GCS of 3: traumatic brain injury N=48 (49%), anoxic brain injury N=27 (28%) and haemorrhagic shock N=22 (23%). The overall mortality was 81%; 91% of the haemorrhagic shock patients, 81% of the ABI patients and 77% of the TBI patients died. Eighteen patients survived of whom five patients (5%) made a good recovery. The pupillary light response and pH on admission were related to mortality. No relation with ISS, age or hypothermia was found., Discussion: Distinguishing salvageable patients from those beyond salvation remains problematic. This study illustrated the diversity of patients, their injuries and their condition upon presentation to the hospital as well as the limitations of therapy., Conclusion: Trauma patients with a GCS of 3 have a poor outcome. Despite aggressive treatment only 5% of the patients made a good recovery. Pupil reactivity and the pH on admission were found to be related to mortality.

Primary Objective: To compare P300 source analysis with conventional analysis in patients with cognitive impairment after brain injury., Methods and Procedures: P300 results were compared with neuropsychological test data and imaging data in 21 healthy control subjects and 33 patients with brain injury. Latency and amplitude parameters were obtained for both P300 analysis methods. Magnetic Resonance Imaging (MRI) was performed between 3-12 months after the injury., Main Outcomes and Results: For both P300 analysis methods, only amplitude parameters correlated with neuropsychological test data. Diagnostic accuracy was better with source analysis than conventional analysis, when compared to the VLT (p = 0.03) and the PASAT (p = 0.04, only for those patients with imaging abnormalities). Patients with normal MRI results and patients with MRI abnormalities had decreased mean P3A amplitude compared to controls. In patients with focal frontal or temporal injury, the presence of mediofrontal lesions was associated with P3A amplitude reduction, while orbitofrontal lesions tended to increase P3A amplitude., Conclusions: Source analysis of P300 resulted in improved detection of neuropsychological abnormality in patients with brain injury. It is advisable to analyse P300 results in conjunction with imaging results. This approach may further facilitate the interpretation and diagnostic applicability of source analysis P300 results in patients with brain injury.

A sensitive gas chromatography-mass spectrometry method for measuring propofol in cerebrospinal fluid is described, validated and applied to four patients after traumatic brain injury. The limit of quantitation was 2 microg/L using a volume of 0.5 mL. The inter- and intra-assay coefficients of variation were 5.9 and 5.1%, respectively. The assay covers the linear concentration range of 2-50 microg/L, which is relevant in clinical pharmacokinetic studies when propofol is used in the Intensive Care Unit as a sedative agent or to lower the intracranial pressure.

Temporal changes in serum S-100 protein levels were compared between patients with ischemic stroke, transient ischemic attack (TIA) and traumatic brain injury (TBI). In addition, S-100 levels were correlated with clinical severity and outcome. Measurements were done with a LIA-mat((R)) Sangtec((R)) 100 using an automated immunoluminometric assay. Serum S-100 was measured in 21 stroke patients, 18 TIA patients and ten TBI patients on days 1 (0-24 h), 2, 3, 4, 5 or 6 and 8 or 9. In a control group of 28 healthy volunteers one measurement was done. For the stroke and TIA patients, National Institutes of Health Stroke Scale (NIHSS) scores were obtained on admission and on day 10. For the TBI patients, Glasgow Coma Scale (GCS) scores were obtained on admission and Glasgow Outcome Scale (GOS) scores were obtained after 6 months. Changes in serum S-100 levels over the first 3 days were significantly different between stroke and TBI patients (P=0.014) and between stroke and TIA patients (P=0.006). Peak concentrations of S-100 were most often observed on day 3 or 4 after stroke and on day 1 or 2 after TBI. In the stroke patients individual S-100 peak levels correlated well with the NIHSS score on admission (r=0.58 P=0.014) and the change in NIHSS score between day 10 and day 1 (r=0.65, P=0. 005). In the TBI patients a good correlation between individual peak levels of S-100 and the GCS score on admission (r=-0.81, P=0.010) and the GOS score 6 months after the trauma was found (r=-0.87, P=0. 004). We conclude that there is a significant difference in temporal changes of S-100 levels between ischemic stroke and TBI patients. This suggests different pathophysiological mechanisms. The results of this study further confirm that peak levels of serum S-100 correlate with neurological deficit resulting from either stroke or TBI.

The frequency of behavioural disturbances early after injury in relation to outcome was prospectively investigated in a series of 67 patients with mild-to-moderate head injury (as defined by GCS on admission). In more than half of the patients, behavioural disturbances were observed. Restlessness occurred in 40% of patients, whereas agitation was seen in 19% of patients. In all patients, restlessness and agitation disappeared before resolution of PTA. In multiple regression analysis, restlessness and PTA were found to be separate factors in predicting outcome. On imaging studies, twice as many lesions were seen in patients with restlessness and agitation (81% compared to 39%), mainly localized in the frontotemporal region. In two thirds of patients with early behavioural disturbances, residual emotional and cognitive impairments were seen 1 year after injury. This study suggests that behavioural disturbances in the early phase after injury are related to frontotemporal lesions and lends support for the view of the existence of a separate profile of patient behaviour in mild-to-moderate head injury.

Serial magnetic resonance imaging (MRI) and computed tomographic (CT) studies were performed in mild to moderate head injury to evaluate whether early and late imaging have additional value in predicting outcome in this category of patients. During 1-year follow-up of a series of 67 patients, a CT scan on admission was performed together with MRI studies within 1 to 3 months and 6 to 12 months after injury. With CT, intracranial lesions were seen in 62% of patients compared with 44% with early and 19% with late MRI, located predominantly in the frontal and temporal regions. More than half of the lesions revealed with CT resulted in focal atrophy on MRI. Outcome was found to be worse in patients with edema and lesions on CT. Likewise, abnormalities detected with MRI were associated with poor outcome scores. In multiple regression analysis, only lesions in the frontal regions detected with early MRI were found to be predictive of outcome. With late MRI, only focal atrophy in the frontotemporal regions was found to be predictive of outcome. The findings in this study suggests that MRI studies may be valuable for predicting long-term outcome in patients with mild to moderate HI.

Objectives: To determine the prognostic value of characteristics of acute injury and duration of post-traumatic amnesia (PTA) for long term outcome in patients with mild to moderate head injury in terms of complaints and return to work., Methods: Patients with a Glasgow coma score (GCS) on admission of 9-14 were included. Post-traumatic amnesia was assessed prospectively. Follow up was performed at 1, 3, 6, and 12 months after injury. Outcome was determined by the Glasgow outcome scale (GOS) 1 year after injury and compared with a more detailed outcome scale (DOS) comprising cognitive and neurobehavioural aspects., Results: Sixty seven patients were included, mean age 33.2 (SD 14.7) years and mean PTA 7.8 (SD 7.3) days. One year after injury, 73% of patients had resumed previous work although most (84%) still reported complaints. The most frequent complaints were headache (32%), irritability (34%), forgetfulness and poor concentration (42%), and fatigue (45%). According to the GOS good recovery (82%) or moderate disability (18%) was seen. Application of the DOS showed more cognitive (40%) and behavioural problems (48%), interfering with return to work. Correlation between the GOS and DOS was high (r=0.87, p<0.01). Outcome correlated with duration of PTA (r=-0.46) but not significantly with GCS on admission (r=0.19). In multiple regression analysis, PTA and the number of complaints 3 months after injury explained 49% of variance on outcome as assessed with the GOS, and 60% with the DOS., Conclusions: In mild to moderate head injury outcome is determined by duration of PTA and not by GCS on admission. Most patients return to work despite having complaints. The application of a more detailed outcome scale will increase accuracy in predicting outcome in this category of patients with head injury.

A summary of the presentation, diagnosis and therapy of head injury is given. The article is focussed on mild head injury, the most frequent type of head injury. The difference between concussion and contusion is explained. Symptoms and abnormalities found at neurological examination are discussed. The Glasgow Coma Scale is described as a tool to diagnose the severity of head injury. The value of additional radiological investigation is discussed. The therapy which depends on the severity of head injury and concomitant complications, is given. Information about eventual persisting complaints and deficits is important. After-care depends on the severity of the injury and the persistence of neurological signs and symptoms. Outcome measurement is done by the Glasgow Outcome Scale. It is emphasized that patients may exhibit persistent complaints although they return to work or school.

Traumatic brain injury is usually assessed with the Glasgow coma scale (GCS), CT, or MRI. After such injury, the injured brain tissue is characterised by calcium mediated neuronal damage and inflammation. Positron emission tomography with the isotope cobalt-55 (Co-PET) as a calcium tracer enables imaging of affected tissue in traumatic brain injury. The aim was to determine whether additional information can be gained by Co-PET in the diagnosis of moderate traumatic brain injury and to assess any prognostic value of Co-PET. Five patients with recent moderately severe traumatic brain injury were studied. CT was performed on the day of admission, EEG within one week, and MRI and Co-PET within four weeks of injury. Clinical assessment included neurological examination, GCS, neuropsychological testing, and Glasgow outcome scale (GOS) after one year. Co-PET showed focal uptake that extended beyond the morphological abnormalities shown by MRI and CT, in brain regions that were actually diagnosed with EEG. Thus Co-PET is potentially useful for diagnostic localisation of both structural and functional abnormalities in moderate traumatic brain injury.

Older adults (OA) after mild traumatic brain injury (mTBI) have a high risk of developing persistent post-injury cognitive impairments. Lower pre-morbid cognitive reserve (CR) is increasingly investigated as a risk factor for cognitive dysfunction in OA. However, how CR protects against effects of mTBI at the brain level remains largely understudied. We examined 22 OA who sustained mTBI (mean 67.69 years, SD 5.11) in the sub-acute phase and 15 age- and CR-matched healthy OA (mean 68 years, SD 5.55) performing a three-level visual N-back task using electroencephalography. We calculated inverse efficiency scores of performance from accuracy and reaction times. Event-related potentials served as neurocognitive correlates of attentional (P2) and working memory (P3) processing. Overall, mTBI OA performed worse than healthy OA (p = 0.031). Lower CR generally decreased performance (p < 0.001). Furthermore, with increasing task difficulty, task performance was more affected by CR (p = 0.004). At the brain level, P2 amplitude was lower in mTBI OA than in healthy OA (p = 0.05). There was no clear effect of CR on P2 or P3 measures. As mTBI OA with lower CR performed worse on a working-memory task, lower CR may be a risk factor for worse recovery after mTBI in this group. [ABSTRACT FROM AUTHOR]

Purpose: Traumatic brain injury (TBI) is a major cause of trauma-related visits to emergency departments (ED). Determination of monitoring requirements of patients with apparently mild TBI is challenging. Patients may turn out to be more severely injured than initially assumed, and failure to identify these patients constitutes a serious threat to patient safety. We, therefore, aimed to identify clinical risk factors for more severe injuries in patients with apparently mild TBI.Methods: In a retrospective cohort analysis performed at two level I trauma centers, 808 patients aged ≥ 16 presenting to the ED with head trauma and a Glasgow Coma Scale (GCS) score 13-15 who received a head CT scan were studied. Discrepancies between the initial TBI severity as determined by GCS and severity as determined post hoc by the Head Abbreviated Injury Score were assessed. Multiple logistic regression was used to identify risk factors of such discrepancies.Results: 104 (12.9%) patients were more severely injured than initially classified. A GCS < 15 at presentation (GCS 13: OR 6.2, [95% CI 3.8-9.9]; GCS 14: OR 2.7, [2.0-3.7]), an SpO2 < 90% (OR 5.4, [1.2-23.4]), loss of consciousness (OR 2.3, [1.5-3.5]), absence of equal and reactive pupils (OR 2.1, [1.6-2.7]), transport by ambulance (OR 2.0, [1.7-2.4]), and use of anticoagulant drugs (OR 1.2, [1.1-1.3]) were independent risk factors of more severe injury.Conclusions: Six risk factors of more severe injury in patients presenting with apparently mild TBI were identified. Patients with any of these factors should be thoroughly monitored for signs of neurologic deterioration. [ABSTRACT FROM AUTHOR]