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Primary Objective: This is Part II of a four-part opinion review on traditional neuropsychological assessment methods and findings associated with mild traumatic brain injury (mTBI). This Part II review focuses on historical, psychometric and statistical issues involving traditional neuropsychological methods that have been used in neuropsychological outcome studies of mTBI, but demonstrates the critical limitations of traditional methods., Research Design: This is an opinion review., Methods and Procedures: Traditional neuropsychological tests are dated and lack specificity in evaluating such a heterogenous and complex injury as occurs with mTBI., Main Outcome and Results: In this review, we demonstrate traditional neuropsychological methods were never developed as standalone measures for detecting subtle changes in neurocognitive or neurobehavioral functioning and likewise, never designed to address the multifaceted issues related to underlying mTBI neuropathology symptom burden from having sustained a concussive brain injury., Conclusions: For neuropsychological assessment to continue to contribute to clinical practice and outcome literature involving mTBI, major innovative changes are needed that will likely require technological advances of novel assessment techniques more specifically directed to evaluating the mTBI patient. These will be discussed in Part IV.

This study is the first to examine cognitive outcomes after pediatric mild TBI using the National Institutes of Health Toolbox Cognition Battery (NIHTB-CB), a computerized cognitive test battery. The NIHTB-CB includes two complex measures of attention and executive function that allow differentiation of accuracy and response speed. We compared performance on the NIHTB-CB among children 8-16 years of age with mild TBI ( n  = 143) versus children with orthopedic injuries (OIs; n  = 74) recruited in emergency departments and followed for 6 months post-injury. Mixed-model analyses showed that the mild TBI group showed significantly lower Fluid Cognition composite scores than the OI group at 10 days (group intercept, p  = 0.018); the magnitude of group differences declined modestly over time (group × time interaction, p  = 0.055). Effect sizes were d  = 0.34 at 10 days post-injury, d  = 0.27 at 3 months, and d  = 0.10 at 6 months. No significant effects of group or time were found for the Crystallized Cognition composite. Analyses of Fluid Cognition subtests indicated that children with mild TBI displayed deficits for as long as 3 months on measures of attention and executive function (e.g., cognitive flexibility, inhibitory control), but not on measures of explicit memory, working memory, or processing speed. The poorer performance of the mild TBI group on measures of attention and executive function was attributable largely to slowed reaction time, not decreased accuracy. The findings suggest that children with mild TBI demonstrate persistent deficits in fluid cognition that are most apparent on tasks that combine demands for both speed and executive function.

Objective: Failure on performance validity tests (PVTs) is common in Veterans with histories of mild traumatic brain injury (mTBI), leading to questionable validity of clinical presentations., Participants: Using diffusion tensor imaging, we investigated white matter (WM) integrity and cognition in 79 Veterans with history of mTBI who passed PVTs (n = 43; traumatic brain injury [TBI]-passed), history of mTBI who failed at least 1 PVT (n = 13; TBI-failed), and military controls (n = 23; MCs) with no history of TBI., Results: The TBI-failed group demonstrated significantly lower cognitive scores relative to MCs and the TBI-passed group; however, no such differences were observed between MCs and the TBI-passed group. On a global measure of WM integrity (ie, WM burden), the TBI-failed group showed more overall WM abnormalities than the other groups. However, no differences were observed between the MCs and TBI-passed group on WM burden. Interestingly, regional WM analyses revealed abnormalities in the anterior internal capsule and cingulum of both TBI subgroups relative to MCs. Moreover, compared with the TBI-passed group, the TBI-failed group demonstrated significantly decreased WM integrity in the corpus callosum., Conclusions: Findings revealed that, within our sample, WM abnormalities are evident in those who fail PVTs. This study adds to the burgeoning PVT literature by suggesting that poor PVT performance does not negate the possibility of underlying WM abnormalities in military personnel with history of mTBI., Competing Interests: The authors report no conflicts of interests.

How neuropsychological assessment findings are deemed valid has been a topic of numerous articles but few have addressed any role that neuroimaging studies could provide. Within military and various clinical samples of individuals undergoing neuropsychological evaluations, high levels of failure on measures of symptom validity testing (SVT) and/or performance validity testing (PVT) have been reported. Where 'failure' is defined as a below cut-score performance on some pre-determined set-point on a SVT/PVT measure, are such failures always indicative of invalid test findings or are there other explanations, especially based on informative neuroimaging findings? This review starts with the premise that even though the SVT/PVT task is designed to be simple and easy to perform, it nonetheless requires intact frontoparietal attention, working memory and task engagement (motivation) networks. If there is damage or pathology within any aspect of these networks as demonstrated by neuroimaging findings, the patient may perform below the cut-point as a result of the underlying damage or pathophysiology. The argument is made that neuroimaging findings should be considered as to where SVT/PVT cut-points are established and there should be much greater flexibility in SVT/PVT measures based on other personal, demographic and neuroimaging information. Several case studies are used to demonstrate these points.

The principal goal of this descriptive study was to establish the test-retest stability of the Reading, Spelling, and Arithmetic subtest scores of the Wide Range Achievement Test (WRAT-3) across two administrations in individuals with autism spectrum disorder. Participants (N = 31) were males ages 6-22 years (M = 15.2, SD = 4.0) who were part of a larger ongoing longitudinal study of brain development in children and adults with autism spectrum disorder (N = 185). Test-retest stability for all three subtests remained consistent across administration periods (M = 31.8 mo., SD = 4.1). Age at time of administration, time between administrations, and test form did not significantly influence test-retest stability. Results indicated that for research involving individuals with autism spectrum disorder with a full scale intelligence quotient above 75, the WRAT-3 Spelling and Arithmetic subtests have acceptable test-retest stability over time and the Reading subtest has moderate test-retest stability over time.

Background: To understand the neurocognitive effects of brain injury, valid neuropsychological test findings are paramount., Review: This review examines the research on what has been referred to a symptom validity testing (SVT). Above a designated cut-score signifies a 'passing' SVT performance which is likely the best indicator of valid neuropsychological test findings. Likewise, substantially below cut-point performance that nears chance or is at chance signifies invalid test performance. Significantly below chance is the sine qua non neuropsychological indicator for malingering. However, the interpretative problems with SVT performance below the cut-point yet far above chance are substantial, as pointed out in this review. This intermediate, border-zone performance on SVT measures is where substantial interpretative challenges exist. Case studies are used to highlight the many areas where additional research is needed. Historical perspectives are reviewed along with the neurobiology of effort. Reasons why performance validity testing (PVT) may be better than the SVT term are reviewed., Conclusions: Advances in neuroimaging techniques may be key in better understanding the meaning of border zone SVT failure. The review demonstrates the problems with rigidity in interpretation with established cut-scores. A better understanding of how certain types of neurological, neuropsychiatric and/or even test conditions may affect SVT performance is needed.

In 2009 Pertab, James, and Bigler published a critique of two prior meta-analyses by Binder, Rohling, and Larrabee (1997) and Frencham, Fox, and Maybery (2005) that showed small effect size difference at least 3 months post-injury in individuals who had sustained a mild traumatic brain injury (mTBI). The Binder et al. and Frencham et al. meta-analyses have been widely cited as showing no lasting effect of mTBI. In their critique Pertab et al. (2009) point out many limitations of these two prior meta-analyses, demonstrating that depending on how inclusion/exclusion criteria were defined different meta-analytic findings occur, some supporting the persistence of neuropsychological impairments beyond 3 months. Rohling et al. (2011) have now critiqued Pertab et al. (2009). Herein we respond to the Rolling et al. (2011) critique reaffirming the original findings of Pertab et al. (2009), providing additional details concerning the flaws in prior meta-analytic mTBI studies and the effects on neuropsychological performance.

Symptom validity testing (SVT) has become a major theme of contemporary neuropsychological research. However, many issues about the meaning and interpretation of SVT findings will require the best in research design and methods to more precisely characterize what SVT tasks measure and how SVT test findings are to be used in neuropsychological assessment. Major clinical and research issues are overviewed including the use of the “effort” term to connote validity of SVT performance, the use of cut-scores, the absence of lesion-localization studies in SVT research, neuropsychiatric status and SVT performance and the rigor of SVT research designs. Case studies that demonstrate critical issues involving SVT interpretation are presented.

The basic premise of symptom validity tests (SVTs) is that appropriate effort can be assessed because the designs of SVT measures are thought to be insensitive to all but the most extreme forms of impairment of memory. In patients with mild traumatic brain injury in particular, it is thought that failure on effort measures consistently reflects poor effort or even conscious exaggeration of symptoms. This study examines the issue of SVT failure as a reflection of cognitive impairment and/or neuropsychiatric impairment by presenting cases of three patients who were given full neuropsychological batteries but in each case failed the Word Memory Test (WMT), a verbal recognition SVT measure. One patient who failed the WMT was probably in the early stages of dementia. The WMT fit the "Genuine Memory Impaired Profile". Two mild traumatic brain injury patients failed the WMT but their patterns of performance suggested that cognitive deficits influenced WMT performance. In determining the validity of neuropsychological test data in the individual case, it is recommended that the examiner consider whether cognitive impairment could affect performance on effort measures and the recommended cut score. Also, it is recommended that examiners use multiple indicators of effort.

Traumatic brain injury (TBI) results in a variable degree of cerebral atrophy that is not always related to cognitive measures across studies. However, the use of different methods for examining atrophy may be a reason why differences exist. The purpose of this manuscript was to examine the predictive utility of seven magnetic resonance imaging (MRI)-derived brain volume or indices of atrophy for a large cohort of TBI patients (n = 65). The seven quantitative MRI (qMRI) measures included uncorrected whole brain volume, brain volume corrected by total intracranial volume, brain volume corrected by the ratio of the individual TICV by group TICV, a ventricle to brain ratio, total ventricular volume, ventricular volume corrected by TICV, and a direct measure of parenchymal volume loss. Results demonstrated that the various qMRI measures were highly interrelated and that corrected measures proved to be the most robust measures related to neuropsychological performance. Similar to an earlier study that examined cerebral atrophy in aging and dementia, these results suggest that a single corrected brain volume measure is all that is necessary in studies examining global MRI indicators of cerebral atrophy in relationship to cognitive function making additional measures of global atrophy redundant and unnecessary.

We present neuropsychological data from an 81-year-old individual who was followed over a six-year period, initially as a healthy control participant. She performed above age-adjusted cutoff scores for impairment on most neuropsychological tests, including learning and memory measures, until the final assessment when she received a diagnosis of probable Alzheimer's disease (AD). Despite generally normal scores on individual cognitive tests, her cognitive profile revealed increasingly large cognitive discrepancies when contrasting verbal versus visuospatial tasks, and complex versus basic-level tasks. The present case provides intriguing evidence that cognitive-discrepancy measures could improve our ability to detect subtle changes in cognition at the earliest, preclinical stages of AD.

Primary Objective: This study presents data from a functional neuroimaging experiment which brings into question whether poor performance on the Word Memory Test (WMT) can be construed as straightforward evidence for 'poor effort' in the context of cognitive assessment, as asserted in a recent report in this journal., Methods and Procedures: Functional magnetic resonance image (fMRI) data were acquired from four participants without brain injury who engaged in the delayed recognition (DR) portion of Green's WMT protocol., Outcomes and Results: Compared to a simple perceptual identification control task, this study found a highly reliable activation pattern across all participants which was restricted almost exclusively to cortical areas most commonly associated with task difficulty, memory load, concentration and other forms of cognitive effort These areas include dorsolateral prefrontal cortex, anterior insula, superior parietal cortex and the dorsal anterior cingulate., Conclusions: These findings demonstrate that the WMT activates numerous cortical regions that are critical for cognitive effort. Given the extensive neural network necessary to perform the WMT, this study raises important questions about what WMT 'failure' truly means in patients with traumatic brain injury, who have increased likelihood of disruption within this neural network of vision, language, attention, effort and working memory.

Atrophy of specific, regional, and generalized brain structures occurs as a result of the Alzheimer's disease (AD) process. Comparing AD patients with histopathological confirmation of the disease at autopsy to those without autopsy but who were clinically diagnosed using the same antemortem criteria will provide further evidence of the utility and accuracy of neuropsychological assessments at the time of diagnosis, as well as the efficacy of quantitative magnetic resonance imaging (qMRI) in demonstrating gross neuropathological changes associated with the disease. The Cache County Study of Aging provides a unique opportunity to determine how closely AD subjects with only the clinical diagnosis match similarly diagnosed AD subjects but with postmortem confirmation of the disease. qMRI volumes of various brain structures, as well as neuropsychological outcome measures from an expanded battery, were obtained in 31 autopsy-confirmed AD subjects and 45 clinically diagnosed AD subjects. Of the various qMRI variables examined, only total temporal lobe volume was different, where those with postmortem confirmation had reduced volume. No significant differences between the two groups were found with any of the neuropsychological outcome measures. These findings confirm the similarity in neuroimaging and neuropsychological assessment findings between those with just the clinical diagnosis of AD and those with an autopsy-confirmed diagnosis in the moderate-to-severe stage of the disease at the time of diagnosis.

Two recent publications in Archives of Clinical Neuropsychology (ACN) have been used by defense attorneys as the centerpiece for an argument that only a 'fixed' battery approach, exemplified by the Halstead-Reitan battery (HRB), satisfies the Daubert criteria for admissibility; and therefore, the HRB represents the only method of forensic neuropsychological assessment that should be admitted into evidence. Since this case has important implications for the practice of clinical neuropsychology in the United States, this 'Motion to Exclude' and its rationale are presented, which demonstrates how the legal profession uses neuropsychological literature. The critical issues of this argument for clinical neuropsychological practice are reviewed.

Autopsy studies were undertaken in a 47-year-old college-educated male patient who, 7 months prior to an unexpected death, had sustained a mild traumatic brain injury (TBI) as manifested by brief loss of consciousness and an initial Glasgow Coma Scale score of 14. The patient died from cardiac arrest secondary to an undiagnosed and unknown arteriosclerotic cardiovascular disease as assessed by the coroners office at the time of autopsy. Gross inspection of the brain at autopsy was normal; however, microscopic analysis demonstrated what were considered trauma findings of hemosiderin-laden macrophages in the perivascular space and macrophages in the white matter, particularly the section taken from the frontal lobe. The patient had partially returned to work at the time of death, but had encountered problems with diminished cognitive performance in his work as an appraiser. Neuropsychological studies were generally within normal limits although several tests of either speed of processing or short-term memory showed lower than expected performance. This case demonstrates the presence of subtle neuropathological changes in the brain of a patient who sustained a mild TBI and was still symptomatic for the residual effects of the injury 7 months post injury when he unexpectedly died.

This study presents normative data on the Trail Making Test Part A and the Chinese version of the Trail Making Test Part B (C-Trails B). The ages of the 110 participants ranged from 21 to 75 (M = 48, SD = 14.7) and years of education from 1 to 20 (M = 12, SD = 5). No gender effects were found on the test scores; however, age and education were significantly associated with scores on both Trails A (p < .01) and C-Trails B (p < .01). Results also suggest a high correlation (Pearson r = .69) between C-Trails B and the Digit Symbol-Coding subtest of the Wechsler Adult Intelligence Scale-Third Edition. In light of our earlier study, this finding provides further evidence that C-Trails B may be equivalent to the standard Trails B. Findings also demonstrate a need for norms adjusted for both age and education for adults whose primary language is Chinese.

Traumatic brain injury (TBI) is common among military personnel and the civilian population and is often followed by a heterogeneous array of clinical, cognitive, behavioral, mood, and neuroimaging changes. Unlike many neurological disorders that have a characteristic abnormal central neurologic area(s) of abnormality pathognomonic to the disorder, a sufficient head impact may cause focal, multifocal, diffuse or combination of injury to the brain. This inconsistent presentation makes it difficult to establish or validate biological and imaging markers that could help improve diagnostic and prognostic accuracy in this patient population. The purpose of this manuscript is to describe both the challenges and opportunities when conducting military-relevant TBI research and introduce the Enhancing NeuroImaging Genetics through Meta-Analysis (ENIGMA) Military Brain Injury working group. ENIGMA is a worldwide consortium focused on improving replicability and analytical power through data sharing and collaboration. In this paper, we discuss challenges affecting efforts to aggregate data in this patient group. In addition, we highlight how "big data" approaches might be used to understand better the role that each of these variables might play in the imaging and functional phenotypes of TBI in Service member and Veteran populations, and how data may be used to examine important military specific issues such as return to duty, the late effects of combat-related injury, and alteration of the natural aging processes.

Personality change due to traumatic brain injury (PC) in children is an important psychiatric complication of injury and is a form of severe affective dysregulation. This study aimed to examine neurocognitive correlates of PC. The sample included 177 children 5-14 years old with traumatic brain injury who were enrolled from consecutive admissions to five trauma centers. Patients were followed up prospectively at baseline and at 6 months, and they were assessed with semistructured psychiatric interviews. Injury severity, socioeconomic status, and neurocognitive function (measures of attention, processing speed, verbal memory, IQ, verbal working memory, executive function, naming/reading, expressive language, motor speed, and motor inhibition) were assessed with standardized instruments. Unremitted PC was present in 26 (18%) of 141 participants assessed at 6 months postinjury. Attention, processing speed, verbal memory, IQ, and executive function were significantly associated with PC even after socioeconomic status, injury severity, and preinjury attention deficit hyperactivity disorder were controlled. These findings are a first step in characterizing concomitant cognitive impairments associated with PC. The results have implications beyond brain injury to potentially elucidate the neurocognitive symptom complex associated with mood instability regardless of etiology.

This study aimed to better understand the occurrence of novel psychiatric disorders (NPDs) in children with mild traumatic brain injury (mTBI) in relation to preinjury variables, injury-related variables, and concurrent neurocognitive outcome. Eighty-seven children aged 5-14 years who had experienced mTBI were studied from consecutive hospital admissions with semistructured psychiatric interviews soon after injury (baseline). Fifty-four children were reassessed 24 months postinjury. Standardized instruments were used to evaluate injury severity, lesion characteristics, preinjury variables (lifetime psychiatric disorder, family psychiatric history, family function, socioeconomic status, psychosocial adversity, adaptive function, and academic function), and finally, postinjury neurocognitive and adaptive function. At 24 months postinjury, NPDs had occurred in 17 of 54 (31%) participants. NPD at 24 months was related to frontal white matter lesions and was associated with estimated preinjury reading, preinjury adaptive function, and concurrent deficits in reading, processing speed, and adaptive function. These findings extend earlier reports that the psychiatric morbidity after mTBI in children is more common than previously thought, and moreover, it is linked to preinjury individual variables and injury characteristics and is associated with postinjury adaptive and neurocognitive functioning.

The objective of this study was to understand how novel psychiatric disorders (NPD) in children with mild traumatic brain injury (MTBI) are related to pre-injury variables, injury-related variables, and concurrent neurocognitive outcome. A group of 79 children, ages 5 to 14 years, who had experienced MTBI, were studied from consecutive hospital admissions with semistructured psychiatric interviews soon after injury (baseline); 60 children were reassessed 12 months post-injury. Standardized instruments were used to assess injury severity; lesion characteristics; pre-injury variables, including psychiatric disorder, family psychiatric history, family functioning, socioeconomic status, psychosocial adversity, adaptive functioning, and post-injury neurocognitive and adaptive functioning. NPD occurred in 17 of 60 participants (28%) in the 6-12-month interval after injury, with disorders that were significantly associated with socioeconomic status, psychosocial adversity, estimated pre-injury academic functioning, and concurrent deficits in adaptive functioning, academic performance, processing speed, memory, and expressive language. NPD was not significantly associated with pre-injury adaptive functioning, injury severity, family psychiatric history, pre-injury psychiatric disorder, lesion location, gender, or age at injury. These findings suggest that the short-term psychiatric morbidity associated with MTBI in children occurs more commonly than previously reported and is related to both pre-injury social factors and concurrent neurocognitive functioning.

To determine if history of mild traumatic brain injury (mTBI) is associated with advanced or accelerated brain aging among the United States (US) military Service Members and Veterans. Eight hundred and twenty-two participants (mean age = 40.4 years, 714 male/108 female) underwent MRI sessions at eight sites across the US. Two hundred and one participants completed a follow-up scan between five months and four years later. Predicted brain ages were calculated using T1-weighted MRIs and then compared with chronological ages to generate an Age Deviation Score for cross-sectional analyses and an Interval Deviation Score for longitudinal analyses. Participants also completed a neuropsychological battery, including measures of both cognitive functioning and psychological health. In cross-sectional analyses, males with a history of deployment-related mTBI showed advanced brain age compared to those without (t(884) = 2.1, p =.038), while this association was not significant in females. In follow-up analyses of the male participants, severity of posttraumatic stress disorder (PTSD), depression symptoms, and alcohol misuse were also associated with advanced brain age. History of deployment-related mTBI, severity of PTSD and depression symptoms, and alcohol misuse are associated with advanced brain aging in male US military Service Members and Veterans. [ABSTRACT FROM AUTHOR]

BACKGROUND: Quantitative neuroimaging analyses have the potential to provide additional information about the neuropathology of traumatic brain injury (TBI) that more thoroughly informs the neurorehabilitation clinician. OBJECTIVE: Quantitative neuroimaging is typically not covered in the standard radiological report, but often can be extracted via post-processing of clinical neuroimaging studies, provided that the proper volume acquisition sequences were originally obtained. METHODS: Research and commercially available quantitative neuroimaging methods provide region of interest (ROI) quantification metrics, lesion burden volumetrics and cortical thickness measures, degree of focal encephalomalacia, white matter (WM) abnormalities and residual hemorrhagic pathology. If present, diffusion tensor imaging (DTI) provides a variety of techniques that aid in evaluating WM integrity. Using quantitatively identified structural and ROI neuropathological changes are most informative when done from a neural network approach. RESULTS: Viewing quantitatively identifiable damage from a neural network perspective provides the neurorehabilitation clinician with an additional tool for linking brain pathology to understand symptoms, problems and deficits as well as aid neuropsychological test interpretation. All of these analyses can be displayed in graphic form, including3-D image analysis. A case study approach is used to demonstrate the utility of quantitative neuroimaging and network analyses in TBI. CONCLUSIONS: Quantitative neuroimaging may provide additional useful information for the neurorehabilitation clinician. [ABSTRACT FROM AUTHOR]

BACKGROUND: An early approach to cognitive rehabilitation therapy (CRT) was developed based on A. R. Luria's theory of brain function. Expanding upon this approach, the Integrative Cognitive Rehabilitation Psychotherapy model (ICRP) was advanced. OBJECTIVE: To describe the ICRP approach to treatment of clients post brain injury and provide a comprehensive list of evaluation tools to determine the client's abilities and needs. Finally, to provide a link between CRT and functional imaging studies designed to improve rehabilitation efforts. METHODS: History of cognitive rehabilitation and neuropsychological testing is reviewed and description of cognitive, academic, psychiatric, and substance abuse tools are provided. Cognitive and emotional treatment techniques are fully described. Additionally, a method of determining the client's stage of recovery and pertinent functional imaging studies is detailed. RESULTS: Authors have been able to provide a set of tools and techniques to use in comprehensive treatment of clients with brain injury. CONCLUSIONS: Inclusive treatment which is outlined in the ICRP model is optimal for the client's recovery and return to a full and satisfying life post brain injury. The model provides a framework for neuropsychologists to integrate issues that tend to co-occur in clients living with brain injury into a unified treatment plan. [ABSTRACT FROM AUTHOR]

Harvey S. Levin obtained his Bachelor's degree from City College of New York, in New York city, Ph.D. in Clinical Psychology from the University of Iowa, in Iowa City, completed his internships in Clinical Neuropsychology and Pediatric Psychology at the University of Iowa Hospitals in Iowa City and Clinical Psychology, Psychiatry and Pediatrics at the Illinois Masonic Medical Center in Chicago, and his fellowship in Neuropsychology at University of Iowa Hospitals in Iowa City. Dr. Levin started his career in 1972 as Instructor with the Department of Psychology at the University of Iowa and transitioned to The University of Texas Medical Branch (UTMB) in Galveston, Texas, in 1974, where he began an internationally renowned career in clinical work, teaching, and, most of all, pioneering research on traumatic brain injury (TBI). He ultimately became the Chela and Jimmy Storm Distinguished Professor in Surgical Research, Division of Neurosurgery, Department of Surgery in 1987. After leaving Texas for two years to take a position with the University of Maryland Medical System and Shock Trauma Institute in Baltimore, he moved back to Houston Texas in 1995 and established the Cognitive Neuroscience Laboratory (CNL) within the Department of Physical Medicine & Rehabilitation at Baylor College of Medicine, which was supported by federal grants, including funding from the National Institutes of Health, Department of Defense, Department of Veterans Affairs, and Centers for Disease Control and Prevention, and numerous private foundations. The CNL integrated rehabilitation and neuroplasticity research with multimodality brain imaging, clinical and neuropsychological assessment, and fluid biomarkers. Dr. Levin was Professor with the Departments of Physical Medicine and Rehabilitation where he served as Director of Research (1995-2014), Pediatrics, and Neurosurgery at Baylor College of Medicine. He was also a Research Scientist and the Director of the Center of Excellence for Traumatic Brain Injury at the Michael E. DeBakey Veterans Affairs Medical Center (2008-2013), and Adjunct Professor with the Department of Psychology at Rice University in Houston, Texas. Dr. Levin's research focused on investigating both acute and long-term outcomes of mild to severe TBI in civilian and military populations, including cognitive and behavioral sequelae in relation to neuropathology using advanced brain imaging modalities. He began prospective, longitudinal studies of adults and children who had sustained TBI associated with closed head trauma upon joining UTMB and developed, in collaboration with Drs O'Donnell and Grossman, the Galveston Orientation and Amnesia Test (GOAT). The GOAT was the first measure to assess post-traumatic amnesia and orientation following moderate to severe TBI, is still most widely used by the clinicians and researchers, and it has been translated to 16 languages. The original publication, "Levin HS, O'Donnell VM, Grossman RG. The Galveston Orientation and Amnesia Test. A practical scale to assess cognition after head injury. J Nerv Ment Dis. 1979 Nov;167(11):675-84. doi: 10.1097/00005053-197911000-00004. PMID: 501342", has over 1200 citations. This work continued with participation in the NINDS Traumatic Coma Data Bank and the organization of outcome assessments for NINDS-funded clinical trials of hypothermia to treat severe TBI. To monitor the quality of outcome data across performing sites, Dr. Levin and colleagues developed a code for the reliability of data collected and implemented the role of an outcome monitor who evaluated adherence to protocol across sites. Following establishment of the CNL, he pursued investigation of TBI outcomes across the lifespan using multimodality brain imaging and biomarkers, errorless learning, translational studies in collaboration with neuroscientists using animal models, and clinical trials of methylphenidate, progesterone, CDP-choline. Dr. Levin spent over 30 years researching neurobehavioral outcomes of head injury in children, starting with a small pilot study funded by the Shriners Hospital in 1991 and continuing with several cycles of a multicenter R01 grant funded by the National Institute of Health. In later years, he used his expertise as a member of several large consortiums, including the Long-term Impact of Military-Relevant Brain Injury Consortium \ Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC) funded by the VA and DoD and the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) funded by the NINDS. During his career, Dr. Levin authored and coauthored more than 400 articles in scientific journals and over 100 books, with one of them, "Levin, H. S., Benton, A. L., & Grossman, R. G. (1982). Neurobehavioral consequences of closed head injury. Oxford University Press, USA", having over 1100 citation, as well as book chapters that advanced knowledge of TBI, epilepsy, neurodegenerative diseases, and other illnesses that affect brain functioning. He was also very active as a reviewer on federal grant panels and as an editor and reviewer for the Journal of Neurotrauma, Journal of Clinical and Experimental Neuropsychology, Archives of Physical Medicine & Rehabilitation, Neuropsychology, Journal of the International Neuropsychological Society, Lancet, JAMA, Pediatrics, and other top-cited journals. He served as president of the International Neuropsychological Society in 1989-1990. Dr. Levin was a recipient of numerous prestigious awards, including the Javits Neuroscience Investigator Award, the Jennett-Plum Award for Research on Traumatic Brain Injury, the Distinguished Career Award by the International Neuropsychological Society, the American Congress of Rehabilitation Gold Key Award, the Distinguished Lifetime Contribution to Neuropsychology Award from the National Academy of Neuropsychology, as well as awards from other head injury and psychological organizations, including the International Brain Injury Association, the National Head Injury Foundation, the North American Brain Injury Society, Texas Psychological Association, and the Defense and Veterans Brain Injury Center. In addition to his stellar scientific accomplishments, Dr. Levin trained, mentored, and provided supervision to interns, fellows, postdocs, residents, medical and psychology students. He was the Director of an NCMRR/NIH T32 Postdoctoral Research Program, and training supervisor in neuropsychology for Baylor College of Medicine and for the Memorial Hermann TIRR Neuropsychology Postdoctoral Fellowship Programs. A passionate educator, he taught classes at Baylor College of Medicine, the University of Houston, and the National and Kapodistrian University of Athens Medical School in Greece and served as an evaluator for the American Board of Clinical Neuropsychology/American Board of Professional Psychology. He was often invited as a lecturer at numerous scientific organizations. The main objective of this symposium is to provide an overview of the current state of research in TBI while highlighting Dr. Levin's contributions to this field. The symposium will start with a brief overview of Dr. Levin's career (Dr. Randall S. Scheibel), followed by presentations focused on the assessment of adult TBI, including posttraumatic amnesia (Dr. Felicia C. Goldstein), the current state of pediatric TBI (Dr. L. Ewing-Cobbs), and novel imaging in TBI (Dr. Erin D. Bigler). There will be a brief discussion session at the end lead by Dr. Elisabeth A. Wilde. [ABSTRACT FROM AUTHOR]

Objectives: Complicated mild traumatic brain injury (mTBI) or cmTBI is based on the presence of visibly identifiable brain pathology on the day-of-injury computed tomography (CT) scan. In a paediatric sample the relation of DOI CT to late MRI findings and neuropsychological outcome was examined. Methods: MRI (>12 months) was obtained in paediatric cmTBI patients and a sample of orthopaedically injured (OI) children. Those children with positive imaging findings (MRI+) were quantitatively compared to those without (MRI−) or with the OI sample. Groups were also compared in neurocognitive outcome from WASI sub-tests and the WISC-IV Processing Speed Index (PSI), along with the Test of Everyday Attention for Children (TEA-Ch) and a parent-rated behavioural functioning measure (ABAS-II). Results: Despite the MRI+ group having significantly more DOI CT findings than the MRI− group, no quantitative differences were found. WASI Vocabulary and Matrix Reasoning scores were significantly lower, but not PSI, TEA-Ch or ABAS-II scores. MRI+ and MRI− groups did not differ on these measures. Conclusions: Heterogeneity in the occurrence of MRI-identified focal pathology was not associated with uniform changes in quantitative analyses of brain structure in cmTBI. Increased number of DOI CT abnormalities was associated with lowered neuropsychological performance. [ABSTRACT FROM PUBLISHER]

Neuropsychological assessments of outcome after traumatic brain injury (TBI) are often unrelated to self-reported problems after TBI. The current study cluster-analyzed the Wechsler Adult Intelligence Scale–Third Edition (WAIS–III) subtest scores from mild, moderate, and severe TBI (n= 220) and orthopedic injury control (n= 95) groups, to determine whether specific cognitive profiles are related to people’s perceived outcomes after TBI. A two-stage cluster analysis produced 4- and 6-cluster solutions, with the 6-cluster solution better capturing subtle variations in cognitive functioning. The 6 clusters differed in the levels and profiles of cognitive performance, self-reported recovery, and education and injury severity. The findings suggest that subtle cognitive impairments after TBI should be interpreted in conjunction with patient’s self-reported problems. [ABSTRACT FROM PUBLISHER]

ABSTRACT The integrity of the fornix using diffusion tensor imaging (DTI) in adolescent participants with acute mild traumatic brain injury (mTBI) compared to a demographically matched control group was examined. Fractional anisotropy (FA) in the fornix was elevated in the mild traumatic brain injured group. Performance on the Automated Neuropsychological Assessment Metrics (ANAM) was lower in the group with mTBI. A relation was found between lower performance on cognitive tasks and higher FA. The potential role of fornix injury as a basis of memory and processing speed deficits in mTBI is discussed. [ABSTRACT FROM AUTHOR]

Objectives: The aim was to determine if there are changes in the integrity and volume of the ventral striatum following severe traumatic brain injury (TBI) and if these changes relate to executive functioning. Methods: This study recruited 14 participants with severe TBI (mean age: 22 years) and 15 demographically-matched controls. All participants underwent magnetic resonance imaging with diffusion tensor imaging (DTI) and volumetric analysis at 6 months post-injury. Participants with TBI underwent neuropsychological testing and the relation between imaging data and cognitive performance was examined. Results: Differences in DTI parameters (fractional anisotropy (FA) and apparent diffusion coefficient (ADC)) were found between participants with TBI and controls. Correlations between right and left ventral striatum ADC and the executive functioning factor of the Neurobehavioural Rating Scale-Revised (NRS-R) were found. Correlations between right ventral striatum FA and the Controlled Oral Word Association Test, Trails Making Test Part B (TMT-B) time and NRS-R executive functioning factor were also found. Volumetric analysis showed a difference only in left nucleus accumbens between TBI and control groups. Conclusions: The integrity of the ventral striatum is affected following severe TBI. Decreases in executive functioning are related to damage to the ventral striatum and its associated structures. [ABSTRACT FROM AUTHOR]

Primary objective: The Word Memory Test (WMT) is a popular symptom validity test in which individuals are required to remember and recall semantically-related word pairs. Research shows successful WMT completion employs a wide neural network which is involved in tasks requiring high cognitive effort. The primary purpose of this study was to replicate earlier fMRI findings using a larger sample and extend previous findings by including male and female subjects. The second purpose was to investigate the neural networks involved during intentional malingering on the WMT. Research design: For all trials, a time-series ANCOVA design was implemented using SPM5 software. Methods and procedures: Ten subjects (five male and five female) underwent fMRI imaging while completing the WMT in full-effort and simulated poor effort conditions. Main outcome and results: Full-effort trials found activation peaks in dorsolateral prefrontal cortex, superior parietal lobe, anterior cingulate, bilateral lingual cortices and anterior insula/frontal operculum, supporting earlier findings. Simulated poor effort trials had similar foci of activation, with additional peak strength in surrounding cortical regions identified previously as relevant to simulated malingering. No sex differences were observed in either condition. Conclusions: These findings demonstrate the neural underpinnings of WMT performance in normal and simulated performance. [ABSTRACT FROM AUTHOR]

Abstract: This study assessed the effects of carbon monoxide (CO) poisoning on the corpus callosum (CC). Sixty-two CO-poisoned patients had MRI scans and a battery of neuropsychological tests within 24 h (day of exposure) of CO poisoning and at 6 months post CO exposure. Serial quantitative magnetic resonance imaging (QMRI) analysis of the CC was carried out, with the day of exposure scans compared to the 6-month scans. There was no difference between normal subjects' CC and the baseline scans in the CO-poisoned patients. We detected a 15-mm2 loss in the cross-sectional surface area of the CC between baseline and the 6-month follow-up scans. The effect on the CC was generalized atrophy rather than CC subregion-specific changes. Neuropsychological test results performed at baseline and at 6 months did not correlate with the level of CC atrophy. Independent of any CC effects, the patients exhibited impaired memory, attention, and executive functioning on baseline testing, with variable improvement in cognitive function at 6 months. Quantitative MRI analysis allows for the detection of subtle CC changes that may not otherwise be observed following CO poisoning. The long-term effects of CO on the brain have been historically underestimated; however, we found subtle but significant CC atrophy and cognitive impairments following CO poisoning. [ABSTRACT FROM PUBLISHER]

This study examined an equivalent of Trail Making Test Part B for native Chinese speakers. Digit Symbol Coding and Trail Making Test Parts A and B were administered to American and Chinese students from an American university. The Chinese group also took a modified Trails B test where numbers in Chinese characters replaced English letters. Independent-samples t tests showed no difference between American and Chinese groups on the Digit Symbol Coding and Trails A, but a difference on Trails B (p <> . [ABSTRACT FROM AUTHOR]

Carbon monoxide (CO) poisoning has been shown to result in neuropathologic changes and cognitive impairments due to anoxia and other related biochemical mechanisms. The present study investigated brain-behaviour relationships between neuropsychological outcome and SPECT, MRI, and Quantitative magnetic resonance imaging (QMRI) in 21 patients with CO poisoning. Ninety-three per cent of the patients exhibited a variety of cognitive impairments, including impaired attention, memory, executive function, and mental processing speed. Ninety-five per cent of the patients experienced affective changes including depression and anxiety. The results from the imaging studies revealed that 38% of the patients had abnormal clinical MRI scans, 67% had abnormal SPECT scans, and 67% had QMRI findings including hippocampal atrophy and/or diffuse cortical atrophy evidenced by an enlarged ventricle-to-brain ratio (VBR). Hippocampal atrophy was also found on QMRI. SPECT and QMRI appear to be sensitive tools which can be used to identify the neuropathological changes and cerebral perfusion defects which occur following CO poisoning. Cerebral perfusion defects include frontal and temporal lobe hypoperfusion. Significant relationships existed between the various imaging techniques and neuropsychological impairments. The data from this study indicate that a multi-faceted approach to clinical evaluation of the neuropathological and neurobehavioural changes following CO poisoning may provide comprehensive information regarding the neuroanatomical and neurobehavioural effects of CO poisoning. [ABSTRACT FROM AUTHOR]

The article cites a study which examined the relationship between "poor" and "well" adjusted chronic diabetic patients on the Halstead-Reitan Neuropsychological Test Battery (HRNTB), Wechsler Adult Intelligence Scale (WAIS), and Wechsler Memory Scale (WMS). Subjects were 39 juvenile onset (Type I) diabetics between the ages of 18 and 47 and were the same subjects reported on in a previous study. The HRNTB was used to assess neuropsychological functioning. The battery consists of a number of independent tests, which evaluate different areas of neuropsychological functioning including sensory-perceptual, motor, language and cognitive abilities.

This article cites a study in Austin, Texas that obtained comprehensive neuropsychometric measures in diabetic patients in whom duration and severity of the diabetic condition was controlled. Researchers compared two groups of Type I diabetics, visually impaired and non-visually impaired, to a non-neurologic chronically ill group and a healthy group on the Halstead-Reitan Neuropsychological Test Battery and the Wechsler Adult Intelligence Scale. The diabetic groups performed like each other and worse than the other two groups on somatosensory examination, motor strength, and motor speed tasks.