Neuropsychological results and neuropathological findings at autopsy in a case of mild traumatic brain injury

Departments of Psychology and Neuroscience, Brigham Young University, Provo, Utah 84602, USA.
Journal of the International Neuropsychological Society (Impact Factor: 2.96). 10/2004; 10(5):794-806. DOI: 10.1017/S1355617704105146
Source: PubMed


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.

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    • ", 1992 ; Povlishock and Katz , 2005 ) . Autopsy studies have demonstrated other micro - scopic findings in mild TBI , such as macrophages in the perivascular space and white matter , especially in the frontal lobe ( Bigler , 2004 ) . As discussed above under Complicated mild TBI , various forms of focal pathology may also occur in a small proportion of patients who oth - erwise fit clinical criteria for mild TBI . "
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    ABSTRACT: Mild traumatic brain injury (TBI) is common but accurate diagnosis and defining criteria for mild TBI and its clinical consequences have been problematic. Mild TBI causes transient neurophysiologic brain dysfunction, sometimes with structural axonal and neuronal damage. Biomarkers, such as newer imaging technologies and protein markers, are promising indicators of brain injury but are not ready for clinical use. Diagnosis relies on clinical criteria regarding depth and duration of impaired consciousness and amnesia. These criteria are particularly difficult to confirm at the least severe end of the mild TBI continuum, especially when relying on subjective, retrospective accounts. The postconcussive syndrome is a controversial concept because of varying criteria, inconsistent symptom clusters and the evidence that similar symptom profiles occur with other disorders, and even in a proportion of healthy individuals. The clinical consequences of mild TBI can be conceptualized as two multidimensional disorders: (1) a constellation of acute symptoms that might be termed early phase post-traumatic disorder (e.g., headache, dizziness, imbalance, fatigue, sleep disruption, impaired cognition), that typically resolve in days to weeks and are largely related to brain trauma and concomitant injuries; (2) a later set of symptoms, a late phase post-traumatic disorder, evolving out of the early phase in a minority of patients, with a more prolonged (months to years), sometimes worsening set of somatic, emotional, and cognitive symptoms. The later phase disorder is highly influenced by a variety of psychosocial factors and has little specificity for brain injury, although a history of multiple concussions seems to increase the risk of more severe and longer duration symptoms. Effective early phase management may prevent or limit the later phase disorder and should include education about symptoms and expectations for recovery, as well as recommendations for activity modifications. Later phase treatment should be informed by thoughtful differential diagnosis and the multiplicity of premorbid and comorbid conditions that may influence symptoms. Treatment should incorporate a hierarchical, sequential approach to symptom management, prioritizing problems with significant functional impact and effective, available interventions (e.g., headache, depression, anxiety, insomnia, vertigo). © 2015 Elsevier B.V. All rights reserved.
    Handbook of Clinical Neurology 12/2015; 127C:131-156. DOI:10.1016/B978-0-444-52892-6.00009-X
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    • "majority of those scanned with mTBI have no CT-identified abnormality (Lee et al. 2008; Van Boven et al. 2009). Importantly, a growing number of post-mortem studies demonstrate subtle brain pathology in mTBI (Bigler 2004; Blumbergs et al. 1994; Oppenheimer 1968) (see also the Bigler and Maxwell review in this special issue) and in sports related chronic traumatic encephalopathy (McKee et al. 2010; Omalu et al. 2010). Thus subtle underlying neuropathology reported in post-mortem studies in mTBI does not provide information useful for the diagnosis, monitoring of recovery, and/or investigating treatment outcome in mTBI as is now possible using novel in vivo neuroimaging techniques , which hold great promise in providing biomarker information to detect brain injury that will help to advance our understanding of mTBI. "
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    ABSTRACT: Contemporary neuroimaging methods and research findings in mild traumatic brain injury (mTBI) are reviewed in this special issue. Topics covered include structural and functional neuroimaging techniques with a particular emphasis on the most contemporary research involving magnetic resonance imaging (MRI). Future research directions as well as applied applications of using neuroimaging techniques to define biomarkers of brain injury are covered.
    Brain Imaging and Behavior 06/2012; 6(2):103-7. DOI:10.1007/s11682-012-9185-0 · 4.60 Impact Factor
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    • "Group differences were, however , observed for the corpus callosum and the internal capsule, where fractional anisotropy (FA) was reduced in the mTBI group compared with controls. Importantly, the latter findings are consistent with histopathology findings in mTBI patients who died from other causes (e.g., Adams et al. 1989; Bigler 2004; Blumbergs et al. 1994; Oppenheimer 1968). These investigators concluded that DTI is an important early indicator of brain injury in mTBI and has the potential for being an important prognostic indicator of later injury. "
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    ABSTRACT: Mild traumatic brain injury (mTBI), also referred to as concussion, remains a controversial diagnosis because the brain often appears quite normal on conventional computed tomography (CT) and magnetic resonance imaging (MRI) scans. Such conventional tools, however, do not adequately depict brain injury in mTBI because they are not sensitive to detecting diffuse axonal injuries (DAI), also described as traumatic axonal injuries (TAI), the major brain injuries in mTBI. Furthermore, for the 15 to 30 % of those diagnosed with mTBI on the basis of cognitive and clinical symptoms, i.e., the "miserable minority," the cognitive and physical symptoms do not resolve following the first 3 months post-injury. Instead, they persist, and in some cases lead to long-term disability. The explanation given for these chronic symptoms, i.e., postconcussive syndrome, particularly in cases where there is no discernible radiological evidence for brain injury, has led some to posit a psychogenic origin. Such attributions are made all the easier since both posttraumatic stress disorder (PTSD) and depression are frequently co-morbid with mTBI. The challenge is thus to use neuroimaging tools that are sensitive to DAI/TAI, such as diffusion tensor imaging (DTI), in order to detect brain injuries in mTBI. Of note here, recent advances in neuroimaging techniques, such as DTI, make it possible to characterize better extant brain abnormalities in mTBI. These advances may lead to the development of biomarkers of injury, as well as to staging of reorganization and reversal of white matter changes following injury, and to the ability to track and to characterize changes in brain injury over time. Such tools will likely be used in future research to evaluate treatment efficacy, given their enhanced sensitivity to alterations in the brain. In this article we review the incidence of mTBI and the importance of characterizing this patient population using objective radiological measures. Evidence is presented for detecting brain abnormalities in mTBI based on studies that use advanced neuroimaging techniques. Taken together, these findings suggest that more sensitive neuroimaging tools improve the detection of brain abnormalities (i.e., diagnosis) in mTBI. These tools will likely also provide important information relevant to outcome (prognosis), as well as play an important role in longitudinal studies that are needed to understand the dynamic nature of brain injury in mTBI. Additionally, summary tables of MRI and DTI findings are included. We believe that the enhanced sensitivity of newer and more advanced neuroimaging techniques for identifying areas of brain damage in mTBI will be important for documenting the biological basis of postconcussive symptoms, which are likely associated with subtle brain alterations, alterations that have heretofore gone undetected due to the lack of sensitivity of earlier neuroimaging techniques. Nonetheless, it is noteworthy to point out that detecting brain abnormalities in mTBI does not mean that other disorders of a more psychogenic origin are not co-morbid with mTBI and equally important to treat. They arguably are. The controversy of psychogenic versus physiogenic, however, is not productive because the psychogenic view does not carefully consider the limitations of conventional neuroimaging techniques in detecting subtle brain injuries in mTBI, and the physiogenic view does not carefully consider the fact that PTSD and depression, and other co-morbid conditions, may be present in those suffering from mTBI. Finally, we end with a discussion of future directions in research that will lead to the improved care of patients diagnosed with mTBI.
    Brain Imaging and Behavior 03/2012; 6(2). DOI:10.1007/s11682-012-9156-5 · 4.60 Impact Factor
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