Brain Injury

Published by Informa Healthcare
Online ISSN: 1362-301X
Print ISSN: 0269-9052
The aim of the study was to investigate the effects of using low-dose mannitol (0.3 g kg(-1)) on the pulsatility index (PI) and minimum diastolic blood flow velocity (FV-min) of the middle cerebral artery in a traumatic brain injury (TBI). Low-dose mannitol (0.3 g kg(-1)) was administered to a group of 20 patients with a TBI. Transcranial Doppler (TCD) ultrasonography was used to monitor the PI and FV-min. The study included patients with a diffuse traumatic brain injury and Glasgow coma score < 8. The initial TCD ultrasonography values were pathological (PI > 1.4 and FV-min < 20 cm s(-1)). TCD ultrasonography examinations were carried out before mannitol administration, immediately after administration and 1, 2 and 3 hours after the administration of mannitol. A one-way analysis of variance revealed significant changes in the PI (F = 8.392; p < 0.001) and FV-min (F = 8.291; p = 0.001) after the use of mannitol. Low-dose mannitol administration appears to be efficacious for improving the indicators of disturbed circulation in a TBI (FV-min increase, PI decrease). The maximum decrease in the PI was recorded 1 hour after the administration of mannitol and was 10.9% of the initial value. The maximum increase in the FV-min was recorded 1 hour after administration and was 29.7% of the initial value. These changes were significant ∼ 2 hours later.
To analyse serum concentrations of two biochemical markers of brain tissue damage, S-100B and NSE (neurone-specific enolase), in male soccer players in connection to the game. Blood samples were taken in players before and after a competitive game and the numbers of headers and of trauma events during soccer play were assessed. Both S-100B and NSE were significantly raised in serum samples obtained after the game in comparison with the pre-game values (S-100B: 0.118 +/- 0.040 microg L(-1) vs 0.066 +/- 0.025 microg L(-1), p < 0.001; NSE: 10.29 +/- 2.16 microg L(-1) vs 8.57 +/- 2.31 microg L(-1), p < 0.001). Only changes in S-100B concentrations (post-game minus pre-game values) were statistically significantly correlated to the number of headers (r = 0.428, p = 0.02) and to the number of other trauma events (r = 0.453, p = 0.02). Playing competitive elite soccer was found to cause increase in serum concentrations of S-100B and NSE. Increases in S-100B were significantly correlated to the number of headers, and heading may accordingly have contributed to these increases.
Serum S-100B protein is an established biochemical marker of traumatic brain injury. At the same time, the question of extra-cranial S-100B release has been raised. This study evaluates the post-traumatic and post-operative release kinetics of S-100B in 45 trauma victims without head injury. Serum S-100B protein was measured on admission and every 24 hours for 4 consecutive days. Initial S-100B was slightly increased (median: 0.54 microg L-1) and correlated with the severity of extra-cranial trauma (p = 0.0004, Mann-Whitney test). Both severely (abdominal or chest trauma with or without bone fractures) and mildly (long bone fractures) injured showed a rapid decline of S-100B (< 0.2 microg L-1) around 72 hours post-trauma. Extra-cranial surgery caused a secondary increase of S-100B, especially in the mildly injured group (p = 0.004, Wilcoxon signed rank test). Extra-cranial injury results in a mild elevation of serum S-100B protein that declines rapidly (1-3 days after injury).
S-100B protein is a new possible indicator of brain damage after severe head injury. In outcome assessment there is an increasing focus on measures of health outcome incorporating the person's own perspective. Therefore, the aim of the study was to investigate the correlation of early S-100B serum level to the quality of life. fifty-one patients with severe head injury were included in a prospective study. Blood samples were taken on admission (mean 2.5 hours). The outcome was assessed at follow-up using the Glasgow Outcome Scale and a questionnaire according to Blau to assess the quality of life. high serum concentrations of S-100B on admission correlate to unfavourable outcome according to the GOS (4.9 micro g/l vs 1.6 micro g/l, mean, p < 0.0008). In addition, the S-100B serum concentrations on admission correlate to quality of life in the survivor group. Patients with S-100B serum levels < or = 0.5 micro g/l scored 71.4 points (mean) on the QoL index compared to patients with elevated S-100B concentrations, who scored 55.4 points (mean, p < 0.05). S-100B seems to be able to assess the extent of primary brain damage after trauma.
To determine the relationship of serum S-100B and C-tau levels to long-term outcome after mild traumatic brain injury (mild TBI). A prospective study of 35 mild TBI subjects presenting to the emergency department. Six hour serum S-100B and C-tau levels compared to 3-month Rivermead Post Concussion Questionnaire (RPCQ) scores and post-concussive syndrome (PCS). The linear correlation between marker levels and RPCQ scores was weak (S-100B: r = 0.071, C-tau: r = -0.21). There was no statistically significant correlation between marker levels and 3-month PCS (S-100B: AUC = 0.589, 95%CI. 038, 0.80; C-tau: AUC = 0.634, 95%CI 0.43, 0.84). The sensitivity of these markers ranged from 43.8-56.3% and the specificity from 35.7-71.4%. Initial serum S-100B and C-tau levels appear to be poor predictors of 3-month outcome after mild TBI.
Temporal profile of ICP, S-100B and NSE during the first 5 days after injury. Values are mean ± SEM.  
The correlation of S-100B max (r ¼ 0.69, p50.001) and NSE max (r ¼ 0.57, p50.0001) (Pearson's correlation) levels with ICP max . Logarithmic values for the biomarker were used in calculation of r and p.  
The correlation of S-100B max (r ¼ À0.63, p50.0001) and NSE max (r ¼ À0.56, p50.0001) (Pearson's correlation) levels with CPP min . Logarithmic values for the biomarker were used in calculation of r and p.  
Objective: The association was studied of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) on S-100B and neuron-specific enolase (NSE) in severe traumatic brain injury (sTBI). The relationship was explored between biomarkers, ICP, CPP, CT-scan classifications and the clinical outcome. Materials and methods: Data were collected prospectively and consecutively in 48 patients with Glasgow Coma Scale score ≤ 8, age 15-70 years. NSE and S-100B were analysed during 5 consecutive days. The initial and follow-up CT-scans were classified according to the Marshall, Rotterdam and Morris-Marshall classifications. Outcome was evaluated with extended Glasgow outcome scale at 3 months. Results: Maximal ICP and minimal CPP correlated with S-100B and NSE levels. Complex relations between biomarkers and CT classifications were observed. S-100B bulk release (AUC = 0.8333, p = 0.0009), and NSE at 72 hours (AUC = 0.8476, p = 0.0045) had the highest prediction power of mortality. Combining Morris-Marshall score and S-100B bulk release improved the prediction of clinical outcome (AUC = 0.8929, p = 0.0008). Conclusion: Biomarker levels are associated with ICP and CPP and reflect different aspects of brain injury as evaluated by CT-scan. The biomarkers might predict mortality. There are several pitfalls influencing the interpretation of biomarker data in respect to ICP, CPP, CT-findings and clinical outcome.
Serum cortisol concentration plotted against time after trauma. Symbols representing each patient (n ¼ 88) are connected with lines. For details, see text. 
To investigate serum levels of cortisol (a biochemical marker of stress), S-100B and neuron-specific enolase (two biochemical markers of brain tissue injury), in acute phase in mild traumatic brain injury patients and the occurrence of post-traumatic stress-related symptoms 1 year after the trauma. Blood samples were taken in patients (n = 88) on admission and approximately 7 hours later for analysis. Occurrence of post-traumatic stress-related symptoms was assessed for 69 patients using items from the Impact of Event Scale questionnaire (IES) at follow-up at 15 +/- 4 months after the injury. Serum levels of cortisol were more increased in the first sample (cortisol/1, 628.9 +/- 308.9 nmol L-1) than in the second blood sample (cortisol/2, 398.2 +/- 219.4 nmol L-1). The difference between these samples was statistically significant (p < 0.001). Altogether 12 patients (17%) showed post-traumatic stress related symptoms at the time of the follow-up. Stepwise forward logistic regression analysis of symptoms and serum concentrations of markers revealed that only S-100B in the second sample was statistically significantly (p < 0.05) associated to symptoms (three symptoms of the avoidance sub-set of IES). A major increase in serum concentrations of cortisol indicates that high stress levels were reached by the patients, in particular shortly ( approximately 3 hours) after the trauma. The association between the occurrence of post-traumatic stress related symptoms and serum levels of S-100B (generally considered as a biochemical marker of brain injury) seem to reflect the complexity of interactions between brain tissue injury and the ensemble of stress reactions.
S-100B and NSE proteins are considered to be neurobiochemical markers for the brain damage. The aim of this study was to consider the diagnostic and prognostic validity of the initial serum levels of S-100B and NSE in clinical use. Forty-five patients with traumatic brain injury were included in this prospective study. Neurologic examination and CCT-scan were performed. S-100B and NSE were analysed. Patients were divided in two groups depending on the severity of injury. The results showed a significant difference between the S-100B serum concentration and the two groups-minor head injuries and severe head injuries. A statistically significant correlation was observed between an increase of S-100B and NSE serum values and a cerebral pathological finding in CT scans. The clear correlation between S-100B and NSE serum concentrations and CCT findings does not validate both markers as an independent predictor of diagnosis and prognosis of brain injury.
Outcome in patients with brain injury after milieu-based day treatment neurorehabilitation was examined at up to 11 years post-discharge. Follow-up data in this cross-sectional study were sought from all admissions since May 1986 to May 1998 at 3 months, 1, 3, 5, 7, 9, and 11 year intervals. The 164 participants who responded had heterogeneous brain injury aetiologies and represented 73.9% of all patients who were successfully discharged from the programme. Rates of productivity (defined as gainful employment, school, and/or volunteer work) and employment (defined as work for pay) were examined in this follow-up sample. The results demonstrate that 83.5% of patients were productive up to 11 years post-discharge, with 67.1% engaged in work or school, and no decline in productivity was seen over time from discharge. Better vocational/school outcomes were associated with younger age, male gender, and higher staff working alliance ratings of patients and their families.
A systematic neuropsychological assessment technique is described for use with severely physically disabled people who may be severely brain-damaged, in an incomplete locked-in state or potentially in vegetative state. The technique allows opinions regarding cognitive state to be statistically based. In the case described, the weight of expert opinion had been that involuntary feeding by gastrostomy tube should be terminated because the patient was functioning at a level little beyond the vegetative state, her quality of life was poor and she was unable to form a view about her present or future circumstances. An assessment approach is described which uses binomial statistics and allows for some variability in responding. Methods of minimizing sources of extraneous bias are also discussed. By use of this technique it was demonstrated that the patient was sentient though impaired, and that her own wish at the time of the assessment was to continue living. It is recommended that neuropsycholgical assessment of this kind should take place in all cases in which withdrawal of treatment is being considered and cognitive ability is not certain.
Function following stroke is often measured using the Functional Independence Measure (FIM). Independence occurs when the patient achieves certain levels of functions. SPECT imaging assesses the regional cerebral blood flow (rCBF). Is it possible to correlate the FIM scores with SPECT imaging and predict functional return? We evaluated total of 69 stroke patients with SPECT imaging using Iofetamine (I-123). Patients were scanned within 14-21 days post-stroke. CT scans were evaluated and correlated with the SPECT images. This information was compared with the admission and discharge FIM scores. The rCBF reperfusion changes and region of stroke were evaluated and correlated with discharge functional status. The right parietal areas demonstrated a strong correlation with SPECT and FIM changes as predictors of return of functional living status (p-value = 0.0438). The right parietal area demonstrated an improvement in ambulation (p-value = 0.0578); the right brain correlated with overall improvement in FIM scores and change in SPECT imaging (p-value = 0.0833); the left brain did not exhibit significant values. Our conclusion was that there were trends seen with the predictive value of stroke recovery using SPECT imaging. The current sample number was not large enough to provide an adequate study, especially for the left brain; a larger study is needed. This information could be useful to help determine patient placement for rehabilitation.
This case study demonstrates the efficacy of treatment of a patient with severe dysarthria long after the accepted period of 'neurological recovery'. A physiological approach to treatment was utilized and resulted in a change from non-verbal communication to functional verbal communication.
To examine the association between apolipoprotein E (ApoE) genotype and visibility of traumatic brain lesions during the first year after traumatic brain injury (TBI). A prospective 1-year follow-up study in unselected victims of TBI. The number and extent of contusions, ventricular size index and semi-quantitative score of other traumatic intraparenchymal lesions were determined with MRI approximately 1 week and 1 year after TBI and the results were analysed in relation to the ApoE genotype in 33 patients after acute non-trivial TBI. The ApoE genotype was not associated with the visible changes occurring during this follow-up. The presence of ApoE4 was not associated with MRI changes during the first year after TBI. This suggests that if the ApoE4 is associated with an unfavourable outcome after TBI, the processes responsible for the repair of visible lesions are not dependent on ApoE genotype.
Mechanisms contributing to the rare but consistent neurotoxicity of contrast media currently in clinical use for the radiological examination of the subarachnoid space remain to be isolated. We assessed, by means of the (14C)-2-deoxy-D-glucose (2-DG) autoradiographic method, the effect of three non-ionic, low-osmolar contrast media, namely metrizamide, iopamidol and iohexol, on the local cerebral glucose utilization in the rat brain after intracisternal application. A significant (-30%) global reduction of the brain's metabolic activity occurred following intracisternal metrizamide injection. When compared with the mock-CSF control group the greater relative changes were observed in the supratentorial grey matter structures. In contrast, no significant changes were observed in metabolic brain activity in rats treated intracisternally with iopamidol and iohexol. These findings were consistent with the hypothesis that metrizamide is a competitive inhibitor of human brain hexokinase. The apparent lack of interference on neural tissue metabolism makes the second generation contrast media less neurotoxic and more suitable for neuroradiological subarachnoid investigations in clinical settings. The present experimental work establishes the 2-DG method as a viable laboratory approach to investigate aspects of neuronal dysfunction induced by contrast media.
To investigate the impact of time since injury on neuropsychological and psychosocial outcome after serious TBI in childhood or adolescence. The subjects were eight patients with serious TBI sustained at a mean age of 14 years who had been assessed neuropsychologically at 1, 7 and 14 years after TBI. A retrospective longitudinal design was chosen to describe the development in six neuropsychological domains on the basis of the assessments. Psychosocial data were gathered from clinical knowledge and a semi-structured interview 14 years after TBI. Performance of verbal IQ shows a declining trend over the three assessments, that the performance of attention and working memory is low and that verbal learning is the cognitive domain which exhibits the largest impairments. The main psychosocial result is that three of the eight subjects went from a school situation with no adjustments to adult life with early retirement. Time since insult is an important factor when assessing outcome after TBI in childhood and adolescence and that assessment of final outcome should not be done before adulthood.
From January to June 1986, 158 patients with extradural haematoma were admitted to our neurosurgical unit. They were divided into four groups, reflecting their clinical features: A. 46 cases (GCS less than or equal to 12) in whom a condition of coma/stupor had occurred at the time of injury and persisted to the time of surgical decompression; B. 41 cases showing deterioration of consciousness (GCS less than or equal to 12) after a lucid interval; C. 46 cases of 'asymptomatic' patients (GCS consistently greater than or equal to 13, no neurological deficits, no signs of increased intracranial pressure); D. 25 cases arriving at our unit in a conscious state, but restless and/or with neurological deficits. The location of the haematoma (temporal in only 35%), the incidence of associated lesions such as cerebral lacerations and/or subdural effusion (30.3%), and the age of the patients (28.4 +/- 18.4 years were similar in the four groups. The size of the haematoma and the displacement of the midline structures were significantly greater in comatose/stuporose patients (groups A and B). The overall mortality was 12% (19 patients), with a morbidity of 14% (22 patients). Factors statistically significant in determining mortality and morbidity were: degree of coma as assessed by GCS; displacement of midline structures: age of the patient; size of the haematoma. There was no mortality or morbidity in those patients who remained conscious (groups C and D). A pronounced increase in the number of CT examinations performed in patients with head injury in our area of referral has caused profound changes in the population of patients admitted to our centre, resulting in a greater proportion of extradural haematomas detected in patients who are still conscious, and in whom operative mortality and morbidity are negligible. One further therapeutic implication of the increase in the number of patients with EDH admitted while asymptomatic may be the option of conservative management in those patients who remain in a good clinical condition, with haematomas of less than 1 cm in thickness and no displacement of midline structures.
To evaluate the effects of estradiol-pre-treated neural stem cells (NSCs) derived from rat hippocampi post-ischemic neurological recovery and neuronal survival, migration and differentiation in rats with cerebral ischemia. A controlled laboratory study in animal model. NSCs were cultured with (CE) or without (CN) 17β-estradiol (E2) and transplanted into the lateral ventricles of rats with middle cerebral artery occlusion (MCAO). A MCAO model alone group and treatment control group served as controls. Transplantation recipients (CN and CE groups) had ameliorated neurological deficits, less severe morphological changes and reduced total infarct volume, while there were no significant differences in these outcomes or in nestin and glial fibrillary acidic protein expression between the CN and CE groups at all time points. On day 1 post-transplantation, the CE group exhibited significantly higher neuron-specific enolase expression compared to all other groups, but there were no significant differences between the CE group and CN groups on days 4 and 7 post-transplantation. The results indicated no measurable improvements of E2 pre-treatment NSCs in neuronal survival, migration or neurological recovery. The findings provide pre-clinical support for the use of NSC transplantation in ischemic injury.
A young woman was rendered tetraplegic and anarthric as a result of a traumatic brain injury in 1993. Two years later, she was considered to be in a minimally conscious state and became the subject of legal debate in the UK with regard to withdrawal of artificial feeding and hydration. Before injury, she made a verbal advanced directive that she would not wish to continue living if ever becoming severely disabled. Neuropsychological assessment found statistically significant evidence for sentience and expression of a wish to live and the application to Court was withdrawn. Further meaningful recovery occurred between 7-10 years after injury. She now lives in the community with 24 hour care. She speaks, initiates conversation and actions, expresses clear and consistent preferences and has a spontaneous sense of humour. She uses an electric wheelchair, eats solid food and drinks through a straw. Her mood is variable and sometimes low. This case demonstrates the need for careful consideration of advanced directives and for specialist neuropsychological assessment in people with severe cognitive and communication difficulties. It supports the view that routine assessment and follow-up of people thought to be in minimally conscious states is important. In addition, it shows that recovery with reduction in disability and significant implications for quality of life can continue for at least 10 years after extremely severe traumatic brain injury.
Background: A proportion of children will experience persistent post-concussion symptoms (PCS) following a mild traumatic brain injury (mTBI). As persistent PCS may be maintained by pathological and psychological factors, this study aimed to describe and evaluate potential pre- and post-injury parent and child predictors of persistent PCS. Methods: A total of 150 children with mTBI and their parents participated. Parents completed measures of their own distress and children's PCS and health-related quality-of-life (HRQoL) at baseline (reflecting pre-injury function). These measures, as well as measures of children's distress and cognitive function were administered at 6 and 18 months post-injury. Results: Children's PCS at 6 months post-injury were predicted by both pre-injury parent distress and children's pre-injury PCS. At 18 months post-injury, children's PCS were predicted by higher levels of parent distress and child PCS at 6 months post-injury, as well as poorer post-injury cognitive functioning. Change in PCS between 6-18 months post-injury was predicted by parent's pre-injury anxiety and children's HRQoL. Conclusions: Children at risk of persistent PCS can be identified by higher levels of pre- and post-injury PCS, parent distress and poorer post-injury cognition. These factors should be addressed by interventions aimed at minimizing the occurrence and impact of child PCS.
The risk of seizures is increased after a traumatic brain injury (TBI), but the impact and duration of this increased risk is not well characterized in children. To identify post-traumatic epilepsy (PTE) and post-concussion symptoms 10 years after a TBI during childhood. The study is a population-based retrospective follow-up study. Ten years after brain injury all 165 survivors, who as children (<18 years) in 1987-1991 as residents in the south western Swedish health care region had had a TBI, were invited to participate in a follow-up. A questionnaire regarding medical conditions and medication was filled out by the patients themselves or their parents as was a 21-item questionnaire (PCSQ) regarding post-concussion symptoms. Of the surviving 165 individuals, 109 participated (67%). Eight of 109 developed immediate seizures. During the follow-up period 12/109 had developed active epilepsy. Of these 12, five had had immediate seizures. The incidence of developing PTE within 10 years after a TBI was thus in this series 11%. The relative risk to develop late onset post-traumatic epilepsy (> or =1 week after injury) for those who had had immediate seizures was 9.018 (p = 0.0003, 95% CI = 3.69-22.05). TBI is a relatively rare cause of epilepsy in childhood, although immediate seizures are associated with an increased risk of developing post-traumatic epilepsy.
Between the years 1984 to 1989, 624 urgent brain CT examinations were performed for head-trauma patients in the Tel-Aviv Medical Center. In 19 patients, epidural haematomas were diagnosed. Different radiological parameters were discussed such as homogeneity of the haematoma, midline shift, ventricular collapse, obliteration of the peri-mesencephalic cistern and the presence of additional brain damage.
Changes in the frequency of the four most relevant mechanisms of deaths due to traumatic brain injury between January 1980 and December 2012 for male, female and all patients. 
Background: To investigate changes in TBI mortality in Austria during 1980-2012 and to identify causes for these changes. Methods: Statistik Austria provided data (from death certificates) on all TBI deaths from January 1980-December 2012. Data included year/month of death, age, sex, residency of the cases and mechanism of accident. Data regarding the size of the age groups was obtained from Statistik Austria. Mortality rates (MR; deaths/10(5) population/year) were calculated for male vs. female patients and for different age groups. Changes in mechanisms of TBI were evaluated. Results: The MR decreased from 28.1 to 11.8 deaths/10(5) population/year. Traffic-related TBI deaths decreased from 62% to 9%. This caused a significant decrease in TBI deaths in younger age groups. Fall-related TBI deaths (mostly geriatric cases) remained unchanged. Falls became the leading cause; its rate increased from 22% to 64% of all TBI deaths. Thus, the mean age of fatal TBI cases increased by 20 years and the rate of cases aged <60 years decreased from 71% to 28%. Another important cause was suicide by firearms; its rate increased from 10% to 23% of all TBI deaths. Conclusions: These findings warrant better prevention of falls in the elderly and of suicides.
Cumulative data from the Virginia Brain Injury Central Registry, which maintains information on persons presenting to the emergency rooms for evaluation and treatment of head trauma, were analysed for fiscal years 1988-1993. Persons age 40 years and younger represented almost 80% of all head injuries presenting to Virginia emergency rooms. Age-adjusted incidence rates were greatest for children under age 6 years (237/100,000 persons-years), and least for persons age 40-69 years (56/100,000 person-years). Head injuries occurred 1.4 times more frequently in males than females, and male mortality rates were 1.6 times greater. Falls exceeded motor vehicle accidents as the most common cause of head trauma after fiscal year 1989 followed by assaults and sports/recreation-related injuries. Head injuries were most common in May through October, and early mortality rates increased progressively with age. Findings are contrasted with prior demographic and epidemiological studies limited to persons hospitalized following moderate to severe head trauma.
Pre-and post-traumatic psychiatric diagnoses among the suicide victims in Northern Finland. 
Depression and substance abuse are common among patients with traumatic brain injury (TBI). However, previous studies have not examined the temporal association between psychiatric disorders, TBI and suicide. To study the prevalence of TBI injury among suicide victims; to determine the association of suicide, psychiatric disorders and TBI severity; and to examine the effect of pre- and post-traumatic psychiatric disorders on their remaining life-time. This study examined all suicides (n = 1,877) committed during a 16-year period in the province of Oulu, Finland. The information of suicide victims was extracted from the official death certificates and the National Hospital Discharge Registers. TBI was found in 5.5% (n = 103) of the victims. Compared to the victims without TBI, those with TBI had significantly more hospital-treated psychiatric and alcohol disorders. If TBI subjects had comorbid psychiatric disorders, the time period between TBI and suicide was under 3 years in approximately 90% of victims in this suicide population. Seriousness of injury, male gender, older age, being unemployed and presence of psychiatric and alcohol disorders are important to identify as possible predictors for suicidal behaviour in TBI patients. Further studies are required to shed light on interventions aimed at better life management.
To aid in determining health care service needs, Wisconsin Department of Health and Social Services (DHSS) data on Wisconsin hospital discharges for traumatic brain injury (TBI), using ICD-9-CM codes for intracranial injury with and without skull fracture, and Wisconsin Department of Transportation data on incapacitating non-fatal head injuries (INHI) from traffic accidents from 1989 through 1992 were reviewed. Yearly TBI hospital discharges in Wisconsin declined 15.0%, and by 23.9% for Milwaukee County residents, over 1989 through 1992, correlating closely with changes in yearly INHI in Wisconsin (r = 0.999; p < 0.01) and in Milwaukee County (r = 0.989; p < 0.05). Using 1990 census data the yearly TBI risk ratio for Milwaukee County residents compared to the rest of Wisconsin increased from 1989 (1.76) to 1990 (1.92) and then decreased in 1991 (1.83) and 1992 (1.51). The results of this pilot study suggest there was a decrease in the incidence of hospitalization of patients with TBI in Wisconsin from 1989 through 1992, paralleling a decline in INHI from motor vehicle accidents. There appeared to be a relatively greater decline in these patients in Milwaukee County from 1991 to 1992 as compared to the rest of the state. The techniques employed in this study may be used to help assess rehabilitation service needs in other areas.
Encephalitis is an uncommon clinical entity compared to traumatic brain injury, and stroke. Many encephalitis survivors have disabling sequelae. There is scant information in the literature addressing outcome following inpatient rehabilitation for encephalitis. Further, it is unclear which of these patients will benefit from acute in-patient rehabilitation. The purposes of this study are to (1) describe the outcome following in-patient rehabilitation in a cohort of patients with encephalitis, and (2) develop preliminary criteria to guide the selection of patients with encephalitis who may benefit from inpatient rehabilitation. The demographic, clinical, functional (functional independence measure-FIM) and neuro-psychological data were retrospectively abstracted for eight subjects with a clinical diagnosis of encephalitis aged 5 to 75 years, who were admitted to a brain injury rehabilitation unit between 1990 and 1997. In the eight subjects, the mean age was 38 years, mean acute hospital stay (ALOS) was 40.3 days, and mean rehabilitation length of stay (RLOS) was 75.9 days. Mean admission FIM (AFIM) was 40.1, mean discharge FIM (DFIM) was 69.9. Mean FIM gain was 29.8 and mean FIM efficiency was 0.39. Adult subjects with an AFIM > 30 at 5 weeks from onset of illness (n = 4) had a FIM LOS efficiency of 0.64 and all four were discharged home. None of the adult subjects with an AFIM < 30 at 5 weeks from onset of illness (n = 3, FIM efficiency = 0.14) were discharged home. A child with an AFIM < 30 (n = 1) had a FIM LOS efficiency of 1.24, made good recovery and was discharged home. FIM LOS efficiency of 0.64 in encephalitis is less, as compared to traumatic brain injury (TBI -1.27) and stroke (1.06). The results of this study showed that, although subjects with encephalitis make functional gains in rehabilitation, the rate of recovery varies and is generally less than that for TBI and stroke. The study also suggests that FIM scores can be used for screening adult patients after encephalitis for admission to inpatient rehabilitation. Adult patients with an AFIM > 30, 5 weeks post onset of illness are likely to make reasonable progress and be discharged home. If replicated, these results suggest that despite low AFIM scores at 5 weeks from onset of illness (AFIM < 30), children may still make good progress and should be given a trial of in-patient rehabilitation.
This investigation evaluated yearly trends in charges and lengths of stay for patients with brain injury in acute care and rehabilitation settings over a 7 year period. Data was collected from 800 consecutive patients enrolled in four NIDRR Model Systems Traumatic Brain Injury programmes. Acute care daily charges showed almost routine increases, averaging nearly $550 per year. Conversely, lengths of stay generally showed a downward trend, with annual reductions averaging 2.25 days. Admission lengths of stay averaged 22-29 days between 1990-1994. Admissions averaged less than 20 days beginning in 1995, with the 1996 average of 16 days, nearly half that of the 1993 average. Between 1990-1996, average daily rehabilitation charges increased each year, with the rise averaging $83 or 7%. The rise in daily rehabilitation charges was offset by corresponding decreases in lengths of stay averaging 3.65 days or 8% annually. Increases in daily charges for brain injury rehabilitation care were roughly comparable to those for general medical care prices. However, the rate of change in acute care charges was substantially greater, with annual increases averaging 10% more than national medical care prices. The steady downward trend in lengths of stay raises serious concerns about the future availability of health care services to persons with brain injury.
Comparison of excessive, cognitive, aggressive and passive/low mood behaviours across groups with brain injury from different causes. 
The Memory and Behavior Problems Checklist-1990R (MBPC-1990R) is a carer-rated measure of (a) problem behaviours and (b) corresponding carer reaction. Although originally developed and validated for dementia, its items are relevant to acquired brain injury (ABI). This study evaluated its validity in this population. Cross-sectional study. In a national postal survey carried out to inform service planning, 222 family carers of adults with TBI (49%), strokes (26%), infections (18%), other (7%) completed the MBPC-1990R, Head Injury Behaviour Scale (HIBS), Barthel Index (BI), Northwick Park Dependency Score (NPDS), Carer Burden Interview (CBI), WHOQOL-BREF and GHQ-28. MBPC-1990R problems correlated well with HIBS problems (r = 0.70), as did MBPC-1990R carer reaction with HIBS distress (r = 0.78) and CBI (r = 0.73) scores, indicating good convergent validity. Discriminant validity was inferred from absent/weak correlations between MBPC-1990R problems and both BI (r = -0.02) and NPDS (r = 0.24); likewise between MBPC-1990R carer reaction and WHOQOL-BREF physical, psychological, social, environmental sub-scales (r = -0.32 to -0.41) and GHQ-28 scores (r = 0.35). Factor analysis revealed excessive, cognitive, aggressive and passive/low mood sub-scales, which showed good internal consistency and varied across ABI groups. The MBPC-1990R is supported as a measure of problem behaviours and carer reaction in ABI. Further validation in ABI groups is recommended.
Gans, in 1983, detailed the prevalence, causes, and implications of hate in the rehabilitation setting, and offered suggestions for therapeutic responses to it. Mullins, in 1989, noted that during the 1980s rehabilitation became a rapidly expanding, increasingly privatized, big business, with seemingly limitless opportunities for advancement and profit. He asserted that during those years hate had been joined by power, envy and greed in the rehabilitation setting. The present article builds upon the two earlier ones and reviews recent events and their effects, including: the continued development of rehabilitation as a business, the national economic slow down, the health-care crisis, the rise of managed care, the fear that rehabilitation workers feel for their jobs, and the loss of control that people feel throughout rehabilitation. Suggestions for improving the current situation are offered to clinicians, administrators, insurers, and educators, and all are urged to do what they know is right.
To examine the epidemiology of traumatic brain injury (TBI) in Finland in 1991-2005. Nationwide population based data of hospitalized and fatal TBI collected from the national registers of Finland. The incidence, age and gender distribution, aetiology, external causes, cursory outcome and mortality are presented. The data were collected from the National Hospital Discharge Register of Finland and from the official cause-of-death register of Statistics Finland. Main outcome and results: The average incidence of hospitalized TBI was 101/100,000 population and the mortality rate 18.1/100,000. The incidence increased by 59.4% in the patients aged 70 years or older while the incidence decreased by 2.4% in the younger age groups. The mortality rate decreased in men. The most common external causes were falls. The oldest patients needed 6.8-times longer stay in the hospital than the youngest. After discharge 54% of the patients needed at least occasional care. TBI prevention should be focused to the main groups at risk. The need for further care, rehabilitation and increasing the awareness of TBI is obvious.
The 1991 National Health Interview Survey was analysed to describe the incidence of mild and moderate brain injury in the United States. Data were collected from 46 761 households and weighted to reflect all non-institutionalized civilians. The report of one or more occurrences of head injury resulting in loss of consciousness in the previous 12 months was the main outcome measure. Each year an estimated 1.5 million non-institutionalized US civilians sustain a non-fatal brain injury that does not result in institutionalization, a rate of 618 per 100,000 person-years. Motor vehicles were involved in 28% of the brain injuries, sports and physical activity were responsible for 20%, and assaults were responsible for 9%. Medical care was sought by 75% of those with brain injury; 14% were treated in clinics or offices, 35% were treated in emergency departments, and 25% were hospitalized. The risk of medically attended brain injury was highest among three subgroups: teens and young adults, males, and persons with low income who lived alone. The incidence of mild and moderate brain injury in the United States is substantial. The National Health Interview Survey is an important national source of current outpatient brain-injury data.
To describe the epidemiology of traumatic brain injury (TBI) among persons 65 years of age and older in Oklahoma from 1992-2003. Descriptive epidemiology of data collected through active statewide surveillance on TBI inpatient hospitalizations and fatalities. Data collected from hospital medical records and the Office of the Chief Medical Examiner. TBI was defined by ICD-9-CM codes for skull fracture 800.0-801.9, 803.0-804.9, concussion or other intracranial injury 850.0-854.1 and head injury, unspecified 959.01; all cases included a description of TBI. TBI rates increased 79% for the study population; however, case-fatality rates decreased from 32% in 1992 to 18% in 2003. The TBI rate increase was observed among all elderly age groups, both genders and all races. Unintentional injuries nearly doubled while both assault and self-inflicted injuries decreased. Fall-related TBI increased by 126%, while MVC-related TBI increased by 17%. Survivors were hospitalized for an average of 6.8 days and over half required post-acute care. The increased TBI rate and decreased case-fatality rate among elderly persons means potentially more persons living with TBI disability. TBI prevention efforts among the elderly must be expanded, especially for fall-related TBI.
The purpose of this study was to assess the relationship between sex and traumatic brain injury (TBI) mortality. A total of 20,465 persons with TBI were identified from a Colorado population-based surveillance system for 1994-1998. Case fatality ratios were calculated to identify sex differences for selected risk factors. Unconditional logistic regression was used to determine the relationship between TBI mortality and sex controlling for risk factors. Adjusting for age, race, metropolitan residence and penetrating injury, the estimated odds of TBI mortality for males compared to females was 1.21 (95% CI 1.10, 1.34) for pre-hospital fatalities and 1.19 (95% CI 1.05, 1.37) for hospital fatalities. Results indicate differences in TBI mortality comparing males and females. Future studies are warranted to identify if behaviour and physiological responses are associated with TBI outcomes among males and females.
The burden of mild traumatic brain injury (TBI) is not well understood at the national level, but hospitalization rates show a decline over time. This paper describes ambulatory care for TBI patients at physician offices, hospital outpatient departments, and emergency departments (EDs) in comparison with non-TBI visits for the US during 1995-1997. An estimated 1.4 million visits for TBI were made each year for an average annual rate of 5.4/1,000 population. A decline in annual visit rate was noted during 1995-1997. Visit rates were higher for those aged 0 -14 and 75 and older. Falls (44%) and motor vehicles (28%) were the primary injury causes. Rural-urban differences were found, also in comparison with non-TBI. In 23% of visits to EDs, a CT scan was ordered or performed and in 33%, a mental status exam was conducted. Further investigations are warranted to describe ambulatory care for TBI in more detail, particularly in light of a decline in hospitalization rates.
The purposes of this study were to provide a national estimate of the incidence of traumatic brain injuries (TBIs) seen in emergency departments (EDs), but not requiring hospitalization and to determine the causes of these injuries. Using the Centers for Disease Control and Prevention case definition of TBI, ED data was analysed from the National Hospital Ambulatory Medical Care Survey (1995-1996). The average overall incidence rate of TBI-related ED visits for persons who were not hospitalized was 392/100,000 population per year, or 1,027,000 visits to hospital EDs in the US each year. This estimate is nearly twice (392 vs. 216) the previously estimated incidence rate, which was based on data from the 1991 National Health Interview Survey Injury Supplement. It was found that the highest incidence rate occurred among children aged 0-14 years, the rate for males was higher than for females, and the primary reported causes of these injuries were 'falls', motor vehicle-related causes, and 'struck by an object'. Although often considered 'mild' TBIs, these injuries can lead to significant cognitive and emotional impairment. Thus, continued surveillance of TBI-related ED visits is an important part of a comprehensive TBI prevention strategy.
To determine the incidence and epidemiology of emergency department (ED)-attended mild traumatic brain injury (mTBI) in the US. Secondary analysis of ED visits for mTBI in the National Hospital Ambulatory Medical Care Survey for 1998--2000. MTBI defined by International Classification of Diseases, 9th Revision, Clinical Modification (ICD9-CM) codes for 'skull fracture', 'concussion', 'intracranial injury of unspecified nature' and 'head injury, unspecified'. The average incidence of mTBI was 503.1/100000, with peaks among males (590/100000), American Indians/Alaska Natives (1,026/100000) and those <5 years of age (1,115.2/100000). MTBI incidence was highest in the Midwest region (578.4/10000) and in non-urban areas (530.9/100000) of the US. Bicycles and sports accounted for 26.4% of mTBI in the 5-14 age group. The national burden of mTBI is significant and the incidence higher than that reported by others. Possible explanations are discussed. Bicycle and sports-related injuries are an important and highly preventable cause of mTBI underscoring the need to promote prevention programmes on a national level.
Head injury rates by remoteness of usual residence, 2000–2001 to 2005–2006. 
Head injury rates by remoteness of usual residence, 2000-2001 to 2005-2006. 
TBI rates by remoteness of usual residence, 2000–2001 to 2005–2006. 
TBI rates by remoteness of usual residence, 2000-2001 to 2005-2006. 
To describe rates of hospitalization for head and traumatic brain injury (TBI) among Australian adults aged 15-24 years. Descriptive analysis of the Australian Institute of Health and Welfare National Hospital Morbidity Database, using data from 1 July 2000 to 30 June 2006. The rate of hospitalization for head injury was 618.5 per 100 000, with 148.1 per 100 000 being high threat to life injuries. In multivariate analysis, males had 3.2-times the rate of females. Youth and young adults living in remote and very remote areas had a 2.6-3.2-fold greater rate of head injury than city-dwellers and a 2.3-2.7-fold greater rate of injuries that were high threat to life. The rate of TBI was 169.3 per 100 000, with 87.1 per 100 000 being high threat to life injuries. In multivariate analysis, males had 3.2-times the rate of females. Youth and young adults living in very remote and remote areas had a 2.5-3.0-fold greater rate of TBI than city-dwellers and a 2.1-2.3-fold greater rate of high threat to life TBI. Males and youth and young adults living remotely were disproportionately represented among those sustaining head injuries. A quarter of hospitalized head injuries were coded as having TBI.
To investigate the epidemiology of TBI in Chinese inpatients. Civilian inpatients of Chinese military hospitals diagnosed with TBI between 2001-2007 were identified using ICD-9-CM codes. Demographic characteristics, admission time, injury cause, injury severity, length of stay and outcomes were compared between ICD-9-CM diagnosis groups. In total, 203 553 civilian patients with TBI (74.86% male, 25.14% female) were identified from >200 Chinese military hospitals. TBI diagnoses increased by a mean of 4.67% each year. Admission peaked during the third quarter of the year and October annually. The leading causes of TBI were motor vehicle-traffic (51.41%), falls (21.49%) and assaults (15.77%). TBI was categorized by abbreviated injury scale score as mild in 36.64%, serious in 20.13%, severe in 26.81% and critical in 15.68% of inpatients. The mean length of stay was 17.8 ± 24.1 days. Recovery rate was 93.06% and mortality was 4.14%. The epidemiological data may contribute to the development of effective, targeted strategies to prevent TBI.
To determine whether US concussed high school athletes complied with recommended return-to-play guidelines during the 2005-2008 school years. Prospective cohort study in 100 nationally-representative US high schools. Certified athletic trainers submitted injury reports for concussed athletes in five boys' (football, soccer, basketball, wrestling, baseball) and four girls' (soccer, basketball, volleyball, softball) sports via High School RIO (Reporting Information Online). Concussions were retrospectively graded and it was determined whether athletes followed American Academy of Neurology (AAN) or Prague return-to-play guidelines. There were 1308 concussions reported during 5 627 921 athlete-exposures (23.2 concussions per 100 000 athlete-exposures), reflecting an estimated 395 274 concussions sustained nationally. At least 40.5% and 15.0% of concussed athletes returned to play prematurely under AAN and Prague return-to-play guidelines, respectively. In football, 15.8% of athletes sustaining a concussion that resulted in loss-of-consciousness returned to play in <1 day. Males (12.6%) were more likely than females (5.9%) to return 1-2 days after sustaining an initial grade II concussion. Too many adolescent athletes are failing to comply with recommended return-to-play guidelines. Sports medicine professionals, parents, coaches and sports administrators must work together to ensure athletes follow recommended guidelines.
The eruption of Al-Aqsa Intifada created a war situation in Palestine, increasing the number of firearms injuries caused by occupying Israeli forces as well as disabling head injuries. No data were available to the Palestinian Ministry of Health and other health organizations on traumatic brain injury (TBI) in Palestine. This study, therefore, sought to determine the causes and outcomes of TBI in patients who were admitted to three hospitals in Nablus, Palestine. Retrospective review of medical records and contacts with patients and/or caregivers. The medical records of patients who were diagnosed with TBI (n=312) and admitted to any one of the three hospitals in 2006 and 2007 were reviewed. Data were also obtained from follow-up home visits and telephone calls with consenting patients and/or caregivers. The major causes of TBI were assault (33%), falls (32.1%), road traffic crashes (29.8%) and impacts from heavy objects (3.2%). Gunshot wounds are a major cause of head injury in Palestine. The study shows that assault with firearms is the most frequent cause of TBI in this population and that patients with head injuries due to assault have poorer outcomes at discharge than those injured in other ways.
AHT incidence and 95% CI among children 4 years of age treated in US Emergency Departments, NEDS, 2006–2009.  
Objective: To study characteristics and outcomes of paediatric patients with abusive head trauma (AHT) treated in emergency departments. Methods: Nationwide Emergency Department Sample (NEDS) data were analysed. The CDC recommended AHT definition was used to classify children ≤ 4 years with head trauma into AHT and non-AHT groups. Outcomes were compared between patients with AHT and patients with non-AHT. Logistic models were fitted to identify risk factors. Results: An estimated 10 773 paediatric patients with AHT were treated in EDs in 2006-2009. The average annual rate was 12.83 per 100 000 for children ≤ 4 years. Children < 1 year of age accounted for most AHT cases (60.6%) and males had a significantly higher AHT rate than females. Medicaid was the primary payer for 66.1% of AHT injuries and 40.3% of non-AHT injuries. The case mortality rate was 53.9 (95% CI = 41.0-66.7) per 1000 patients with AHT compared with 1.6 (95% CI = 1.4-1.9) per 1000 patients with non-AHT. Conclusions: Child caregivers should be educated about the serious consequences of AHT and proper techniques for caring for infants. Unbiased and accurate documentation of AHT by physicians and medical coders is crucial for monitoring AHT injuries.
Introduction: mTBI has been termed the 'signature injury' of recent conflicts in Afghanistan and Iraq. Most mTBI research uses retrospective accounts of exposure and point of injury symptoms; mTBI is reportedly less common among UK than US Forces. Methods: This study examined the rate of mTBI exposure and symptoms in 1363 UK military personnel deployed in Afghanistan in 2011 using a self-report questionnaire. Data were collected in the operational location during the 5th month of a 6-month deployment. Personnel reported injuries and symptoms related to six events including fragmentation, blast, bullet, fall, motor vehicle accident and 'other' exposure. Results: Eighty (5.9%) reported at least one potential mTBI exposure during the current deployment and 1.6% (n = 22) reported injury and one or more mTBI symptoms (1 year incidence rate = 3.2%). Higher PTSD symptom scores were significantly associated with reporting potential mTBI (p ≤ 0.001) and mTBI with symptoms (p ≤ 0.001). Conclusion: This study used contemporaneous data gathered in the deployed location which are subject to less memory distortion than studies using post-deployment recall. The incidence of mTBI was substantially lower than those reported in both US and UK post-deployment studies which is consistent with inflated reporting of symptoms when measured post-deployment.
The purpose of this paper is to review the dynamics and functioning of families with a severely head-injured member. In order to stress the unique problems faced by persons with brain damage and their families, a comparison with spinal cord-injured persons is presented. The review's major conclusion is that a head injury exposes the family to a complex of problems that are unique to this disability and, therefore, necessitates the delivery of special family support services focused on the family, rather than on the head-injured person.
To assess health-related quality of life (HRQoL) and its determinants in a cohort who had sustained a traumatic brain injury 22 years earlier. Cohort study with a postal follow-up survey. Two hundred and fifty-nine individuals with traumatic brain injury responded to the Short Form-36 (SF-36) and General Health Questionnaire-30 (GHQ-30) questionnaires. SF-36 scores were compared with a general population sample (n = 6800). In multiple linear regression analysis determinants of physical and mental component summary scores (PCS, MCS) of SF-36 and the GHQ-30 total score were assessed. Except on the physical functioning scale, SF-36 scores were lower in the traumatic brain injury cohort than in the general population, after adjusting for age, sex and education. In multiple linear regression analysis, reported psychiatric disease and headache >or=1 day per month were associated with impaired MCS and GHQ-30 total scores. Age, severe headache 3 months after the injury, previous sick leave, lung disease and heart disease were associated with PCS. No injury variable was associated with HRQoL. Headache 3 months after traumatic brain injury and later comorbidity were associated with HRQoL 22 years after traumatic brain injury, but there was no association of HRQoL with injury data.
Top-cited authors
Steven Laureys
  • University of Liège
Lars Rönnbäck
  • University of Gothenburg
Birgitta Johansson
  • University of Gothenburg
Juan Carlos Arango-Lasprilla
  • Giunti Psychometrics
Marie-Aurelie Bruno
  • University of Liège