Predictive ability of preinjury stressful life events and post-traumatic stress symptoms for outcomes following mild traumatic brain injury: analysis in a prospective emergency room sample.

BACKGROUND: A subset of persons with mild traumatic brain injury (mTBI) experience long-term difficulties. Preinjury stress has been hypothesised to play a role in long-term maintenance of symptoms. OBJECTIVE: To investigate the predictive ability of preinjury stressful life events and post-traumatic stress symptoms to health-related quality of life and emotional distress after mTBI. METHODS: Within 2 weeks of injury, 186 participants with mTBI who were admitted to an emergency centre completed an interview and questionnaires regarding preinjury functioning, including the Stressful Life Events Questionnaire and the Post-Traumatic Stress Disorder Checklist. Outcomes were assessed at 3 months after injury and included the depression and anxiety subscales of the Brief Symptom Inventory, and the physical and mental component scores of the 36-item Short-Form Health Survey (SF-36). The incidence and type of stressful life events were reported. Hierarchical regression analyses were used to determine the predictive utility of Stressful Life Events Questionnaire and Post-Traumatic Stress Disorder Checklist after controlling for age, injury severity (complicated versus uncomplicated mild) and preinjury depression. RESULTS: Several potentially life-altering stressful events were endorsed by at least 25% of participants as having been experienced prior to injury. The incidence of stressful life events was a significant predictor of all four outcome variables. History of post-traumatic stress symptoms was predictive of scores on the SF-36 mental health component. CONCLUSIONS: A history of stressful events may predispose persons with mTBI to have poor outcomes. History of stress should be assessed during the early stages after mTBI to help identify those who could benefit from therapies to assist with adjustment and maximise recovery.

Adult respiratory distress syndrome: a complication of induced hypertension after severe head injury.

OBJECT: The factors involved in the development of adult respiratory distress syndrome (ARDS) after severe head injury were studied. The presence of ARDS complicates the treatment of patients with severe head injury, both because hypoxia causes additional injury to the brain and because therapies that are used to protect the lungs and improve oxygenation in patients with ARDS can reduce cerebral blood flow (CBF) and increase intracranial pressure (ICP). In a recent randomized trial of two head-injury management strategies (ICP-targeted and CBF-targeted), a fivefold increase in the incidence of ARDS was observed in the CBF-targeted group. METHODS: Injury severity, physiological data, and treatment data in 18 patients in whom ARDS had developed were compared with the remaining 171 patients in the randomized trial in whom it had not developed. Logistic regression analysis was used to study the interaction of the factors that were related to the development of ARDS. In the final exact logistic regression model, several factors were found to be significantly associated with an increased risk of ARDS: administration of epinephrine (5.7-fold increased risk), administration of dopamine in a larger than median dose (10.8-fold increased risk), and a history of drug abuse (3.1-fold increased risk). CONCLUSIONS: Although this clinical trial was not designed to study the association of management strategy and the occurrence of ARDS, the data strongly indicated that induced hypertension in this high-risk group of patients is associated with the development of symptomatic ARDS.

Use of the Disability Rating Scale Recovery curve as a predictor of psychosocial outcome following closed-head injury.

Rapid rate of recovery has been associated with better outcome following closed-head injuries, but few studies have compellingly demonstrated this. This study used growth curve analyses of Disability Rating Scale (DRS) scores at acute hospitalization discharge, 1, 3, and 6 months post injury in a sample of 55 patients with a closed-head injury. Six month post-injury outcome measures were taken from significant other (SO) responses on the NYU Head Injury Family Interview (NYU-HIFI) including severity and burden ratings of affective/neurobehavioral disturbance, cognitive deficits, and physical/dependency status. Rate of recovery (linear and curvilinear recovery curve components) was significantly related to the level of affective/neurobehavioral severity, and the severity and burden of SO-perceived cognitive deficits. Only the intercept of the DRS recovery curve was associated with the SO-perceived severity and burden of physical/dependency status. Growth curve modeling is a meaningful and powerful tool in predicting head injury outcome.

The relation between acute physiological variables and outcome on the Glasgow Outcome Scale and Disability Rating Scale following severe traumatic brain injury.

The relation between outcome and duration of adverse physiological events was studied, using suggested critical physiological values. Subjects were 184 patients with severe traumatic brain injury who received continuous monitoring of intracranial pressure (ICP), mean arterial pressure (MAP), cerebral perfusion pressure (CPP), and jugular venous oxygen saturation. Longer durations of adverse physiological events were significantly related to Glasgow Outcome Scale (GOS) scores and Disability Rating Scale (DRS) scores for all variables at all timepoints postinjury. When analyses excluded patients who died, the relation between adverse physiological events and GOS was nonsignificant; however, duration of ICP, MAP, and CPP still accounted for a significant portion of the variance in DRS scalres. The relative sensitivity of the GOS and DRS is discussed.

Functioning of the corpus callosum in children with early hydrocephalus.

The development and organization of the corpus callosum is described as well as the relationship between the timing of insults and the type of partial agenesis of the corpus callosum are discussed. Neuropathology and callosal damage associated with spina bifida meningomyelocele, aqueductal stenosis, and prematurity-IVH are outlined. Relationships between corpus callosum/whole brain ratios and cognitive functioning as well as interhemispheric transfer in children with these disorders are outlined. Shortcomings of current research and future directions are suggested.

A review of outcome after moderate and severe closed head injury with an introduction to life care planning.

Forensic consultation regarding moderate and severe closed head injury (CHI) generally focuses on determination of severity of residual deficits and the implications of these deficits for future health care needs, personal independence, and employment. This information can be used to develop a life care plan that describes the patient's needs for continued medical care, rehabilitation, and daily assistance or supervision and estimates the long-term costs for these services. This article provides brief reviews of CHI classification, epidemiology, residual deficits, expected outcomes, and factors predictive of outcome. An introduction to the process of developing a life care plan is presented.

Validation of a controlled cortical impact model of head injury in mice.

A controlled cortical impact model of head injury was validated with mice. Mice were randomly assigned to moderate head injury, mild head injury, and sham injury groups. Beam balancing, open field activity, slant board inclination, grasp strength, and motor coordination were assessed prior to the injury and on days 1-5 postinjury. Morris water maze performance was evaluated on days 11-15 postinjury. Moderately head-injured mice took a significantly longer time to complete the motor coordination task and to find the hidden platform on the Morris water maze and had significantly fewer successful trials on both tasks than the mildly head-injured and sham-injured mice. Mildly head-injured and sham-injured mice performed similarly on both tasks. Contusion volume at the site of impact varied with severity of injury. Moderately head-injured mice had significantly larger contusions than mice with a mild head injury, and these mice in turn had significantly larger contusions than the sham-injured mice. Both moderately and mildly head injured mice had significantly fewer surviving cells in CA1 than the sham-injured mice but did not differ from each other in this regard. Although there was a group effect, only the mildly head-injured mice had significantly fewer surviving cells in CA3.

Prevention of secondary ischemic insults after severe head injury.

OBJECTIVE: The purpose of this study was to compare the effects of two acute-care management strategies on the frequency of jugular venous desaturation and refractory intracranial hypertension and on long-term neurologic outcome in patients with severe head injury. DESIGN: Randomized clinical trial. SETTING: Level I trauma hospital. PATIENTS: One hundred eighty-nine adults admitted in coma because of severe head injury. INTERVENTIONS: Patients were assigned to either cerebral blood flow (CBF)-targeted or intracranial pressure (ICP)-targeted management protocols during randomly assigned time blocks. In the CBF-targeted protocol, cerebral perfusion pressure was kept at >70 mm Hg and PaCO2 was kept at approximately 35 torr (4.67 kPa). In the ICP-targeted protocol, cerebral perfusion pressure was kept at >50 mm Hg and hyperventilation to a PaCO2 of 25-30 torr (3.33-4.00 kPa) was used to treat intracranial hypertension. MEASUREMENTS AND MAIN RESULTS: The CBF-targeted protocol reduced the frequency of jugular desaturation from 50.6% to 30% (p = .006). Even when the frequency of jugular desaturation was adjusted for all confounding factors that were significant, the risk of cerebral ischemia was 2.4-fold greater with the ICP-targeted protocol. Despite the reduction in secondary ischemic insults, there was no difference in neurologic outcome. Failure to alter long-term neurologic outcome was probably attributable to two major factors. A low jugular venous oxygen saturation was treated in both groups, minimizing the injury that occurred in the ICP-targeted group. The beneficial effects of the CBF-targeted protocol may have been offset by a five-fold increase in the frequency of adult respiratory distress syndrome. CONCLUSIONS: Secondary ischemic insults caused by systemic factors after severe head injury can be prevented with a targeted management protocol. However, potential adverse effects of this management strategy may offset these beneficial effects.

Corpus callosum damage and interhemispheric transfer of information following closed head injury in children.

We evaluated the relationship of corpus callosum atrophy and/or lesions on magnetic resonance imaging (MRI) to functional hemispheric disconnection following closed head injury (CHI) in 51 pediatric patients, including mild CHI, moderate to severe CHI with extracallosal lesions, and moderate to severe CHI with callosal atrophy and/or lesions. Interhemispheric transfer of information was assessed using auditory, motor, tactile, and visual tests in patients and in 16 uninjured children. Total and regional callosal areas were measured from the midsagittal MRI slice by morphometry. The corpus callosum lesion group demonstrated a greater right ear advantage on verbal dichotic listening than all other groups. Areas of the posterior corpus callosum were negatively correlated with laterality indices of verbal dichotic listening performance and tachistoscopic identification of verbal material. The relationship of corpus callosum atrophy and/or lesions to asymmetry in dichotic listening is consistent with previous investigation of posttraumatic hemispheric disconnection effects in adults.

Construct validity of the Continuous Recognition Memory test.

A principal factor analysis was performed on variables derived from a neuropsychological battery administered to 100 healthy young adults in order to investigate the construct validity of the Continuous Recognition Memory test (CRM). It was hypothesized that CRM "hits" and "false alarms" would load on different factors. The factors that emerged in the analysis were labeled "Verbal Ability", "Divided Attention", "Attention to Visual Detail", "Visuomotor Integration and Planning", and "Learning and Memory". As expected, CRM hits had a significant loading on the Learning and Memory factor. However, CRM false alarms did not have a significant loading on the Divided Attention factor as expected and, instead, loaded significantly on the Attention to Visual Detail factor. A second analysis was performed using variables from the delayed condition of the memory measures. In this analysis, the CRM delayed recognition variable had significant loadings on both a "Nonverbal Memory" factor and a "Verbal Memory" factor. These analyses support the construct validity of CRM hits as a measure of learning and memory and suggest that false alarms provide a measure of attention to visual detail.

Hyperglycemia increases neurological damage and behavioral deficits from post-traumatic secondary ischemic insults.

The effects of post-traumatic administration of glucose 2.0 g/kg was compared to saline infusion with and without control of brain temperature at 37 degrees C on behavioral and histological measures of brain injury after controlled cortical impact injury complicated by a secondary ischemic insult. The glucose infusion increased blood glucose concentration from 114 +/- 4 to 341 +/- 76 mg/dl prior to the secondary ischemic insult. The resulting outcome measures were significantly worse in the glucose infusion group than in either control group. Mortality rate was significantly increased by the glucose administration, from 0% to 55% (p < 0.001). The median contusion volume was increased from 7.9 to 64.2 by glucose administration (p < 0.001) and the neuronal loss in the CA1 and CA3 areas of the hippocampus were greater in the glucose infusion group. In the animals that survived for the 2 weeks of behavioral studies, the duration of beam balance was shorter; the percent of animals that could balance on the beam for at least 60 s was less, the percent of animals that could perform the beam-walking task was less, and the length of time required to find the platform in the Morris water maze task was longer in the glucose infusion group. These studies demonstrate that the infusion of glucose after the cortical impact injury significantly increases the damage caused by post-traumatic ischemic insults. The adverse effect on neurological outcome could not be explained by the temperature effects of glucose infusion.

Predictors of psychological health in caregivers of patients with closed head injury.

The purpose of the current study was to investigate the contribution of coping strategies, subjective burden, and social support to psychological health in caregivers. The sample included 69 primary caregivers of patients with severe closed head injuries. There were three groups of caregivers: acute (0-6 months post-injury); intermediate (6 months-1.5 years); and long-term (> 1.5 years). All had participated in rehabilitation. Caregivers completed an interview and series of questionnaires, including the Ways of Coping Questionnaire, Social Support Questionnaire, Subjective Burden Measure, and General Health Questionnaire. The Disability Rating Scale was completed by staff to assess patients' level of functioning at the time of caregivers' assessment. ANOVA revealed no between-group differences in coping style or social support. Multiple regression revealed that greater use of emotion-focused coping was associated with greater emotional distress. Coping style contributed to a greater proportion of the variance in caregivers' psychological health that did patients' level of functioning. Increased satisfaction with social support was associated with less emotional distress. The full model, including group, caregiver gender, emotion-focused coping, social support, patient level of recovery, burden, and the burden x coping interaction accounted for over half of the variance in psychological health. Results support a multidimensional model for explaining caregivers' adjustment.

The neuropsychology of trichotillomania.

The pathophysiology of trichotillomania (TM) is not well understood. Overlap with obsessive compulsive disorder (OCD) has been proposed, although extant data are inconsistent in this regard. In the neuropsychological domain, some data have supported the proposed TM-OCD overlap. However, the available studies are limited in number, and they typically have sampled a restricted range of performance domains. To examine further neuropsychological functioning in TM, the present study compared performance of 21 patients with TM and 17 normal control (NC) participants on a broad battery of tests assessing intellectual functioning, auditory perception and language, visual perception, somatosensory function, motor ability, memory, concept formation, attention and information processing speed, impulsivity, and cerebral dominance. The TM group demonstrated poorer performance on all measures of divided, but not focused, attention. Correlational data suggested the potentially important role of negative affect in TM. Implications of the data for the conceptualization of TM are discussed.

Head injury and the Satz-Mogel type short form WAIS-R.

The current study investigated the efficacy of a Satz-Mogel type short form of the WAIS-R in a closed head injury (CHI) population and whether the short form's effectiveness varied by lesion site. Data were taken from the files of 79 CHI patients, 20 with left hemisphere damage, 15 with right hemisphere damage, 29 with bilateral damage, and 15 with only diffuse damage. Information about IQ scores and age-corrected subtest scores was examined. As expected, correlations between two forms, for both IQ scores and subtest scores were high. However, there was a remarkable percentage of deviation in scaled score points and changes in intellectual classification for some of these scores. No evidence was found to support the notion that usefulness of the short form varied according to the location of lesion.

Continuous recognition memory tests: are the assumptions of the theory of signal detection met?

Two continuous recognition memory tests were administered to 20 males and 20 females using the confidence rating procedure to determine if the underlying assumptions of the theory of signal detection (TSD) are met by these tasks. Z-score transformed ROC curves proved to be straight lines parallel to the positive diagonal of the ROC graph. These findings suggest that the distributions of familiarity for old and new stimuli are normal and of equal variance for the Continuous Recognition Memory and Continuous Visual Memory Tests. TSD interpretation of test data appears to be justified.

Effects of chronic alcoholism on hemispheric functioning: an examination of gender differences for cognitive and dichotic listening tasks.

A pattern of intact verbal abilities and impaired visuospatial abilities has led to a hypothesis of alcohol-induced right-hemisphere dysfunction in male chronic alcoholics. The applicability of this hypothesis to chronic female alcoholics was examined by administering the WAIS-R, Stark Paired Associates Tasks, and dichotic listening tasks to 15 male and 10 female alcoholics and 15 male and 10 female controls of similar age and education. Alcoholics had significantly lower Full Scale IQ scores on the WAIS-R but neither sex had a Verbal-Performance IQ difference indicative of right-hemisphere dysfunction. Male alcoholics showed deficits on both the Verbal and Visuospatial Stark Tasks, the deficit being greater on the Visuospatial Task. Male alcoholics showed an increased right-ear superiority on the verbal dichotic listening task and a decreased left-ear superiority on the musical dichotic listening task, both indicative of right-hemisphere dysfunction. The results, except for the WAIS-R, support the hypothesis that male but not female chronic alcoholics exhibit right-hemisphere dysfunction. Females, alcoholic or not, appear to be less lateralized in function.

Self-report of right-left confusion in college men and women.

Self-report questionnaires of difficulty in right-left discrimination and handedness were given to 575 male and 607 female undergraduates. Significantly more men and lefthanders reported having right-left confusion frequently or all the time. The validity of such self-report measures in predicting actual performance on right-left discrimination tasks is questioned since the results, at least as a function of handedness, depended on the question asked.

Visual Continuous Recognition Memory in normal and closed-head-injured adolescents.

The Continuous Recognition Memory Test was administered to 46 normal adolescents and 91 closed-head-injured adolescents. Performance on the test varied significantly with severity of injury as measured by the Glasgow Coma Scale score and duration of impaired consciousness. The performance of adolescents with diffuse injury, right, left, or bilateral mass lesions did not differ significantly. The efficacy of the test for use with head-injured adolescents is demonstrated.

Focal right temporo-occipital blood flow changes associated with judgment of line orientation.

Focal cerebral blood flow changes for judgment of line orientation were determined using the 133Xe inhalation technique with 18 normal right-handed male subjects. Measurements were made during three conditions in the same session: a line orientation task, a sensorimotor control task, and normal rest. Blood flow changes attributable to the judgment of line orientation were found for the measure f1 at a detector centered over the right temporo-occipital region. For the measure IS this activation was significant in the temporo-occipital region in both hemispheres but significantly greater in the right hemisphere. For f1 the change in blood flow and for IS the percent change in blood flow in the right temporo-occipital region attributable to judgment of line orientation decreased as performance on the line orientation task improved.

Relationships among anxiety, defensiveness, sex, task difficulty, and performance on various neuropsychological tasks.

The relationships between sex, personality differences, task difficulty, and the performance on neuropsychological tests were investigated. On the basis of trait anxiety and defensiveness, 120 college students were divided into three groups by coping style: high anxious, true low anxious, and repressor groups. As predicted, women obtained significantly higher scores than men on Digit Symbol and word fluency tests, while the opposite sex difference was found for Block Design and Finger Tapping tests. Performance did not vary with trait anxiety. However, on Block Design and one-word fluency test, rated by subjects as the most difficult tests, high state anxiety was associated with significantly poorer performance.