Consciousness recovery after various periods in vegetative state.

BACKGROUND: Recent studies suggest that late recovery from vegetative state (VS) is more prevalent today than previously thought. This study examined the decline in the rate of recovery from VS with time after admission to rehabilitation, and established a new time frame, in which the odds of recovery from VS remain substantial. METHODS: Data of 206 patients with VS after traumatic and non-traumatic brain injuries (TBI and NTBI), who were treated at the Loewenstein Rehabilitation Hospital (LRH), in Raanana, Israel, between 2003 and 2015, and described in a previous publication, were further analysed. Rate of recovery from VS was monitored at several time points after admission to intensive care and consciousness rehabilitation (ICCR). RESULTS: The odds of consciousness recovery were at least 54% at admission to ICCR, and 48%, 33%, 19%, and 7% at 3, 6, 9, and 12 months after admission, respectively. CONCLUSIONS: The rate of recovery from VS decreases significantly with time, but contrary to previous consensus, 6-12 months after admission to ICCR, the odds of recovery from VS after TBI and NTBI remain substantial.

Validation of the QOLIBRI - Quality of Life after Brain Injury questionnaire in patients after TBI in Israel.

BACKGROUND: The QOLIBRI - Quality of Life after Brain Injury questionnaire was developed by the QOLIBRI Task Force (QTF). Our goal was to investigate the applicability, validity and reliability of the QOLIBRI in Israel. METHODS: Validation of the Hebrew questionnaire was performed after it had been administered to 128 adults with traumatic brain injury (TBI), who were between 3 months' and 15 years' post-discharge from rehabilitation. RESULTS: The internal consistency of the QOLIBRI subscales with the QOLIBRI Total scale was high (Cronbach's α = 0.92); the same was true regarding the correlations between each QOLIBRI subscale and its own items (α = 0.92-0.95). Significant and high Pearson's and Spearman's correlations of the QOLIBRI subscales with demographic and clinical characteristics of the GOSE, ADL, HADS, SF-36, and various aspects of self-reported health status were found. Factor analyses (FA) were applied to confirm the validity of the Hebrew version, using the maximum likelihood method. The six subscales explained 100% of the variance. CONCLUSION: The Hebrew version of the QOLIBRI was found to be useful, meaningful and meeting psychometric criteria in persons after TBI in Israel. The findings support the cross-cultural applicability of the QOLIBRI, regardless of cultural and social differences.

Survival and mortality following TBI.

OBJECTIVES: Evaluation of life expectancy (LE) post traumatic brain injury (TBI) is important for planning services for patients and for dealing with medico-legal aspects. We hypothesized that LE for patients who survived 2 years post injury is equal to that of the general population (GP). METHODS: A cohort of 279 patients was assembled during a 5-year period and was followed for 22-27 years. During follow-up, 32 patients (11.5%) died, creating a huge censored data (88.5%). Analyses included standard mortality ratio (SMR), Kaplan-Meier method (KM), Cox proportional hazards regression analysis (PH) and calculations of life expectancy. RESULTS: About 77% of the patients were under 35 years of age at injury. This age cut-off point yielded differences for survival longevity by χ2 tests (p < 0.0001), by KM analysis (p < 0.0001) and by Cox PH regression analysis (p < 0.0001, HR = 13.95). SMR for the entire cohort was 1.86. Shortening of LE in comparison with the GP is 3.58 years. Estimated shortening of LE by severity for mild, moderate and severe injury were -0.51, 4.11 and 13.77 years, respectively. CONCLUSIONS: Patients with mild TBI have a LE similar to the GP, and a reduction in LE was closely related to moderate and severe brain injury.

Vegetative state outcomes improved over the last two decades.

OBJECTIVE: To describe late outcomes in patients with prolonged unawareness, and factors affecting them. DESIGN: A retrospective study of 154 patients with traumatic brain injury (TBI) and 52 with non-traumatic brain injury (NTBI), admitted for intensive care and consciousness rehabilitation (ICCR), in a vegetative state (VS) lasting over 1 month. RESULTS: Survival rate (67% total) was higher than in past studies carried out at the same facility (p < 0.01). Consciousness recovery rate (54% total) was higher in NTBI VS patients (p < 0.01) than in earlier cohorts, and similar in TBI VS patients, despite their older age than that of earlier cohorts. No meaningful differences were found in characteristics or in outcomes between the TBI and NTBI groups. Age, length of stay in ICCR, and hydrocephalus were found to affect survival (p < 0.001). Younger age, absence of hydrocephalus, and anti-Parkinsonian medication contributed to consciousness recovery after VS (p < 0.05). CONCLUSIONS: The present study demonstrated an improvement in survival and recovery of consciousness in VS patients over the last two decades, and similar outcomes for both TBI and NTBI VS. Outcomes suggest that acute medical care and ICCR have contributed to advances in VS care.

Long-term functional outcome after moderate-to-severe paediatric traumatic brain injury.

BACKGROUND: Long-term follow-up studies after severe and moderate pediatric traumatic brain injury (TBI) are not common and inconclusive. Most studies focused on neurobehavioural sequelae, less data is reported about age appropriate function. Different prognostic factors were noted over past decades. METHODS: A prospective historical study describing the functional long-term outcome after childhood moderate and severe TBI was conducted. Seventy-seven children who suffered either severe or moderate TBI were followed for an average of ten years and clinical functional outcome was recorded. Factors influencing prognosis were investigated. RESULTS: All children but six were integrated into educational systems after discharge from rehabilitation settings (department and day-care); 61% of children who suffered severe-moderate TBI were able to function within their normative age peers. Positive outcome predictors were Glasgow Coma Scale (GCS) >5, length of unconsciousness (LOC) <11 days, Functional Independence Measure (FIM) and Intelligence Quotient (IQ) at discharge from rehabilitation, length of acute hospitalization and rehabilitation. Negative outcome predictors were vegetative state at admission to rehabilitation and associated anoxic brain injury. CONCLUSIONS: Guarded optimistic functional outcome can be expected after severe or moderate childhood TBI.

[Temporal change in rehabilitation outcome of patients following severe traumatic brain injury].

The clinical experience in recent years regarding vocational outcome of patients following traumatic brain injury (TBI) led to the impression of worse outcomes in recent years. A comparative study was therefore conducted between a "control group" of patients who were treated during the years 1980-1985 (n=147), evaluated during 1993 and a "research group" hospitalized between 1998-2001 and evaluated during 2004 (n=247). No significant differences were found between the control and research groups regarding most of the demographic and injury-related parameters. Significant differences were found regarding the length of inpatient rehabilitation stay which was found to be shorter in the "research group" (165 and 117 days respectively, p < 0.0001). More patients in the research group were left with cognitive and behavioral disturbances at the time of discharge (p < 0.0001) and less patients in the research group were able to achieve gainful employment (50.6% and 34.8% respectively, p < 0.0001). On many occasions, recommendations given at the time of discharge were not fulfilled. The compliance for further treatment was quite high regarding physiotherapy (85%) but when it came to cognitive or behavioral treatment the percentage dropped to only about 60%. Patients were not satisfied with the attitudes of their health care providers, especially with regard to health funds and insurance companies. It is concluded that discharge of patients who may physically look fit is premature. The effect of residual cognitive and behavioral disturbances, which, at the end, determine the overall outcome of patients with TBI, is underestimated and treatment is prematurely discontinued, leading to a less successful outcome for these young patients in recent years. It is speculated that any saving in cost due to shortening of the stay in hospital leads to a worse outcome and possible larger compensations due to inability to achieve gainful employment.

Methylphenidate effect on hemispheric attentional imbalance in patients with traumatic brain injury: a psychophysical study.

PRIMARY OBJECTIVE: We found spatially asymmetric allocation of attention in patients with traumatic brain injury (TBI) without overt asymmetry on neurological examination. The possible effect of Methylphenidate in reducing this asymmetry is evaluated in the current research. RESEARCH DESIGN: Psychophysical study using a visual spatial attention task. Identification rates were measured after precuing attention to different visual field loci. TBI patients were tested before, during and after administration of Methylphenidate. METHODS AND PROCEDURES: After precuing to a locus 5 degrees into the left or right hemifield, target patterns were presented briefly at the cued location (valid), or on the opposite side (invalid) - requiring an attentional shift. Patients were treated with a gradually increasing dosage of a psychostimulant over two weeks, followed by a similar two-week period of gradually diminishing dosage. Patients were tested before treatment, at its peak, and (twice) following its completion. MAIN OUTCOME AND RESULTS: Patients demonstrated significantly worse performance with leftward than with rightward cross-hemifield shifts of attention. This difference was significantly reduced during and following treatment. CONCLUSIONS: Asymmetric performance and improvement with treatment suggest that diffuse TBI damage leads to a lateralized attention-related deficit. These findings support the hypotheses that attention is a distributed and asymmetrically lateralized function. The findings are consistent with the conclusion that Methylphenidate may be an effective treatment for attentional deficits in TBI patients.

Hemispheric visual atentional imbalance in patients with traumatic brain injury.

We find a spatially asymmetric allocation of attention in patients with traumatic brain injury (TBI) despite the lack of obvious asymmetry in neurological indicators. Identification performance was measured for simple spatial patterns presented briefly to a locus 5 degrees into the left or right hemifield, after precuing attention to the same (ipsilateral) or opposite (cross-hemifield) side. Though the cue was non-predictive of target location overall, performance was significantly slower for cross than for ipsilateral trials in both patients and controls. We tested 21 TBI patients without overt focal brain damage and nine control subjects. Only patients demonstrated significantly worse performance for left side presentation in the ipsilateral condition. Furthermore, in the cross-hemifield condition, the left-right difference seen in TBI patients was significantly larger-reflecting a failure in producing a leftward attention shift. Again no significant difference was found in controls. These hemifield effects suggest an asymmetry in the ability of TBI patients in shifting attention to the left hemifield, whether from central fixation or from a cue in the contra-lateral hemifield. The results support basic hypotheses regarding visual attention: Attentional control may be asymmetric and attention may be a distributed, rather than localized cortical function.

Vegetative state.

Nowadays more and more patients survive severe brain injury, whether due to traumatic or other causes, owing to the technological advances in medicine. Added to this is a better understanding of pathophysiologic processes, the quality and availability of emergency medicine, and increased medical knowledge in the field. More patients are regaining consciousness than previously. Recovery of functional ability ranges from those still requiring significant nursing care to those able to function independently in activities of daily living. These changes in the levels of consciousness and function can also occur after very long periods of vegetative state. In our personal experience in the hospital, in 2004, 81% of patients in a post-traumatic vegetative state recovered some level of consciousness.

Differential time and related appearance of signs, indicating improvement in the state of consciousness in vegetative state traumatic brain injury (VS-TBI) patients after initiation of dopamine treatment.

OBJECTIVE: The goal of the study was to look for the response of treatment with increasing doses of dopaminergic medication on the recovery of vegetative state patients post-TBI. DESIGN: A prospective study of eight patients aged 25-50 years in vegetative state (VS) of mean duration of 104 days following traumatic brain injury (TBI) was performed by investigating changes of their state of consciousness while they were treated with levodopa/carbidopa. RESULTS: Initial improvement was observed in all patients within a mean of 13 days after onset of treatment. Seven patients recovered consciousness after a mean time of 31 days of treatment. The remaining patient showed only slight improvement to minimally conscious state. The sequence of symptoms leading to recovery was the same in all patients; the first to appear was moving a limb on a request, which appeared at a mean time of 13 days. Gradual increase of dose leads to the appearance of better-organized responses like reacting to more than one command, than opening the mouth and appearance of a reciprocal contact. The only side effect was visual hallucinations in one patient, which disappeared after decreasing the dosage. CONCLUSIONS: Clinical awareness to the structured order of responses and to the effect of dosage can help clinicians in early assessment of response to dopaminergic treatment in VS patients.

Script memory for typical and atypical actions: controls versus patients with severe closed-head injury.

OBJECTIVE: When typical and atypical information about a situation is presented, the latter is usually better recognized. This phenomenon is referred to as the 'typicality effect'. It is claimed by most theories that typical and atypical information are mediated by automatic and effortful processes, respectively. Previous studies reported that patients with closed-head injury (CHI) are impaired only on memory tasks that required effortful but not automatic processes. Accordingly, it was hypothesized that these patients would not show the typicality effect when presented with scripts composed of typical and atypical actions. METHOD: Twenty-two patients with CHI and 23 matched controls listened to two scripts which consisted of typical and atypical activities. RESULTS: As predicted, the findings of the present study revealed impaired typicality effect for patients with CHI as compared with controls. The advantage of the control group over the CHI group was more pronounced in the recognition of atypical than typical actions. CONCLUSIONS: The results are discussed in terms of the limited attentional capacity or passive learning strategy, characteristic of memory impairment in patients with CHI.

Impaired skill learning in patients with severe closed-head injury as demonstrated by the serial reaction time (SRT) task.

A group of 20 patients who sustained closed-head injury (CHI) and a matched control group of 20 individuals were tested on the serial reaction time (SRT) task. Three different sequence-learning measures were generated from the task: two implicit and one explicit. The two implicit sequence-learning measures include: (1) the learning rate on the first five blocks of the repeated sequence, assumed to reflect primarily general reaction time learning, and (2) the difference between the fifth block of the repeated sequence and the sixth block, a random sequence that reflects implicit sequence-specific learning. In addition, an explicit measure of sequence learning was generated. The results indicate that the CHI group was impaired on the explicit measure of sequence learning. The groups did not differ on general reaction time learning, one of the implicit measures of sequence learning. However, the control group was superior to the CHI group in learning the specific sequence repeated in the SRT task. This pattern of results is unique to the CHI group, corresponding with neither that of amnesic patients nor with that of patients with dysfunction of the basal ganglia (i.e., Parkinson's diseases).

Quantitative imaging in late TBI. Part II: cognition and work after closed and penetrating head injury: a report of the Vietnam head injury study.

CONTEXT: Functional outcome in relation to CT findings in traumatic brain injured (TBI) patients is not well established in relation to cognitive and vocational outcome. OBJECTIVE: To investigate the possible correlation between relatively simple quantitative radiological measurements and cognitive and vocational outcome. DESIGN: Retrospective analysis of quantitative assessment of CT studies in relation to post-injury cognitive changes and vocational outcome. SETTING: US Army Medical Centre. PATIENTS: 74 penetrating head injured (PHI) and 37 closed head injured (CHI) Vietnam war veterans. OUTCOME MEASURES: The Armed Forces Qualification Test (AFQT); Disability score; Return to work. RESULTS: Total brain volume loss, third ventricle width (3VW), ventricular score (VS), and septum-caudate distance (SCD) were significantly related to cognitive change and return to work in PHI patients. Volume loss and 3VW were the most valuable radiologic predictors of outcome in multivariate linear and logistic regression models for both CHI and PHI. CONCLUSION: 3VW on late CT scans following traumatic brain injury is a powerful predictor of overall long-term cognitive outcomes and potential for return to work.

Searching with unilateral neglect.

We address two longstanding conflicts in the visual search and unilateral neglect literature by studying feature and conjunction search performance of neglect patients using laterally presented search arrays. The first issue relates to whether feature search is performed independently of attention, or rather requires "spread attention." If feature search is "preattentive," it should survive neglect. However, we find neglect effects for both feature and conjunction search, suggesting that feature search, too, has an attentional requirement. The second controversy refers to the space- or object-based nature of neglect following unilateral right-hemisphere parietal lobe damage. If neglect were a purely spatial phenomenon, then we would expect no detriment in performance in the right (nonneglect) field, and diminished performance for the whole left (neglect) field. On the other hand, if neglect were purely object-based, we would expect diminished performance on the left side of the search array, irrespective of its location in the visual field. We now demonstrate a combination of strong object-based and space-based neglect effects for conjunction search with laterally placed element arrays, suggesting that these two mechanisms work in tandem.

Quantitive imaging in late traumatic brain injury. Part I: late imaging parameters in closed and penetrating head injuries.

OBJECTIVE: To ascertain the value of relatively simple quantitative radiologic measurements after head injury. Despite major advances in neuroradiology, analysis and reporting of imaging studies is based primarily on individual subjective and local experience, rather than on reproducible, standardized parameters; reliance on newer technologies can improve care, but also raises diagnostic costs. DESIGN: Blinded, retrospective, quantitative assessment of computerized tomography studies done some 14 years post-injury. OUTCOME MEASURES: Frontal horn width (FHW); septum-caudate distance (SCD); temporal horn width (THW); interuncal distance (IUD); third ventricle width (3VW); ventricular score (VS); sulcal width (SW); gray-white matter discriminability (GWMD) and subjective assessment of atrophy (SAOA). RESULTS: Diffuse and frontal damage was noted in both closed (CHI) and penetrating (PHI) head injury groups. Enlargement of frontal lobe parameters (septum caudate distance and frontal horn width suggest frontal injury in both closed and penetrating traumatic brain injury (TBI). Temporal horn width and inter-uncal distance were related to VS, 3VW and FHW in closed, but not in penetrating head injury. CONCLUSIONS: Simple linear CSF space measurements are correlated with volumetric and parenchymal measures, and can represent valuable and reliable low-cost quantitative measures of long term brain damage after TBI.