Sleep Disruption Persists and Relates to Memory Disability After Traumatic Brain Injury: A Cross-Sectional Study of Adults in the Chronic Phase of Injury.

OBJECTIVE: To examine sleep disruption in chronic traumatic brain injury (TBI) across 3 aims: (1) to examine differences in self-reported sleep disruption between adults with and without a chronic history of TBI; (2) to query reported changes in sleep after TBI; and (3) to explore the relationship between self-reported sleep disruption and memory failures in daily life. SETTING: Community-dwelling participants completed self-report sleep and memory surveys as part of their participation in a larger patient registry. PARTICIPANTS: This study included 258 participants, and half (n = 129) of them have a chronic history of moderate-severe TBI (mean time since injury is 5.1 [SD 6.5] years). DESIGN: We report descriptive statistics from this matched cross-sectional study on sleep in the chronic phase of injury. We also used planned Wilcoxon ranked-sum tests and exploratory correlations to examine the relationships of sleep disruption with TBI diagnosis, injury chronicity, and memory. MAIN MEASURES: We used the Pittsburgh Sleep Quality Index to measure sleep disruption and the Epworth Sleepiness Scale to measure daytime sleepiness. Participants answered questions about postinjury sleep and responded to the Everyday Memory Questionnaire as a measure of memory failures in daily life. RESULTS: Individuals with TBI had significantly higher rates of sleep disruption than those without TBI, as measured by the Pittsburgh Sleep Quality Index but not on the Epworth Sleepiness Scale. Sleep disruption in TBI manifested more in sleep quality than quantity. Half of the participants with TBI reported a negative change in sleep postinjury. In an exploratory analysis, sleep disruption was related to memory failure in daily life in the TBI sample. CONCLUSIONS: Sleep disruption persists long after TBI but may be under-recognized in people with chronic TBI. Given that sleep is critical for memory and rehabilitation outcomes well into the chronic phase of injury, steps to improve the identification and management of sleep disruption are needed. Key words:chronic, memory, sleep, traumatic brain injury.

Measurement of Sleep in Chronic Traumatic Brain Injury: Relationship Between Self-report and Actigraphy.

OBJECTIVE: To examine the relationship between self-report and actigraphy measurement of sleep in people with and without traumatic brain injury (TBI) by addressing 2 aims: (1) to assess the relationship between self-report and actigraphy for sleep quantity in people with and without TBI; and (2) to explore how self-report and actigraphy capture sleep quality in TBI. SETTING: Participants completed the study over 2 weeks in their own homes. They wore activity monitors, day and night, throughout the experiment and completed morning sleep diaries while interacting with an experimenter on videoconference. PARTICIPANTS: This project was embedded in a larger study on sleep and word learning in 100 adults: 50 with chronic, moderate-severe TBI and 50 demographically matched noninjured peers. Of the 100 participants who completed the larger study, 92 participants (45 with TBI and 47 noninjured peers) had sufficient actigraphy data for inclusion in the current study. DESIGN: We used multilevel linear regression models and correlation analyses to assess how well participants' self-report corresponded to actigraphy measurement of sleep. MAIN MEASURES: Actigraphy measures included nightly sleep duration and nighttime wakeups. Sleep diary measures included self-reported nightly sleep duration, nighttime wakeups, sleep quality, and morning fatigue. RESULTS: People with and without TBI did not differ in the relationship between self-reported and actigraphy measurement of sleep quantity. Performance on a neuropsychological memory assessment did not correlate with the difference in self-reported and actigraphy-measured sleep in the TBI group. Sleep characteristics that were measured by actigraphy did not predict subjective experiences of sleep quality or fatigue. CONCLUSIONS: Short-term self-report diaries capture accurate information about sleep quantity in individuals with TBI and may support self-report of other daily habits. Future research is needed to identify reliable metrics of sleep quality, and how they relate to other domains such as memory and mood, in the chronic phase of TBI.

Emotion recognition of faces and emoji in individuals with moderate-severe traumatic brain injury.

BACKGROUND: Facial emotion recognition deficits are common after moderate-severe traumatic brain injury (TBI) and linked to poor social outcomes. We examine whether emotion recognition deficits extend to facial expressions depicted by emoji. METHODS: Fifty-one individuals with moderate-severe TBI (25 female) and fifty-one neurotypical peers (26 female) viewed photos of human faces and emoji. Participants selected the best-fitting label from a set of basic emotions (anger, disgust, fear, sadness, neutral, surprise, happy) or social emotions (embarrassed, remorseful, anxious, neutral, flirting, confident, proud). RESULTS: We analyzed the likelihood of correctly labeling an emotion by group (neurotypical, TBI), stimulus condition (basic faces, basic emoji, social emoji), sex (female, male), and their interactions. Participants with TBI did not significantly differ from neurotypical peers in overall emotion labeling accuracy. Both groups had poorer labeling accuracy for emoji compared to faces. Participants with TBI (but not neurotypical peers) had poorer accuracy for labeling social emotions depicted by emoji compared to basic emotions depicted by emoji. There were no effects of participant sex. DISCUSSION: Because emotion representation is more ambiguous in emoji than human faces, studying emoji use and perception in TBI is an important consideration for understanding functional communication and social participation after brain injury.

Memory for social media images following traumatic brain injury.

PRIMARY OBJECTIVE: An emerging body of research examines the role of computer-mediated communication in supporting social connection in persons with traumatic brain injury (TBI). We examine the cognitive impacts of engaging with images posted to social media for persons with moderate-severe TBI. RESEARCH DESIGN: Prior work shows that after viewing social media posts, adults have better memory for posts when they generate a comment about the post. We examined if persons with TBI experience a memory benefit for commented-upon social media images similar to non-injured comparison participants. METHODS AND PROCEDURES: 53 persons with moderate-to-severe TBI and 52 non-injured comparison participants viewed arrays of real social media images and were prompted to comment on some of them. After a brief delay, a surprise two-alternative forced choice recognition memory test measured memory for these images. MAIN OUTCOMES AND RESULTS: Persons with TBI remembered social media images at above-chance levels and experienced a commenting-related memory boost much like non-injured comparison participants. CONCLUSIONS: These findings add to a growing literature on the potential benefits of social media use in individuals with TBI and point to the benefits of active engagement for memory in social media contexts in TBI.

Evidence of impaired naming in patients with hippocampal amnesia.

Object naming involves accessing meaning and retrieving the associated word form from remote semantic memory. Historically, previously acquired semantic knowledge (i.e., remote semantic memory) was thought to be independent of the hippocampus via neocortical consolidation. This view is based on evidence demonstrating a dissociation in behavior in patients with hippocampal amnesia: amnesic patients are impaired in acquiring new vocabulary yet can name and define previously acquired words. More recently, the view that remote semantic memory is hippocampus-independent has been challenged by the documentation of disruptions in aspects of remote semantic memory in patients with hippocampal amnesia, particularly in language use and depth of semantic knowledge. Based on these findings, we hypothesized that the hippocampus plays a long-term role in remote semantic memory. We tested amnesic patients and demographically matched healthy comparison participants in an extensive naming task using photographic images of objects normalized for familiarity, object agreement, and visual complexity. Amnesic patients were less likely to correctly name objects than healthy comparison participants. Further, amnesic patients' performance worsened for words that were less familiar, more visually complex, and had less object agreement. These findings suggest that the hippocampus may play a long-term role in semantic memory processes, rather than a time-limited role in the initial acquisition of semantic information, and that hippocampal damage can disrupt object naming.

Worse Than Death: Survey of Public Perceptions of Disability Outcomes After Hypothetical Traumatic Brain Injury.

OBJECTIVE: The aim of this study was to determine the health utility states of the most commonly used traumatic brain injury (TBI) clinical trial endpoint, the Extended Glasgow Outcome Scale (GOSE). SUMMARY BACKGROUND DATA: Health utilities represent the strength of one's preferences under conditions of uncertainty. There are insufficient data to indicate how an individual would value levels of disability after a TBI. METHODS: This was a cross-sectional web-based online convenience sampling adaptive survey. Using a standard gamble approach, participants evaluated their preferences for GOSE health states 1 year after a hypothetical TBI. The categorical GOSE was studied from vegetative state (GOSE2) to upper good recovery (GOSE8). Median (25th percentile, 75th percentile) health utility values for different GOSE states after TBI, ranging from -1 (worse than death) to 1 (full health), with 0 as reference (death). RESULTS: Of 3508 eligible participants, 3235 (92.22%) completed the survey. Participants rated lower GOSE states as having lower utility, with some states rated as worse than death, though the relationship was nonlinear and intervals were unequal between health states. Over 75% of participants rated a vegetative state (GOSE2, absence of awareness and bedridden) and about 50% rated lower severe disability (GOSE3, housebound needing all-day assistance) as conditions worse than death. CONCLUSIONS: In the largest investigation of public perceptions about post-TBI disability, we demonstrate unequally rated health states, with some states perceived as worse than death. Although limited by selection bias, these results may guide future comparative-effectiveness research and shared medical decision-making after neurologic injury.

Unexpected absence of aphasia following left temporal hemorrhage: a case study with functional neuroimaging to characterize the nature of atypical language localization.

Unexpected absence of aphasia after left-hemisphere perisylvian damage is often assumed to reflect right-hemisphere language lateralization, but other potential explanations include bilateral language representation, or sparing of critical left-hemisphere regions due to individual variability. We describe the case of a left-handed gentleman who presented with no aphasia after a left temporal hemorrhage. We used functional neuroimaging to determine how his language network had been spared. In this case, we observed unequivocal right-hemisphere lateralization of language function, explaining his lack of aphasia. We discuss the variability of language organization and highlight outstanding questions about the implications of damage in different scenarios.

Disability and the COVID-19 Pandemic: A Survey of Individuals With Traumatic Brain Injury.

OBJECTIVES: To identify the consequences of the coronavirus 2019 (COVID-19) pandemic for individuals with traumatic brain injury (TBI), with particular attention to unique effects for individuals with chronic disability. DESIGN: Individuals with and without a history of TBI completed a web-based survey. SETTING: Participants were recruited from the Vanderbilt Brain Injury Patient Registry in Nashville, TN, and completed the survey from their homes between May and June 2020, during social distancing related to the COVID-19 pandemic. PARTICIPANTS: Participants (N=47) in the chronic phase of moderate-severe TBI (>6mo postinjury) and 51 noninjured comparison (NC) peers completed the survey. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants, or respondents, answered a mix of multiple choice and free text questions about how the COVID-19 pandemic has affected their work, education, medical care, social communication, sources of information and decision making, and mental and physical well-being. Individuals with TBI also answered questions about how TBI has affected their experiences of the pandemic. RESULTS: As a group, respondents with TBI reported less pandemic-related behavior change (eg, daily habits, virtual social visits, and masking) than NC peers. Both NCs and respondents with TBI identified health care providers as trusted sources of public health information. One-third of individuals with TBI indicated that brain injury has made coping with the pandemic more difficult, and respondents identified mental health challenges and social isolation as key barriers. CONCLUSIONS: These results suggest that health care providers should look for ways to provide tailored education and reduce social isolation for individuals with disability during the ongoing COVID-19 pandemic. We discuss several direct suggestions from participant responses.

Traumatic brain injury in the acute care setting: assessment and management practices of speech-language pathologists.

PRIMARY OBJECTIVE: To characterize current knowledge, beliefs, confidence, and practice patterns of acute care speech-language pathologists (SLPs) in assessing and managing cognitive-communication disorders following traumatic brain injury (TBI). RESEARCH DESIGN: We developed an online survey to learn more about current TBI knowledge and practice patterns of acute care SLPs, with the goal of establishing a baseline upon which changes in SLP training and practice standards may be measured. METHODS AND PROCEDURES: We distributed the survey to 1800 SLPs in 18 states via postal mail, in addition to posting it to relevant online groups. One hundred and eighty-two practicing acute care SLPs responded to the survey. MAIN OUTCOMES AND RESULTS: Respondents were highly variable in their training and knowledge about TBI, their beliefs about cognitive-communication rehabilitation, and their practice patterns in assessing, managing, and communicating about TBI during the acute stage of injury. CONCLUSIONS: These results highlight the need for more consistent training about cognitive-communication deficits during and after graduate school, as well as the development of sensitive, specific, and standardized assessment tools, education protocols, and shared language for describing patients with TBI along the continuum of care.

Traumatic brain injury and creative divergent thinking.

PRIMARY OBJECTIVE: The current study examined how creative divergent thinking (i.e., the ability to produce varied and original solutions to a problem) is impacted by moderate-to-severe traumatic brain injury (TBI). RESEARCH DESIGN: Descriptive, observational. METHODS AND PROCEDURES: We administered two tasks of divergent thinking, the Abbreviated Torrance Test for Adults (ATTA) and the Alternative Uses Test (AUT), as well as a battery of neuropsychological tests and psychosocial variables (assessing memory and learning, processing speed, set shifting and psychological distress), to 29 individuals with TBI and 20 demographically-matched healthy comparison participants. MAIN OUTCOMES AND RESULTS: Individuals with TBI performed similarly to healthy individuals on both tests of creative thinking, although they were impaired on the neuropsychological tasks. Moreover, there was no significant correlation between performance on the ATTA and performance on neuropsychological tests, but within the TBI group AUT performance and memory were significantly and positively associated. CONCLUSIONS: Our findings reveal that divergent thinking, as measured by the ATTA and AUT, might be spared following moderate-to-severe TBI. These findings further our understanding of the higher-level cognitive sequelae of TBI and suggest that divergent thinking might be leveraged during treatment planning.

Ventromedial Prefrontal Cortex Is Necessary for Normal Associative Inference and Memory Integration.

The ability to flexibly combine existing knowledge in response to novel circumstances is highly adaptive. However, the neural correlates of flexible associative inference are not well characterized. Laboratory tests of associative inference have measured memory for overlapping pairs of studied items (e.g., AB, BC) and for nonstudied pairs with common associates (i.e., AC). Findings from functional neuroimaging and neuropsychology suggest the ventromedial prefrontal cortex (vmPFC) may be necessary for associative inference. Here, we used a neuropsychological approach to test the necessity of vmPFC for successful memory-guided associative inference in humans using an overlapping pairs associative memory task. We predicted that individuals with focal vmPFC damage (n = 5; 3F, 2M) would show impaired inferential memory but intact non-inferential memory. Performance was compared with normal comparison participants (n = 10; 6F, 4M). Participants studied pairs of visually presented objects including overlapping pairs (AB, BC) and nonoverlapping pairs (XY). Participants later completed a three-alternative forced-choice recognition task for studied pairs (AB, BC, XY) and inference pairs (AC). As predicted, the vmPFC group had intact memory for studied pairs but significantly impaired memory for inferential pairs. These results are consistent with the perspective that the vmPFC is necessary for memory-guided associative inference, indicating that the vmPFC is critical for adaptive abilities that require application of existing knowledge to novel circumstances. Additionally, vmPFC damage was associated with unexpectedly reduced memory for AB pairs post-inference, which could potentially reflect retroactive interference. Together, these results reinforce an emerging understanding of a role for the vmPFC in brain networks supporting associative memory processes.SIGNIFICANCE STATEMENT We live in a constantly changing environment, so the ability to adapt our knowledge to support understanding of new circumstances is essential. One important adaptive ability is associative inference which allows us to extract shared features from distinct experiences and relate them. For example, if we see a woman holding a baby, and later see a man holding the same baby, then we might infer that the two adults are a couple. Despite the importance of associative inference, the brain systems necessary for this ability are not known. Here, we report that damage to human ventromedial prefrontal cortex (vmPFC) disproportionately impairs associative inference. Our findings show the necessity of the vmPFC for normal associative inference and memory integration.

The Hippocampus Promotes Effective Saccadic Information Gathering in Humans.

It is well established that the hippocampus is critical for memory. Recent evidence suggests that one function of hippocampal memory processing is to optimize how people actively explore the world. Here we demonstrate that the link between the hippocampus and exploration extends even to the moment-to-moment use of eye movements during visuospatial memory encoding. In Experiment 1, we examined relationships between study-phase eye movements in healthy individuals and subsequent performance on a spatial reconstruction test. In addition to quantitative measures of viewing behaviors (e.g., how many fixations or saccades were deployed during study), we used the information-theoretic measure of entropy to assess the amount of randomness or disorganization in participants' scanning behaviors. We found that the use of scanpaths during study that were lower in entropy (e.g., more organized, less random) predicted more accurate spatial reconstruction both within and between participants. Scanpath entropy was a better predictor of reconstruction accuracy than were the quantitative measures of viewing. In Experiment 2, we found that individuals with hippocampal amnesia tended to engage in viewing patterns that were higher in entropy (less organized) relative to healthy comparisons. These findings reveal a critical role of the hippocampus in guiding eye movement exploration to optimize visuospatial relational memory.

Lonely But Not Alone: Neuroticism Mediates the Relationship Between Social Network Size and Loneliness in Individuals With Traumatic Brain Injury.

Objectives: Although individuals with traumatic brain injury (TBI) often report higher levels of social isolation, little is known about the factors influencing their self-perception of loneliness. The aim of the current study was to investigate the relationship between loneliness, social network size, and personality variables (neuroticism and extraversion) after TBI, and in particular whether specific personality variables mediate the relationship between social network size and perception of loneliness. Methods: Here, we assessed self-reported loneliness, personality variables, and social network size of 24 individuals with moderate-to-severe TBI and 41 healthy comparison participants. We then carried out a mediation analysis to examine whether personality variables mediated the relationship between loneliness and social network size. Results: Our results indicate that individuals with TBI reported higher levels of loneliness and neuroticism, but there was no group difference in social network size or extraversion. The mediation analysis revealed that the association between social network size and loneliness was mediated by neuroticism, but not by extraversion. Conclusions: Our findings show that neuroticism is an intervening variable in the relationship between social network size and self-perception of loneliness in individuals with moderate-to-severe TBI, and presents a new possible target for clinicians and rehabilitators seeking to address reports of loneliness and social isolation in TBI. (JINS 2019, 25, 266-274).

Characterizing computer-mediated communication, friendship, and social participation in adults with traumatic brain injury.

BACKGROUND: Adults with traumatic brain injury (TBI) report loss of friendship and reduced social participation after injury, but there is limited information regarding quantity of friends and methods of communication. Our objective was to characterize friendship networks, social participation, and methods of communication, including computer-mediated communication (CMC), used by adults with TBI compared to uninjured adults. METHODS: Participants were 25 adults with TBI and 26 uninjured healthy comparisons (HC) adults, who completed the Participation Assessment with Recombined Tools-Objective (PART-O) and the Social Network Questionnaire (SNQ). RESULTS: Adults with TBI had significantly fewer total friends and significantly lower levels of productivity and overall social participation. Face-to-face interaction was the preferred method of contact for both groups. Adults with TBI were significantly less likely to use texting as a primary method of communication than their uninjured peers, but used other methods of communication at similar rates. CONCLUSION: Our study supports prior findings of reduced friendships and reduced social participation after TBI and adds new information about similarities and differences in communication methods between adults with and without TBI.

The Necessity of the Hippocampus for Statistical Learning.

Converging evidence points to a role for the hippocampus in statistical learning, but open questions about its necessity remain. Evidence for necessity comes from Schapiro and colleagues who report that a single patient with damage to hippocampus and broader medial temporal lobe cortex was unable to discriminate new from old sequences in several statistical learning tasks. The aim of the current study was to replicate these methods in a larger group of patients who have either damage localized to hippocampus or broader medial temporal lobe damage, to ascertain the necessity of the hippocampus in statistical learning. Patients with hippocampal damage consistently showed less learning overall compared with healthy comparison participants, consistent with an emerging consensus for hippocampal contributions to statistical learning. Interestingly, lesion size did not reliably predict performance. However, patients with hippocampal damage were not uniformly at chance and demonstrated above-chance performance in some task variants. These results suggest that hippocampus is necessary for statistical learning levels achieved by most healthy comparison participants but significant hippocampal pathology alone does not abolish such learning.

Hand gestures support word learning in patients with hippocampal amnesia.

Co-speech hand gesture facilitates learning and memory, yet the cognitive and neural mechanisms supporting this remain unclear. One possibility is that motor information in gesture may engage procedural memory representations. Alternatively, iconic information from gesture may contribute to declarative memory representations mediated by the hippocampus. To investigate these alternatives, we examined gesture's effects on word learning in patients with hippocampal damage and declarative memory impairment, with intact procedural memory, and in healthy and in brain-damaged comparison groups. Participants learned novel label-object pairings while producing gesture, observing gesture, or observing without gesture. After a delay, recall and object identification were assessed. Unsurprisingly, amnesic patients were unable to recall the labels at test. However, they correctly identified objects at above chance levels, but only if they produced a gesture at encoding. Comparison groups performed well above chance at both recall and object identification regardless of gesture. These findings suggest that gesture production may support word learning by engaging nondeclarative (procedural) memory.

Convergent thinking and traumatic brain injury: an investigation of performance on the remote associate test.

OBJECTIVE: While deficits in several cognitive domains following moderate-to-severe traumatic brain injury (TBI) have been well documented, little is known about the impact of TBI on creativity. In the current study, our goal is to determine whether convergent problem solving, which contributes to creative thinking, is impaired following TBI. METHODS: We administered a test of convergent problem solving, the Remote Associate Task (RAT), as well as a battery of neuropsychological tests, to 29 individuals with TBI and 20 healthy comparisons. RESULTS: A mixed-effect regression analysis revealed that individuals with TBI were significantly less likely to produce a correct response, although on average they attempted to respond to the same number of items. Moreover, we found that the TBI (but not the comparison) group's performance on the RAT was significantly and positively associated with verbal learning and memory, providing further evidence supporting the association between declarative memory and creative convergent thinking. CONCLUSION: In summary, our findings reveal that convergent thinking can be compromised by moderate-to-severe TBI, furthering our understanding of the higher-level cognitive sequelae of TBI.

Friendship Quality, Friendship Quantity, and Social Participation in Adults with Traumatic Brain Injury.

Adults with traumatic brain injury (TBI) often report reduced social participation and loss of friends, but little is known about quality of friendship after TBI. Our objective was to characterize social participation, friendship quantity, and friendship quality of adults with TBI and a comparison group of uninjured adults. Participants included 18 adults with moderate to severe TBI and 16 of their informant friends; and 18 uninjured adults and 11 of their informant friends. The main measures used were the Participation Assessment with Recombined Tools-Objective, the Social Network Questionnaire, and the McGill Friendship Questionnaire. Participants with TBI reported significantly less social participation and had fewer total friends, although this difference was not statistically significant. Adults with TBI differed from their friends on one measure of friendship quality, but reports for friendship quality were high in both groups. Adults with TBI reported overall high levels of friendship quality despite having lower levels of social participation compared with uninjured adults. Future research should investigate how the balance of quantity and quality of friendships relates to satisfaction with social participation and overall quality of life.

Role of resilience in the rehabilitation of adults with acquired brain injury.

PURPOSE: The goals of this review paper are to present an overview of the literature on resilience in adults with ABI, to describe approaches to measuring resilience in clinical practice and to discuss practical suggestions for promoting resilience in rehabilitation of adults with ABI. METHOD: We employed systematic review of journal articles, books, and websites related to resilience in adults with acquired brain injury (ABI). RESULTS: Resilience was associated with adaptation and adjustment for individuals faced with serious injury such as ABI. However, research examining the construct of resilience is limited. CONCLUSION: While rehabilitation typically focuses on the identification and reduction of impairments for improving functioning, a focus on resilience may allow for recovery in a broader sense that exceeds expected outcomes.

Investigating the Neural Correlates of Schemas: Ventromedial Prefrontal Cortex Is Necessary for Normal Schematic Influence on Memory.

Schemas, as memory representations of typical contexts, allow for generalization from previous experiences while often improving memory organization and accuracy. However, these advantageous characteristics of schematic memory may come at the cost of episode-specific information. In the human brain, this tradeoff between general and specific knowledge has been linked to differential contributions of the medial temporal lobes (MTL) to episode-specific memory and the ventromedial prefrontal cortex (vmPFC) to generalized, schematic memory. Here, we used a neuropsychological approach to test whether participants with focal vmPFC damage (n = 6) would show a reduced influence of schematic memory relative to healthy normal comparison participants (n = 12) in a recognition task that presented schematically congruent or incongruent contexts at study. As predicted, normal comparison participants were more likely to identify items as old after studying them in congruent contexts, and this effect was reflected in increased true and false recognition. These effects of prior context on recognition were not observed in the vmPFC group, suggesting that vmPFC damage reduced the influence of schematic memory. These findings are consistent with the proposition that the vmPFC plays an important role in integrating previous experience into ongoing memory processes while acting as part of a larger memory network. SIGNIFICANCE STATEMENT: In the human brain, new memories are strongly influenced by existing knowledge of relevant context (sometimes called "schemas"). Schemas can benefit memory by expediting learning and increasing capacity in familiar contexts, but these benefits may simultaneously reduce episode-specific memory. Here we show that damage to the human ventromedial prefrontal cortex (vmPFC) reduced the influence of existing knowledge on new memories. Our findings suggest that the vmPFC plays a key role in schematic memory processes by integrating previous experiences and contextual information to influence memory. These findings provide novel insight into the brain regions necessary for normal schematic memory and enhance our understanding of the brain networks supporting memory processes.