Risk Factors and Outcomes of Late Posttraumatic Seizures in Combat-Related Traumatic Brain Injury.

INTRODUCTION: Post-traumatic seizures (PTSs) contribute to morbidity after traumatic brain injury (TBI). Early PTS are rare in combat casualties sustaining TBI, but the prevalence of late PTS is poorly described. We sought to define the prevalence and risk factors of late PTS in combat casualties with computed tomography evidence of TBI. METHODS: From 2010 to 2015, 687 combat casualties were transferred to a military treatment facility and included in the Department of Defense Trauma Registry. 71 patients with radiographic evidence of TBI were analyzed. Data collection included demographics, injury characteristics, interventions, medications, and outcomes. RESULTS: Of the 71 patients with evidence of TBI, 66 patients survived hospitalization and were followed. No patients had early PTS, and most received antiepileptic drugs (AEDs) for prophylaxis. At a median follow-up of 7.4 y, late PTS occurred in 25.8% of patients. Patients with late PTS were more severely injured (median Injury severity score 30 versus 24, P = 0.005) and required more blood products (18 units versus 2, P = 0.045). Patients with late PTS were more likely to have had a penetrating TBI (76.5% versus 38.8%, P = 0.01), multiple types of intracranial hemorrhage (94.1% versus 63.3%, P = 0.02), and cranial decompression (76.5% versus 28.6%, P = 0.001). Six-month Glasgow outcome scores were worse (3.5 versus 4.1 P = 0.001) in the late PTS population. No significant relationship was observed between administration of AEDs for early PTS prophylaxis and late PTS. CONCLUSIONS: Combat casualties with TBI suffering late PTS are more severely injured and require more blood products. Penetrating TBI, intracranial hemorrhage, and need for cranial decompression are correlated with late PTS, and associated with worse Glasgow Outcome Score. The administration of prophylactic AEDs for early PTS was not associated with a difference in rates of late PTS.

Attention deployment in natural scenes: Higher-order scene statistics rather than semantics modulate the N2pc component.

Which properties of a natural scene affect visual search? We consider the alternative hypotheses that low-level statistics, higher-level statistics, semantics, or layout affect search difficulty in natural scenes. Across three experiments (n = 20 each), we used four different backgrounds that preserve distinct scene properties: (a) natural scenes (all experiments); (b) 1/f noise (pink noise, which preserves only low-level statistics and was used in Experiments 1 and 2); (c) textures that preserve low-level and higher-level statistics but not semantics or layout (Experiments 2 and 3); and (d) inverted (upside-down) scenes that preserve statistics and semantics but not layout (Experiment 2). We included "split scenes" that contained different backgrounds left and right of the midline (Experiment 1, natural/noise; Experiment 3, natural/texture). Participants searched for a Gabor patch that occurred at one of six locations (all experiments). Reaction times were faster for targets on noise and slower on inverted images, compared to natural scenes and textures. The N2pc component of the event-related potential, a marker of attentional selection, had a shorter latency and a higher amplitude for targets in noise than for all other backgrounds. The background contralateral to the target had an effect similar to that on the target side: noise led to faster reactions and shorter N2pc latencies than natural scenes, although we observed no difference in N2pc amplitude. There were no interactions between the target side and the non-target side. Together, this shows that-at least when searching simple targets without own semantic content-natural scenes are more effective distractors than noise and that this results from higher-order statistics rather than from semantics or layout.

Use of Levetiracetam for Post-Traumatic Seizure Prophylaxis in Combat-Related Traumatic Brain Injury.

INTRODUCTION: Post-traumatic seizure (PTS) prophylaxis is recommended in patients with traumatic brain injury (TBI) at high risk for PTSs, but consensus on the optimal pharmacologic therapy has not yet been established. Levetiracetam is frequently used for seizure prophylaxis in combat-related TBI, but its efficacy and safety in this patient population has not yet been described. METHODS: A retrospective cohort of 687 consecutive casualties transferred to the CONUS from October 2010 to December 2015 was analyzed. Seventy-one patients with combat-related injuries and radiographic evidence of skull fractures or intracranial hemorrhage were included. Data collection included demographics and injury characteristics including initial Glasgow Coma Scale, computed tomography findings, interventions, and 6-month Glasgow Outcome Score. RESULTS: All patients in this cohort were male, with an average age of 25 (median 24; Interquartile range (IQR) 4.5) and an average Injury Severity Score of 28 (median 27; IQR 15). The most common mechanism of injury was explosive blast (76%). Penetrating TBI was common (51%). Most patients (88.7%) were administered seizure prophylaxis. Of these, the majority (61/63) received levetiracetam, and the additional two were administered phenytoin. The remaining 11.3% of patients were deemed not to require seizure prophylaxis. The incidence of seizures while on prophylaxis was low (2.8%) and occurred in patients who suffered transcranial gunshot wounds and ultimately died. No serious adverse effects were attributed to levetiracetam. CONCLUSIONS: Levetiracetam appears to be a safe and effective medication for PTS prophylaxis in combat casualties. The rate of PTSs in combat-related TBI on appropriate prophylaxis is low.

Attention in natural scenes: Affective-motivational factors guide gaze independently of visual salience.

In addition to low-level stimulus characteristics and current goals, our previous experience with stimuli can also guide attentional deployment. It remains unclear, however, if such effects act independently or whether they interact in guiding attention. In the current study, we presented natural scenes including every-day objects that differed in affective-motivational impact. In the first free-viewing experiment, we presented visually-matched triads of scenes in which one critical object was replaced that varied mainly in terms of motivational value, but also in terms of valence and arousal, as confirmed by ratings by a large set of observers. Treating motivation as a categorical factor, we found that it affected gaze. A linear-effect model showed that arousal, valence, and motivation predicted fixations above and beyond visual characteristics, like object size, eccentricity, or visual salience. In a second experiment, we experimentally investigated whether the effects of emotion and motivation could be modulated by visual salience. In a medium-salience condition, we presented the same unmodified scenes as in the first experiment. In a high-salience condition, we retained the saturation of the critical object in the scene, and decreased the saturation of the background, and in a low-salience condition, we desaturated the critical object while retaining the original saturation of the background. We found that highly salient objects guided gaze, but still found additional additive effects of arousal, valence and motivation, confirming that higher-level factors can also guide attention, as measured by fixations towards objects in natural scenes.

Competition with and without priority control: linking rivalry to attention through winner-take-all networks with memory.

Competition is ubiquitous in perception. For example, items in the visual field compete for processing resources, and attention controls their priority (biased competition). The inevitable ambiguity in the interpretation of sensory signals yields another form of competition: distinct perceptual interpretations compete for access to awareness. Rivalry, where two equally likely percepts compete for dominance, explicates the latter form of competition. Building upon the similarity between attention and rivalry, we propose to model rivalry by a generic competitive circuit that is widely used in the attention literature-a winner-take-all (WTA) network. Specifically, we show that a network of two coupled WTA circuits replicates three common hallmarks of rivalry: the distribution of dominance durations, their dependence on input strength ("Levelt's propositions"), and the effects of stimulus removal (blanking). This model introduces a form of memory by forming discrete states and explains experimental data better than competitive models of rivalry without memory. This result supports the crucial role of memory in rivalry specifically and in competitive processes in general. Our approach unifies the seemingly distinct phenomena of rivalry, memory, and attention in a single model with competition as the common underlying principle.