Post-traumatic amnesia: a scoping review & content analysis of behavioral disturbances.

OBJECTIVE: The aim of this scoping review was to identify behavioral disturbances exhibited by patients in post-traumatic amnesia (PTA). While behavioral disturbances are common in PTA, research into their presentation and standardized measures for their assessment are limited. DESIGN: The study protocol was registered with PROSPERO (CRD42021268275). A scoping review of databases was performed according to pre-determined criteria on 29 July 2021 and updated on 13 July 2022. A conventional content analysis was used to examine and categorize behavioral disturbances. RESULTS: Thirty papers met the inclusion criteria, of which 27 reported observations and/or scores obtained on behavioral scales, and 3 on clinician interviews and surveys. None focused exclusively on children. Agitation was the most frequently assessed behavior, and Agitated Behavior Scale was the most used instrument. Content analysis, however, bore eight broad behavioral categories: disinhibition, agitation, aggression, lability, lethargy/low mood, perceptual disturbances/psychotic symptoms, personality change and sleep disturbances. CONCLUSION: Our study revealed that while standardized assessments of behavior of patients in PTA are often limited to agitation, clinical descriptions include a range of behavioral disturbances. Our study highlights a significant gap in the systematic assessment of a wide range of behavioral disturbances observed in PTA.

Systematic evaluation of the degree of joint amnesia in patients after total hip arthroplasty with direct anterior approach (DAA) compared with posterior approach (PA).

OBJECTIVE: A comparative study of joint amnesia in patients undergoing total hip arthroplasty with the direct anterior approach and posterior approach was conducted through a comprehensive evaluation. METHODS: The literature on joint amnesia in postoperative patients who underwent total hip arthroplasty by the direct anterior approach and the posterior approach was systematically searched in PubMed, Embase, Web of Science, Cochrane Library, CNKI, CBM, Wanfang, and VIP databases from the time of library construction until February 13, 2023. Meta-analysis was performed using RevMan 5.3 software after independent searching, screening of the literature, data extraction, and quality assessment of the included studies by two investigators in strict accordance with the guidelines for conducting meta-analyses. RESULTS: A total of one RCT and six cohort studies were included in this meta-analysis. Meta-analysis results indicated that at 1 month postoperatively (MD = 2.08, 95% CI (0.20, 3.96), P = 0.03), 3 months (MD = 10.08, 95% CI (1.20, 18.96), P = 0.03), and 1 year (MD = 6.74, 95% CI (1.30, 12.19), P = 0.02), DAA total hip arthroplasty was associated with better FJS compared to PA at 1 year postoperatively. However, there was no statistical significance in FJS between the two groups at 5 years postoperatively (MD = 1.35, 95% CI (- 0.58, 3.28), P = 0.17). CONCLUSION: Current evidence suggests that the degree of joint amnesia after THA for DAA was not found to be superior to that of PA. Further, these findings require confirmation by including a larger number of high-quality randomized controlled studies. STUDY DESIGN: Systematic review; Level of evidence, 3.

Risk of Two Sport-Related Concussions in the Same Year: Is the Second Concussion Worse?

OBJECTIVES: 1) Evaluate the frequency of same-year, repeat concussions; (2) assess predictors of sustaining a repeat concussion; and (3) compare outcomes of athletes with repeat concussions with athletes with single concussion. DESIGN: A retrospective, case-control study. SETTING: Regional sports concussion center. PATIENTS: Adolescents sustaining a sport-related concussions (SRC) from November 2017 to October 2020. INDEPENDENT VARIABLES: Participants were dichotomized into 2 groups: (1) athletes with a single concussion; and (2) athletes with repeat concussions. MAIN OUTCOME MEASURES: Between group and within group analyses were completed to look for differences in demographics, personal and family history, concussion history, and recovery metrics between the 2 groups. RESULTS: Of 834 athletes with an SRC, 56 (6.7%) sustained a repeat concussion and 778 (93.3%) had a single concussion. Between group: Personal history of migraines (19.6% vs 9.5%, χ 2 = 5.795, P = 0.02), family history of migraines (37.5% vs 24.5%, χ 2 = 4.621, P = 0.03), and family history of psychiatric disorders (25% vs 13.1%, χ 2 = 6.224, P = 0.01) were significant predictors of sustaining a repeat concussion. Within group: Among those with a repeat concussion, initial symptom severity was greater (Z = -2.422; P = 0.02) during the repeat concussion and amnesia was more common (χ 2 = 4.775, P = 0.03) after the initial concussion. CONCLUSIONS: In a single-center study of 834 athletes, 6.7% suffered a same-year, repeat concussion. Risk factors included personal/family migraine history and family psychiatric history. For athletes with repeat concussions, initial symptom score was higher after the second concussion, yet amnesia was more common after the initial concussion.

Case of transient global amnesia-like syndrome after recreational cold-water swimming.

We document a case of a transient global amnesia (TGA)-like syndrome following open water swimming. This case was atypical for TGA, in that symptoms were prolonged and ischaemic infarct was considered within the differential. MRI did not demonstrate any changes associated with acute ischaemia although did show a mild degree of small vessel change. With amnesia taking greater than 24 hours to resolve, we have labelled this case to be a TGA-like syndrome, provoked by the commonly reported TGA precipitant of cold water immersion. The possibility of a tiny, strategic infarct causing these symptoms was considered and antiplatelet therapy commenced.

[Epileptic Amnesia].

With the rise in the number of elderly individuals with dementia, the importance of the following two types of epileptic amnesia has become increasingly recognized. One is transient epileptic amnesia (TEA), which is known to have a high frequency of complications such as accelerated long-term forgetting and autobiographical amnesia; the definition and significance of the TEA complex syndrome (TEACS), an extension of the TEA concept, are described. The other is epileptic cognitive impairment resembling Alzheimer's disease (ECI-A), the definition and characteristics of which are presented along with cases encountered by the author, as reported for TEACS.

Prolonged duration of post-traumatic amnesia: A sensitive classification for predicting cognitive outcomes in children recovering from traumatic brain injury.

OBJECTIVE: A paucity of data exists regarding the duration of post-traumatic amnesia (PTA) as a predictor of cognitive functioning among children after traumatic brain injury (TBI). The study aimed to assess the relationship between PTA duration and areas of neurocognitive function among the pediatric population in the sub-acute phase of recovery and rehabilitation. METHODS: Data were collected from medical files on 103 children aged 5.5-16.5 hospitalized at a pediatric rehabilitation department with a diagnosis of moderate-severe TBI (msTBI) between the years 2004-2019. The Children Orientation and Amnesia Test was used to evaluate PTA duration. Measures of high-order cognitive abilities of attention and executive function were collected using the Test of Everyday Attention-Child version (TEA-Ch). RESULTS: Three PTA duration groups were assembled out of a cluster analysis: "Long PTA" (M = 21 days), "Very Long PTA" (M = 47 days), and "Extremely Long PTA" (M = 94 days). Analyses revealed that the "Long PTA" group preformed significantly better than the "Very Long PTA" and "Extremely Long PTA" groups on all TEA-Ch measures, that is, Selective Attention, Attentional Control Switching, and Sustained Attention. CONCLUSIONS: This study is the first to demonstrate that PTA duration is a useful predictor of high-order cognitive functions among children with msTBI in the sub-acute phase of recovery and rehabilitation. The findings emphasize the importance of using a more sensitive classification of prolonged PTA durations to improve outcome prediction and allocation of resources to those who can benefit most after severe brain injuries.

INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part I: Posttraumatic Amnesia.

INTRODUCTION: Posttraumatic amnesia (PTA) is a common occurrence following moderate to severe traumatic brain injury (TBI) and emergence from coma. It is characterized by confusion, disorientation, retrograde and anterograde amnesia, poor attention and frequently, agitation. Clinicians and family need guidelines to support management practices during this phase. METHODS: An international team of researchers and clinicians (known as INCOG) met to update the INCOG guidelines for assessment and management of PTA. Previous recommendations and audit criteria were updated on the basis of review of the literature from 2014. RESULTS: Six management recommendations were made: 1 based on level A evidence, 2 on level B, and 3 on level C evidence. Since the first version of INCOG (2014), 3 recommendations were added: the remainder were modified. INCOG 2022 recommends that individuals should be assessed daily for PTA, using a validated tool (Westmead PTA Scale), until PTA resolution. To date, no cognitive or pharmacological treatments are known to reduce PTA duration. Agitation and confusion may be minimized by a variety of environmental adaptations including maintaining a quiet, safe, and consistent environment. The use of neuroleptic medications and benzodiazepines for agitation should be minimized and their impact on agitation and cognition monitored using standardized tools. Physical therapy and standardized activities of daily living training using procedural and errorless learning principles can be effective, but delivery should be tailored to concurrent levels of cognition, agitation, and fatigue. CONCLUSIONS: Stronger recommendations regarding assessment of PTA duration and effectiveness of activities of daily living training have been made. Evidence regarding optimal pharmacological and nonpharmacological management of confusion and agitation during PTA remains limited, with further research needed. These guidelines aim to enhance evidence-based care and maximize consistency of PTA management.

Factor Structure of the Agitated Behavior Scale in Traumatic Brain Injury During Posttraumatic Amnesia.

OBJECTIVE: To investigate the factor structure of the Agitated Behavior Scale (ABS) in patients with traumatic brain injury (TBI) in posttraumatic amnesia (PTA). SETTING: Inpatient TBI rehabilitation ward in Victoria, Australia. PARTICIPANTS: A total of 364 patients aged 16 to 92 years meeting diagnostic criteria for TBI and PTA admitted between September 2013 and October 2020. DESIGN: Retrospective cohort study utilizing electronic medical record data. MAIN MEASURES: The ABS and the Westmead Post-Traumatic Amnesia Scale (WPTAS). RESULTS: Exploratory factor analysis uncovered 2 moderately correlated underlying factors (0.52), labeled Restlessness and Aggression/Lability. Two items failed to demonstrate sufficiently large loadings on either factor. Both factors demonstrated adequate reliability (Cronbach α = 0.87 and 0.81 for Restlessness and Aggression/Lability, respectively). Linear regression indicated that higher WPTAS scores were associated with lower levels of Restlessness (ß = -.14, P < .001), supporting construct validity. Conversely, WPTAS scores were not significantly associated with Aggression/Lability (ß = -.12, P = .08). Subgroup analysis indicated that a history of mood disorder was associated with greater severity of Aggression/Lability (P = .02). Confirmatory factor analysis indicated superior fit of the identified 2-factor solution when compared with previously explored 1-, 2-, 3-, and 4-factor structures. CONCLUSION: This study suggests that the latent structure of the ABS is best explained by a single construct of agitation with 2 discrete facets reflecting Restlessness and Aggression/Lability. These subscales may be used in clinical practice to evaluate the severity of different aspects of agitated behavior, inform treatment decisions, and judge the efficacy of interventions over time. Further research is required to explain low factor loadings demonstrated by 2 items.

Effectiveness of Non-Pharmacological Interventions for Agitation during Post-Traumatic Amnesia following Traumatic Brain Injury: A Systematic Review.

Agitation is common in the early recovery period following traumatic brain injury (TBI), known as post-traumatic amnesia (PTA). Non-pharmacological interventions are frequently used to manage agitation, yet their efficacy is largely unknown. This systematic review aims to synthesize current evidence on the effectiveness of non-pharmacological interventions for agitation during PTA in adults with TBI. Key databases searched included MEDLINE Ovid SP interface, PubMed, CINAHL, Excerpta Medica Database, PsycINFO and CENTRAL, with additional online reviewing of key journals and clinical trial registries to identify published or unpublished studies up to May 2020. Eligible studies included participants aged 16 years and older, showing agitated behaviours during PTA. Any non-pharmacological interventions for reducing agitation were considered, with any comparator accepted. Eligible studies were critically appraised for methodological quality using Joanna Briggs Institute Critical Appraisal Instruments and findings were reported in narrative form. Twelve studies were included in the review: two randomized cross-over trials, three quasi-experimental studies, four cases series and three case reports. Non-pharmacological interventions were music therapy, behavioural strategies and environmental modifications, physical restraints and electroconvulsive therapy. Key methodological concerns included absence of a control group, a lack of formalised agitation measurement and inconsistent concomitant use of pharmacology. Interventions involving music therapy had the highest level of evidence, although study quality was generally low to moderate. Further research is needed to evaluate non-pharmacological interventions for reducing agitation during PTA after TBI.Systematic review registration number: PROSPERO (CRD42020186802), registered May 2020.

Predictive validity of the Westmead Post-Traumatic Amnesia Scale for functional outcomes in school-aged children who sustained traumatic brain injury.

The Westmead Post-Traumatic Amnesia Scale (WPTAS) is routinely used for the assessment of post-traumatic amnesia (PTA) in children who sustained traumatic brain injury (TBI). Yet, the WPTAS' predictive validity for functional outcomes is largely unknown. We aimed to determine whether PTA duration measured by the WPTAS (i) differentially predicts functional outcomes and (ii) contributes to predictions of outcomes beyond the Glasgow Coma Scale (GCS) in children who sustained TBI. Participants were children and adolescents with moderate-to-severe TBI (n = 55) aged 8-15 years. PTA duration was assessed with the WPTAS. Outcomes at the first outpatient follow-up were scored on the Kings Outcome Scale for Childhood Head Injury (KOSCHI) and the TBI Outcome Domain Scale-Extended (ODS-E). Longer PTA and lower GCS were both significantly correlated with worse (i) global outcomes: presence of disability on the KOSCHI and lower score on the ODS-E and (ii) select specific outcomes on the ODS-E: mobility, mood and cognition. PTA duration predicted cognitive outcome on the ODS-E independently, beyond GCS. Together, PTA duration and GCS, predicted the global KOSCHI outcome, as well as the ODS-E mobility and mood outcomes. Neither GCS nor PTA duration correlated with the ODS-E communication, impulsivity/disinhibition, headache, fatigue, sensory impairments or somatic complaints outcomes. PTA duration measured by the WPTAS is a significant unique predictor of functional cognitive outcomes in children who sustained moderate-to-severe TBI, and in combination with the GCS, a significant predictor of global, and several specific functional outcomes.

[Predictors of the duration of post-traumatic amnesia following traumatic brain injury]. / Variables predictoras de la duración de la amnesia postraumática tras un traumatismo craneoencefálico.

INTRODUCTION: The duration of post-traumatic amnesia (PTA) helps estimate the level of recovery following traumatic brain injury (TBI). Yet, little information is available about which sociodemographic and clinical variables influence its duration. This study aims to identify them and create a predictive model that makes it possible to estimate the time it takes for a patient to emerge from PTA. PATIENTS AND METHODS: The sample consisted of 40 adult patients with PTA admitted to a neurorehabilitation centre. A total of 89.7% had suffered a severe TBI, whereas the remaining 10.3% had had a moderate TBI. Cognitive status was assessed using the Galveston Orientation and Amnesia Test (GOAT) - a scale for determining at what point a patient can be considered to be emerging from PTA. RESULTS: A regression equation was found (F = 8.511; p < 0.001; R2 = 0.415), in which the following variables (ranked in order of importance) explained 41.5% of the variability observed in the duration of PTA: a) GOAT administered on arrival at the neurorehabilitation centre; b) years of formal education of the patient; and c) days with PTA prior to admission to the neurorehabilitation centre. The equation derived was as follows: 104.284 + (-0.708 x GOAT-initial) + (-4.124 x years formal education) + (0.219 x hospital acute-APT). CONCLUSIONS: The time it takes for a patient to emerge from PTA is conditioned by the score obtained in the first GOAT administered on admission to the neurorehabilitation centre, their level of education, and the number of days elapsed with PTA between occurrence of the TBI and admission to the neurorehabilitation centre.

TITLE: Variables predictoras de la duración de la amnesia postraumática tras un traumatismo craneoencefálico.Introducción. La duración de la amnesia postraumática (APT) ayuda a estimar el nivel de recuperación tras un traumatismo craneoencefálico (TCE). Sin embargo, apenas se dispone de información sobre qué variables sociodemográficas y clínicas influyen en su duración. Este estudio pretende identificarlas y crear un modelo predictivo que permita estimar el tiempo que un paciente tarda en emerger de la APT. Pacientes y métodos. La muestra estaba formada por 40 pacientes adultos en APT ingresados en un centro neurorrehabilitador. El 89,7% había sufrido un TCE grave; el 10,3% restante, un TCE moderado. Su estado cognitivo se valoró mediante el Galveston Orientation and Amnesia Test (GOAT) ­escala que permite determinar en qué momento se puede considerar que un paciente emerge de la APT­. Resultados. Se encontró una ecuación de regresión (F = 8,511; p menor de 0,001; R2 = 0,415), en la que las siguientes variables (clasificadas por su orden de importancia) explicaron el 41,5% de la variabilidad observada en la duración de la APT: a) GOAT administrado a la llegada al centro neurorrehabilitador; b) años de formación reglada del paciente; y c) días que estuvo en APT antes de ingresar en el centro neurorrehabilitador. La ecuación de regresión derivada fue la siguiente: 104,284 + (­0,708 × GOAT-inicial) + (­4,124 × años formación reglada) + (0,219 × APT-hospital agudos). Conclusiones. El tiempo que un paciente tarda en emerger de la APT está condicionado por la puntuación que obtiene en el primer GOAT administrado al ingresar en el centro neurorrehabilitador, el nivel de estudios, y los días que permanece en APT entre el momento del TCE y el ingreso en el centro neurorrehabilitador.

Long-Term Retrograde Global Amnesia Following Minor Trauma.

BACKGROUND Retrograde amnesia has several causes and may be the core concern in several conditions. When acute, somatic, and neurologic causes are excluded, along with substance use, a consideration of psychiatric disease is imminent. Here, we present a case with amnesia, where diagnostics and treatment were challenging due to severe psychiatric symptoms and course of the disease. CASE REPORT After a minor trauma while driving an electric scooter, a 41-year-old man lost all memories of the past 20 years. The patient was raised in a refugee camp, where he experienced traumatic events, and later came to Denmark and established family and work life. He had 1 prior contact with the psychiatric ward. After the incident, the patient was brought to the emergency room. The patient could not recognize his wife or children and believed he was 21 years old and living with his mother in the refugee camp. A full somatic and neurological workup was performed and no somatic or organic cause could explain the retrograde amnesia. He developed post-traumatic stress disorder (PTSD) and psychotic symptoms. Treatment consisted of a combination of psychoeducation, cognitive remediation, and medical treatment for psychotic symptoms and PTSD. CONCLUSIONS The diagnosis "prolonged delirium", "PTSD", and "dissociative amnesia" were considered. Psychiatric comorbidity and previous traumatic experiences might have contributed to the development of long-term amnesia, which eventually was considered to be dissociative. During 8 months, the patient slowly regained his memory. It is impossible to conclude with certainty whether the successful outcome was the result of psychological treatment, pharmacological treatment, the passing of time, or a mixture of these.

"This looks like a movie": a case report of post-surgical amnesia.

A 52-year-old male patient with a background of adaptive personality disorder was admitted for mitral valve repair and cardiac ablation for atrial fibrillation. He suffered intraoperative complications with severe mitral insufficiency that suffered ischemia.. Post-operatively, he demonstrated acute loss of retrograde autobiographical memory, prosopagnosia and a loss of public semantic memory. His CT scan was normal and MRI was not possible due to intra-cardiac leads. An initial diagnosis of hypoxic-ischemic encephalopathy was considered. A neuropsychological examination undertaken 20 days after his surgery showed a severe alteration of retrograde autobiographical memory, marked alteration of semantic knowledge and prosopagnosia. He demonstrated an average performance in tasks measuring constructional praxis, visuospatial ability, and executive functions. 34 days after surgery, and after a short nap, the patient "returns" to the day before admission and consequently recovers his memory. Repeat neuropsychological assessment demonstrated performance within the normal range across all previously tested domains. This sudden recovery of memory, together with a normal MRI, led to a rethinking of the diagnosis of dissociative amnesia. This case illustrates the long-standing discussion about the organic or functional origin of some memory disorders, in which, despite advances in neuroimaging techniques, it is still difficult to know their etiology .

Pathological Slow-Wave Activity and Impaired Working Memory Binding in Post-Traumatic Amnesia.

Associative binding is key to normal memory function and is transiently disrupted during periods of post-traumatic amnesia (PTA) following traumatic brain injury (TBI). Electrophysiological abnormalities, including low-frequency activity, are common following TBI. Here, we investigate associative memory binding during PTA and test the hypothesis that misbinding is caused by pathological slowing of brain activity disrupting cortical communication. Thirty acute moderate to severe TBI patients (25 males; 5 females) and 26 healthy controls (20 males; 6 females) were tested with a precision working memory paradigm requiring the association of object and location information. Electrophysiological effects of TBI were assessed using resting-state EEG in a subsample of 17 patients and 21 controls. PTA patients showed abnormalities in working memory function and made significantly more misbinding errors than patients who were not in PTA and controls. The distribution of localization responses was abnormally biased by the locations of nontarget items for patients in PTA, suggesting a specific impairment of object and location binding. Slow-wave activity was increased following TBI. Increases in the δ-α ratio indicative of an increase in low-frequency power specifically correlated with binding impairment in working memory. Connectivity changes in TBI did not correlate with binding impairment. Working memory and electrophysiological abnormalities normalized at 6 month follow-up. These results show that patients in PTA show high rates of misbinding that are associated with a pathological shift toward lower-frequency oscillations.SIGNIFICANCE STATEMENT How do we remember what was where? The mechanism by which information (e.g., object and location) is integrated in working memory is a central question for cognitive neuroscience. Following significant head injury, many patients will experience a period of post-traumatic amnesia (PTA) during which this associative binding is disrupted. This may be because of electrophysiological changes in the brain. Using a precision working memory test and resting-state EEG, we show that PTA patients demonstrate impaired binding ability, and this is associated with a shift toward slower-frequency activity on EEG. Abnormal EEG connectivity was observed but was not specific to PTA or binding ability. These findings contribute to both our mechanistic understanding of working memory binding and PTA pathophysiology.

The amnestic syndrome of posterior cerebral artery infarction.

BACKGROUND AND PURPOSE: Little is known about the character and underlying lesions of ischaemic amnesia. Episodic memory functions and brain lesions were therefore studied in 84 patients with acute ischaemic infarcts in the supply territory of the posterior cerebral artery. The aim was also to learn how the neural memory systems are organized. METHODS: Standard neuropsychological tests were used to assess verbal and figural memory. Patients were split into memory-impaired and memory-intact groups. Lesions were demarcated, normalized and anatomically labelled, using standard mapping procedures. RESULTS: Of the 84 patients more than 80% had an amnestic syndrome, mostly with combined memory impairment, less often with figural or verbal memory impairment. Amnesia in subjects with left hemispheric lesions was more frequent and more severe, with significantly lower scores on the verbal memory test. Normal performance or figural amnesia were prevalent after right hemispheric lesions. However, no amnesia subtype was strictly tied to left- or right-sided brain damage. Hippocampal and thalamic lesions were common, but 30% of lesions were extrahippocampal located in the ventral occipito-temporal cortex and long occipital white matter tracts. Most amnestic patients lacked awareness for their memory impairment. CONCLUSIONS: Memory impairment is a key clinical manifestation of acute posterior cerebral artery stroke. Amnesia is more frequent and more severe after left stroke, suggesting a left hemisphere dominance of the two memory systems. Domain specific memory appears not to be strictly lateralized, since deficits in verbal and figural memory were found after lesions of both sides. Extrahippocampal lesions may also cause memory impairment.