Characteristics of impaired awareness after traumatic brain injury

The condylar constrained total knee arthroplasty was performed on 29 patients undergoing 33 procedures and were reviewed clinically and radiographically at an average follow-up of 5 years (range, 2-10 years). There were 21 women and 8 men. The average age at the time of surgery was 70 years (range, 32-84). Of the 16 knees that were revision total knee arthroplasties, 8 had a previous infected total knee arthroplasty, and 17 knees had severe deformities requiring the use of the condylar constrained prosthesis. The patients were rated according to the Knee Society clinical and radiological evaluation protocol. Measurements of femoral and tibial component position were obtained as well as femoral tibial angle, patella position, and cement bone radiolucencies. All clinical measurements were made by an independent physical therapist. Clinical results revealed an improvement from an average preoperative knee score of 38 points to an average postoperative score of 86 points. The clinical results for 19 (58%) knees were excellent, 8 (24%) had a good result, 1 (3%) was fair, 2 (6%) were poor, and 3 (9%) were failures. The patients' average functional levels increased from 24 to 58. The final average flexion was 96 degrees. Three knees have been revised (9%). One was revised for recurrent infection, one for periprosthetic fracture, and one for mechanical loosening of the tibial component. There were no other knees with evidence of radiologic loosening. We conclude that the condylar constrained total knee prosthesis provides an acceptable solution for revision and complex primary total knee replacements at an intermediate follow-up term of 5 years.     

Delayed traumatic cerebral aneurysm after brain injury

Traumatic aneurysms (TAs) are an unusual etiology for late neurological deterioration after traumatic brain injury (TBI) and represent less than 1% of all cerebral aneurysms. TAs most often are diagnosed acutely but may be delayed in presentation. To increase awareness of this serious but treatable condition when diagnosed early, we report a delayed TA after a motor vehicle accident. The patient experienced a seizure on day 46 postinjury while in rehabilitation and demonstrated persistent lethargy and hemiparesis. Neuroimaging revealed a large, ruptured left pericallosal artery TA, which was surgically clipped. The patient completed his rehabilitation course and was eventually discharged home with family. Among TBIs, TAs are associated with penetrating injuries and skull base or anterior cranial fossa fractures. Associated mortality is high, especially if rupture has occurred. Although TAs are rare, the clinician should be vigilant in the at-risk patient.     

Rehabilitation after traumatic brain injury in adults

PURPOSE: Traumatic brain injury (TBI) stands as a major public health problem and one of the most important challenges for neurological rehabilitation. This review discusses advances that have occurred in the past 10 years in rehabilitation after severe TBI in adults. METHOD: First, theoretical concepts, goals of rehabilitation and organization of resources are reviewed. Then specific questions that arise in the rehabilitation of severe TBI patients are considered. RESULTS: Three phases are distinguished in post-traumatic evolution. Acute rehabilitation takes place during coma and arousal states. Specific aims are to prevent orthopaedic and visceral complications, and to provide sensory stimulations with the hope of accelerating arousal. Secondly subacute (generally inpatient) rehabilitation is designed to facilitate and accelerate recovery of impairments, and to compensate for disabilities. Motility, cognition, behaviour, personality and affect should be simultaneously addressed in an holistic approach. Physical as well as psychological independence and self-awareness are the major goals to emphasize. A third, post-acute rehabilitation phase includes outpatient therapy for achieving physical, domestic and social independence, reduction of handicaps and re-entry into the community. CONCLUSIONS: Problems with returning home, obtaining financial independence, driving, returning to work, participating in social relationships and leisure activities, and the importance of psychosocial adjustment and self-acceptance, are outlined. Questions about economic aspects and rehabilitation in the future are addressed.     

Impaired awareness and employment outcome after traumatic brain injury

Inaccurate self-awareness is a common finding after traumatic brain injury. Such impaired awareness has been hypothesized to limit patients' eventual functional outcomes by decreasing motivation for treatment and resulting in selection of inappropriate long-term goals. Previous investigations of the association between impaired awareness and employment outcome have produced inconsistent results. The present article reviews these studies and presents the results of our new investigation of this issue. In addition, we studied the comparability of two methods of measuring impaired awareness. Results provided strong support for a positive relationship between accurate self-awareness and favorable employment outcome at follow-up.     

Posttraumatic stress symptomatology after childhood traumatic brain injury

The purpose of this study was to quantify and to identify predictors of posttraumatic stress disorder (PTSD) symptomatology after traumatic brain injury (TBI). Fifty children aged 6 to 14 years, hospitalized after TBI, were assessed soon after TBI regarding injury severity and preinjury psychiatric, socioeconomic, family functioning, and family psychiatric history status; neuroimaging was also analyzed. Psychiatric assessments were repeated 3, 6, 12, and 24 months after TBI. Only 2 of 46 (4%) subjects with at least one follow-up assessment developed PTSD. However, the frequency with which subjects experienced at least one PTSD symptom ranged from 68% in the first 3 months to 12% at 2 years in assessed children. The presence of an internalizing disorder at time of injury followed by greater injury severity were the most consistent predictors of PTSD symptomatology. It is apparent, therefore, that PTSD and subsyndromal posttraumatic stress disturbances occur despite neurogenic amnesia. These problems should be treated, particularly if symptoms persist beyond 3 months.     

Access and organization of goal-derived categories after traumatic brain injury

This study examined the access and organization of goal-derived categories in semantic memory with a group of chronic traumatic brain injured TBI adults and a group of age and gender-matched neurologically-intact controls. Goal-derived categories are developed by individuals for use in specialized contexts to achieve a goal, such as 'things to take on a camping trip.' Categories were presented to subjects in two task contexts: category verification and exemplar generation. Overall, the TBI subjects were able to accurately identify and organize category exemplars within particular categories. Interestingly, the TBI subjects produced significantly more total responses than the neurologically-intact subjects on exemplar generation; however, a high percentage of their responses (one-third) were inaccurate, consisting of out-of-set responses and repetitions. These findings suggest that difficulties in retrieval may exist in the presence of relatively intact access and organization of goal-derived category structure. The results are discussed relative to deficits in the executive control of verifying goal-directed behaviour and incomplete category representation.     

Awareness of disability and long-term outcome after traumatic brain injury.

The degree of long-term (7.41 yrs postinjury) impairment of disability awareness was quantified in 63 adults (aged 18–45 yrs) with closed-head injuries as the difference between self-ratings and staff ratings on the Scales of Independent Behavior. Other measures included the Wechsler Adult Intelligence Scale--Revised (WAIS--R), the Wechsler Memory Test—Revised, the Wisconsin Card Sorting Test, and ratings of actual functional status based on classifications in vocational and independent living level. Impaired awareness and its relationship to actual level of present vocational and residential status, maladaptive behaviors, attention and freedom from distractibility, and a measure of frontal system functioning was examined. Impaired awareness was significantly associated with lower vocational and residential status, maladaptive behavior, greater distractibility, and increased perseveration. Impaired awareness is directly proportional to duration of posttraumatic amnesia and general memory. Impaired awareness of disability appears to be a consequence of a general cognitive impairment rather than a specific deficit. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Awareness of errors in naturalistic action after traumatic brain injury

A prospective study was performed to develop a method for assessing "on-line" error detection and correction during performance of naturalistic action, to determine whether traumatic brain injury (TBI) affects error detection and correction, and to compare actual task performance with verbal self-ratings of performance. Participants included 18 persons who had sustained severe TBI from 34 to 186 days prior to study and who were comparable to controls in their rate of naturalistic action error, along with 18 control subjects chosen to be demographically comparable to subjects with TBI. Subjects performed two different tests of naturalistic action in which they completed everyday activities (eg, wrapping a gift, making toast) at different levels of complexity, as manipulated by the addition of distractor objects, the number of tasks that had to be completed per trial, and other demands on planning and working memory. Using a specially developed coding system, each error on these tasks was scored as to whether the subject corrected it and whether the subject otherwise demonstrated awareness of the error. Error scores were also compared to subjects' responses to a questionnaire in which they rated their own performance on the most challenging level of the naturalistic action test. In general, subjects with TBI corrected and showed awareness of proportionally fewer of their errors when compared to controls. Qualitative patterns for some error types also differed between groups. Despite making more errors than control subjects on the most challenging task, subjects with TBI did not rate themselves as performing more poorly with respect to its cognitive demands. However, for subjects with TBI, the number of errors was correlated with performance ratings on certain questionnaire items. This study showed that error detection and correction can be reliably measured during naturalistic action and appear to be impaired in severe TBI even when the base rate of error is controlled. TBI may affect error detection and correction by reducing, or impairing the allocation of, attentional resources needed for the simultaneous execution and monitoring of routine action.     

Factors contributing to attentional impairments after traumatic brain injury.

The aim of the present study was to investigate the contribution of impaired information processing speed and strategic control of attention to performance on attentional tasks after traumatic brain injury (TBI). Forty moderately to severely injured rehabilitation inpatients and 40 healthy controls completed a selection of attentional tasks. Slowed processing speed in the TBI group was identified on the Symbol Digit Modalities Test (SDMT), 2&7 Selective Attention Test (2&7), Selective Attention (SAT), and Four Choice Reaction Time (4CRT) tasks. Impaired working memory was evident on the Letter Number Sequencing (LNS) task. Structural equation modeling revealed that the group difference in RT on the complex SAT was accounted for by slowed speed of processing on the simple SAT, and not working memory. TBI participants made more errors and missed responses on the complex version of the SAT, suggesting impairment in some aspects of strategic control of attention, and appeared unable to benefit from the automatic condition of the 2&7 Test. There was little evidence of deficit on the Sustained Attention to Response Task (SART). The present study provides evidence for a significant contribution of slowed processing speed to impaired performance on attentional tasks after TBI. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Executive functioning as outcome in patients after traumatic brain injury

The shape of rate-intensity functions recorded from individual neurons of the auditory nerve using stimulus frequencies at and below the characteristic frequency have been both well-characterized and modeled by other researchers. However, previous studies of rate-intensity functions using stimulus frequencies above the characteristic frequency have primarily focused on the slopes of the rising phases of the functions. Hence, they did not determine whether rate-intensity functions recorded using stimulus frequencies above the characteristic frequency saturate, and, if so, at what firing rates the saturation occurs. In this study, rate-intensity functions have been obtained from neurons of the eighth nerve of the chinchilla in response to gated, sinusoidal stimuli in order to investigate saturation firing rates for frequencies above the characteristic frequency. For each neuron, rate-intensity functions were obtained for stimulus intensities up to 90 dB SPL at the characteristic frequency and at as many frequencies above the characteristic frequency as time would allow. These data clearly reveal that, for frequencies above the characteristic frequency, saturation occurs at a rate that decreases monotonically as the frequency of stimulation is increased. In addition, an empirical equation is given which summarizes the dependence of saturation on stimulus frequency for the data of this study.     

Regional calpain and caspase-3 proteolysis of alpha-spectrin after traumatic brain injury

Activity of calpains and caspase-3 inferred from proteolysis of the cytoskeletal protein alpha-spectrin into signature spectrin breakdown products (SBDPs) was used to provide the first systematic and simultaneous comparison of changes in activity of these two families of cysteine proteases after traumatic brain injury (TBI) in rats. Distinct regional and temporal patterns of calpain/caspase-3 processing of alpha-spectrin were observed in brain regions ipsilateral to the site of injury after TBI, including large increases of 145 kDa calpain-mediated SBDP in cortex (up to 30-fold), and enduring increases (up to 2 weeks) of 145 kDa SBDP in hippocampus and thalamus. By contrast, 120 kDa caspase-3-mediated SBDP was absent in cortex and showed up to a 2-fold increase in hippocampus and striatum at early (hours) after TBI. Future studies will clarify the pathological significance of large regional differences in activation of calpain and caspase-3 proteases after TBI.     

Long-term neuropsychological outcome and loss of social autonomy after traumatic brain injury

OBJECTIVE: To assess which social activities were still impaired 5 years after a traumatic brain injury (TBI) in adults, and which neuropsychological impairments were associated with this loss of social autonomy. DESIGN: Cross-sectional study of 79 patients selected from the follow-up cohort of an epidemiologic survey of 2,116 TBI patients. SETTING: The present study was of ambulatory patients seen at hospital or at their homes. The inception cohort was from the trauma center of a university hospital and from a general hospital that is representative of level II trauma centers in Aquitaine, France. PATIENTS: Seventy-nine patients selected from a representative sample of 407 patients who were included in the 5-year follow-up study of the initial cohort (convenience sample). MAIN OUTCOME MEASURES: Glasgow Outcome Scale (GOS) and loss of social autonomy as assessed by the European Brain Injury Society's European Head Injury Evaluation Chart; assessment of neurobehavioral impairments by means of the Neurobehavioral Rating Scale-Revised. RESULTS: Up to 16 patients suffered disability for at least one social skill because of cognitive/behavioral reasons. Seven needed full-time supervision. Performing administrative tasks and financial management, writing letters and calculating, driving, planning the week, and using public transport were the most impaired social abilities. Loss of social autonomy was mainly observed in severely injured patients. Univariate analysis showed that mental fatigability, motor slowing, memory difficulties, and disorders of executive function were associated with low scores on the GOS, unemployment, and difficulties in shopping, using public transport, and performing financial management and administrative tasks. CONCLUSION: Persistent impairments of executive functions and speed of psychomotor processing are major factors associated with loss of social autonomy and inability to return to work long after TBI in adults. Improving these impairments in concrete social situations represents a major challenge for cognitive rehabilitation.     

Children's recollections of traumatic and nontraumatic events

Whereas the social and emotional consequences of childhood trauma are well documented, less is known about how young children understand, represent, and remember traumatic experiences. A review of the literature indicates striking similarities in the development of young children's ability to recall traumatic and nontraumatic events. More specifically, events experienced before the age of about 18 months do not seem to be verbally accessible; events experienced between about 18 months and 2.5-3 years are reported in fragmentary fashion and seem to be prone to increasing error over time. From about age 3 years on, children can give reasonably coherent accounts of their past experiences and can retain these memories over long durations. The ways in which children are able to participate in conversations about events as they are occurring and in retrospect seems to play a critical role in their developing event memories. Implications of the empirical data for understanding trauma memory in childhood are discussed.     

Meta-analysis of facial affect recognition difficulties after traumatic brain injury.

Objective: Difficulties in communication and social relationships present a formidable challenge for many people after traumatic brain injury (TBI). These difficulties are likely to be partially attributable to problems with emotion perception. Mounting evidence shows facial affect recognition to be particularly difficult after TBI. However, no attempt has been made to systematically estimate the magnitude of this problem or the frequency with which it occurs. Method: A meta-analysis is presented examining the magnitude of facial affect recognition difficulties after TBI. From this, the frequency of these impairments in the TBI population is estimated. Effect sizes were calculated from 13 studies that compared adults with moderate to severe TBI to matched healthy controls on static measures of facial affect recognition. Results: The studies collectively presented data from 296 adults with TBI and 296 matched controls. The overall weighted mean effect size for the 13 studies was ?1.11, indicating people with TBI on average perform about 1.1 SD below healthy peers on measures of facial affect recognition. Based on estimation of the TBI population standard deviation and modeling of likely distribution shape, it is estimated that between 13% and 39% of people with moderate to severe TBI may have significant difficulties with facial affect recognition, depending on the cut-off criterion used. Conclusion: This is clearly an area that warrants attention, particularly examining techniques for the rehabilitation of these deficits. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Fluorometric assay of nitrite and nitrate in brain tissue after traumatic brain injury and cerebral ischemia

Nitric oxide synthase (NOS) is distributed within the brain, and nitric oxide (NO) is felt to be involved in the pathophysiology of deterioration after head injury and cerebral ischemia. This study determined the levels of the stable end products of NOS (NOx=nitrite+nitrate) after traumatic brain injury (TBI) and transient cerebral ischemia. A fluorometric assay using nitrate reductase and the NADPH regenerating system was used to quantitate NOx in ultrafiltered (10-kDa cutoff) cortical and hippocampal extracts after reduction of nitrate. In TBI rats, both the plasma and tissue showed a sharp increase in NOx levels 5 min after injury. Plasma NOx returned to control levels by 2 h after injury. Ipsilateral-cortex NOx levels returned to control levels approximately 6 h after injury and remained constant from 6-24 h. Contralateral-cortex returned near to control levels after 1 h. Hippocampus also followed a similar trend. In gerbils, there was a significant elevation in tissue NOx levels immediately after 10 min transient cerebral ischemia, which gradually returned to control levels over 24 h reperfusion. This striking burst of NO synthesis immediately after injury is clearly evident whether the injury is head trauma or ischemia, or whether the measurements were performed on tissue or plasma. It is unknown whether endothelial NOS, neuronal NOS, or both caused the elevation of the NO end products seen after the CNS insults.     

Gender differences in learning and memory after pediatric traumatic brain injury.

Thirty boys and 30 girls who sustained a traumatic brain injury (TBI) were evaluated within 1 year postinjury with the California Verbal Learning Test--Children's Version (CVLT-C; D. C. Delis, J. H. Kramer, E. Kaplan, & B. A. Ober, 1994). Boys had statistically significantly lower performance on the CVLT-C than girls in the absence of statistically significant group differences on various demographic and neurological variables. Although the effect size for this difference was modest (η=.09), gender accounted for a statistically significant amount of the variance (5%) in CVLT-C scores in addition to effects of injury severity and age. It is concluded that male gender is associated with an increased risk for retrieval deficits after pediatric TBI, possibly because of reduced speed or efficiency of information processing. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Attention-deficit hyperactivity symptomatology after traumatic brain injury: a prospective study

OBJECTIVE: To study prospectively the course of attention-deficit hyperactivity (ADH) symptomatology in children and adolescents after traumatic brain injury (TBI). It was hypothesized that ADH symptomatology would be significantly related to severity of injury. METHOD: Subjects were children (n = 50) aged 6 to 14 years at the time they were hospitalized after TBI. The study used a prospective follow-up design. Assessments of preinjury psychiatric, behavioral, socioeconomic, family functioning, and family psychiatric history status were conducted. Severity of injury was assessed by standard clinical scales, and neuroimaging was analyzed. RESULTS: The main finding of this study was that change in ADH symptomatology in the first 2 years after TBI in children and adolescents was significantly related to severity of injury. Overall ADH symptomatology during the study was significantly related to a measure of family dysfunction when family psychiatric history, socioeconomic status, and severity of injury were controlled. CONCLUSION: The presence of a positive "dose-response" relationship between severity of injury and change in ADH symptoms, present from the 3-month assessment, was consistent with an effect directly related to brain damage.     

Changes in orientation during acute rehabilitation after traumatic brain injury.

Objective: To examine the profile of scores on a measure of orientation in a sample of patients with traumatic brain injury (TBI) during acute rehabilitation as a means of (a) assessing the extent of neural compromise, (b) assessing recovery of functioning, and (c) determining the relative difficulty of different indicators of orientation. Design: Repeated measures. Setting: Acute rehabilitation hospital. Participants: Forty-three patients with severe TBI interviewed daily throughout rehabilitation. Measures: The Orientation Log (O-Log) is a 10-item measure of orientation to place, time, and situation. Items are scored 0–3 on the basis of whether they are recalled spontaneously (3), with cueing (2), via recognition (1), or not at all (0). Results: O-Log score was correlated with severity of TBI. Return of orientation followed a consistent trajectory, with initial gains preceding a plateau effect. Patients had relatively more difficulty orienting to hospital name and date than to year, month, and city. Conclusions: The O-Log is sensitive to the severity of TBI. Progress in orientation, on average, occurs at a similar rate across patients, including those who present as severely disoriented, although those with severe disorientation may not achieve orientation by rehabilitation discharge. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Self and parent ratings of executive functioning after adolescent traumatic brain injury.

Objective: To examine the level of agreement between adolescents with traumatic brain injury (TBI) and their parents in standardized ratings of executive functioning, and to determine correlates of discrepancies between those ratings. Participants: Ninety-eight 11- to 16-year-old adolescents with TBI and their parents, and 97 neuropsychologically healthy controls. Method: Five-year consecutive series of rehabilitation referrals for TBI. Measures: Behavior Rating Inventory of Executive Function–Self Report (BRIEF–SR) and Behavior Rating Inventory of Executive Function (BRIEF) parent report versions. Results: Self and parent ratings were moderately positively correlated in both the TBI group and the control group, but parents generally identified more executive dysfunction than did the adolescents. Parent-adolescent discrepancies were statistically significantly greater in the TBI group than in the control group on the Metacognitive index but not the Behavioral Regulation index. The degree of the former discrepancy was predicted by duration of coma in the TBI group. Conclusions: Adolescents with more severe TBI may underestimate their own degree of executive dysfunction in daily life, particularly aspects of metacognitive abilities, possibly, in part, because of an organic-based lack of deficit awareness. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Impact of age on long-term cognitive function after traumatic brain injury.

Objective: To examine the association of age and time postinjury with cognitive outcome 5–22 years following traumatic brain injury (TBI), in relation to matched uninjured controls. Methods: One hundred twelve participants with mild to very severe TBI, aged 16–81 years at the time of injury, were cognitively assessed on measures of processing speed and attention, verbal and visual memory, executive function, and working memory. Results were compared with those of 112 healthy controls individually matched for current age, gender, education, and estimated IQ. Results: Older injured individuals performed worse than did younger injured individuals across all cognitive domains, after controlling for the performance of controls. In relation to matched controls, long-time survivors performed disproportionately worse than did more recently injured individuals, irrespective of age. Conclusions: After maximum spontaneous recovery from TBI, poorer cognitive functioning appears to be associated with both older age at the time of injury and increased time postinjury. These findings have implications for prognosis, early treatment recommendations, and long-term issues of differential diagnosis and management planning. (PsycINFO Database Record (c) 2010 APA, all rights reserved)