Studies on head trauma complications with special reference to Mild Traumatic Brain Injury

Traumatic brain injury (TBI) is a recognised public health problem. Patients with mild traumatic brain injury (MTBI) represent the main part of the total TBI population attending hospital. The aim of this thesis was to study some clinically important aspects of post-acute complications and long-term consequences after head trauma with special reference to MTBI. The pathophysiological basis of persisting complaints, which are reported by a substantial subgroup of adult patients with MTBI, is far from clear. A computerised tomography (CT) examination is most often used to detect brain tissue damage in the acute setting. Nevertheless, it is generally considered that CT scanning and other neuroimaging techniques might be insensitive to minor structural and functional abnormalities and that there is a need for other, more sensitive methods. It has been suggested that biochemical markers such as the protein S 1 00B are useful, both for the acute diagnosis and to predict persistent complaints. In a prospective cohort of patients with a primarily uncomplicated MTBI, corresponding to an ordinary brain concussion, the mixed form S 1 00B as well as two more specific forms, S 1 00A 1 B and S 1001313, were analysed in sera in order to examine their diagnostic and predictive value. Serum concentrations of the specific form, S 1 00A 1 B, were elevated in 64% of the patients who had sustained an MTBI and the corresponding figure for the mixed form, S 1 00B, was 4 1 %, when compared to non-inj ured persons. Using a control group with mild orthopaedic injuries, S 1 00B did not differentiate the trauma groups, while S 1 00A1 B concentrations were significantly higher in the MTBI group (p<0.001). However, the diagnostic accuracy of S100A1B was not strong (sensitivity 64%, specificity 77% when the 97.5 percentile in healthy controls was used for cut-off). In contrast, S 1 00B more accurately identified the subgroup of patients with MTBI who had traumatic abnormalities on a CT scan or magnetic resonance images than S 1 00A 1 B did. We suggest that elevated serum concentrations of S 1 00A 1 B and S 1 00B respectively, reflect different pathophysiological mechanisms. Neither S 1 00A 1 B, nor S 1 00B predicted symptoms or signs of cognitive impairment. Serum concentrations of the specific form S 1 00BB were too low to draw any conclusion. The early, clinical follow-up of patients with MTBI must consider the risk of delayed intracranial complications. Data on the rate and risk factors of these complications are scarce. By conducting a case-control study, utilising the high-quality Inpatient Registry available in Sweden, we demonstrated that the rate of these complications in patients who have been discharged after uncomplicated, hospitalised observation, is low (0.13%) and that it declines during the first three weeks post-injury. Identified risk factors were clinical severity grade (OR 2.0 (Cl 1.2-3.6)) and male gender (OR 2.2 (Cl 1.4-3.5)). We could not demonstrate any protective effect of an early CT scan. TBI has long been considered a possible risk factor for brain tumour but previous studies have yielded inconsistent results. By conducting a population-based cohort study, utilising the Swedish Inpatient Registry as well as the Cancer Registry, we found evidence that TBI is not a risk factor for brain tumour (SIR 1.0 (Cl 0.9-1.2))

Prevelance, types and correlates of sleep problems in head injury patients during the rehabilitation period

&lt;i&gt;Objectives:&lt;/i&gt; The prevalence of sleep difficulties is high after head injury (HI). Previous research suggests that HI patients with sleep problems require longer stays in rehabilitation units and that disturbance of arousal disrupts engagement in rehabilitation activities. The present study explored the prevalence and types of sleep disorders in patients with severe HI undergoing inpatient rehabilitation and whether the presence of sleep problems affects their rehabilitation.&lt;p&gt;&lt;/p&gt; &lt;i&gt;Methods:&lt;/i&gt; Twenty-three (n = 23) severe HI patients responded to a semi-structured clinical screening interview about their sleep–wake patterns and wore an actiwatch (an activity monitor that is associated with sleep and wakefulness) for 7 days. Participants also completed self-report measures on sleep, mood, fatigue, pain and daytime sleepiness. Information on rehabilitation variables, including frequency of aggressive behaviour, engagement in rehabilitation and level of disability was collected retrospectively from staff and rehabilitation notes.&lt;p&gt;&lt;/p&gt; &lt;i&gt;Results:&lt;/i&gt; Fifteen participants (65.2%) had sleep problems. Of these, 10 (43.8%) met formal diagnostic criteria for a sleep disorder and in five (21.7%) no underlying cause for sleep problems was identified. Diagnosed sleep disorders in the sample comprised insomnia (21.7%), post-traumatic hypersomnia (8.7%), circadian rhythm disorder (8.7%), sleep apnoea (4.3%), periodic limb movement disorder (4.3%) and rhythmic movement disorder (4.3%). Senior rehabilitation therapists estimated sleep disturbance as interfering with the rehabilitation process in 26% of the overall research sample (n = 23). Sleep quality, assessed by self-report measures (Pittsburgh Sleep Quality Index; PSQI) was not significantly associated with rehabilitation variables (Hopkins Rehabilitation Engagement Rating Scale). Poor sleep quality (PSQI) was associated with greater anxiety (r = 0.611), fatigue (r = 0.683) and daytime sleepiness (r = 0.529).&lt;p&gt;&lt;/p&gt; &lt;i&gt;Conclusions:&lt;/i&gt; Consistent with previous studies, sleep disorder and disturbed sleep was common in HI patients undergoing rehabilitation and was associated with anxiety, fatigue and daytime sleepiness. These findings highlight the importance of assessing and treating sleep problems in HI patients undergoing rehabilitation

Protocol for a systematic review of prognosis after mild traumatic brain injury : an update of the WHO Collaborating Centre Task Force findings

Background: Mild traumatic brain injury (MTBI) is a major public-health concern and represents 70-90% of all treated traumatic brain injuries. The last best-evidence synthesis, conducted by the WHO Collaborating Centre for Neurotrauma, Prevention, Management and Rehabilitation in 2002, found few quality studies on prognosis. The objective of this review is to update these findings. Specifically, we aim to describe the course, identify modifiable prognostic factors, determine long-term sequelae, and identify effects of interventions for MTBI. Finally, we will identify gaps in the literature, and make recommendations for future research. Methods: The databases MEDLINE, PsychINFO, Embase, CINAHL and SPORTDiscus were systematically searched (2001 to date). The search terms included 'traumatic brain injury', 'craniocerebral trauma', 'prognosis', and 'recovery of function'. Reference lists of eligible papers were also searched. Studies were screened according to pre-defined inclusion and exclusion criteria. Inclusion criteria included original, published peer-reviewed research reports in English, French, Swedish, Norwegian, Danish and Spanish, and human participants of all ages with an accepted definition of MTBI. Exclusion criteria included publication types other than systematic reviews, meta-analyses, randomized controlled trials, cohort studies, and case-control studies; as well as cadaveric, biomechanical, and laboratory studies. All eligible papers were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Two reviewers performed independent, in-depth reviews of each eligible study, and a third reviewer was consulted for disagreements. Data from accepted papers were extracted into evidence tables, and the evidence was synthesized according to the modified SIGN criteria. Conclusion: The results of this study form the basis for a better understanding of recovery after MTBI, and will allow development of prediction tools and recommendation of interventions, as well as informing health policy and setting a future research agenda

Protocol for a systematic review of prognosis after mild traumatic brain injury: an update of the WHO Collaborating Centre Task Force findings

Abstract Background Mild traumatic brain injury (MTBI) is a major public-health concern and represents 70-90% of all treated traumatic brain injuries. The last best-evidence synthesis, conducted by the WHO Collaborating Centre for Neurotrauma, Prevention, Management and Rehabilitation in 2002, found few quality studies on prognosis. The objective of this review is to update these findings. Specifically, we aim to describe the course, identify modifiable prognostic factors, determine long-term sequelae, and identify effects of interventions for MTBI. Finally, we will identify gaps in the literature, and make recommendations for future research. Methods The databases MEDLINE, PsychINFO, Embase, CINAHL and SPORTDiscus were systematically searched (2001 to date). The search terms included 'traumatic brain injury', 'craniocerebral trauma', 'prognosis', and 'recovery of function'. Reference lists of eligible papers were also searched. Studies were screened according to pre-defined inclusion and exclusion criteria. Inclusion criteria included original, published peer-reviewed research reports in English, French, Swedish, Norwegian, Danish and Spanish, and human participants of all ages with an accepted definition of MTBI. Exclusion criteria included publication types other than systematic reviews, meta-analyses, randomized controlled trials, cohort studies, and case-control studies; as well as cadaveric, biomechanical, and laboratory studies. All eligible papers were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Two reviewers performed independent, in-depth reviews of each eligible study, and a third reviewer was consulted for disagreements. Data from accepted papers were extracted into evidence tables, and the evidence was synthesized according to the modified SIGN criteria. Conclusion The results of this study form the basis for a better understanding of recovery after MTBI, and will allow development of prediction tools and recommendation of interventions, as well as informing health policy and setting a future research agenda