Brain Activity Patterns Uniquely Supporting Visual Feature Integration after Traumatic Brain Injury

Traumatic brain injury (TBI) patients typically respond more slowly and with more variability than controls during tasks of attention requiring speeded reaction time. These behavioral changes are attributable, at least in part, to diffuse axonal injury (DAI), which affects integrated processing in distributed systems. Here we use a multivariate method sensitive to distributed neural activity to compare brain activity patterns of patients with chronic phase moderate to-severe TBI to those of controls during performance on a visual feature integration task assessing complex attentional processes that has previously shown sensitivity to TBI. The TBI patients were carefully screened to be free of large focal lesions that can affect performance and brain activation independently of DAI. The task required subjects to hold either one or three features of a Target in mind while suppressing responses to distracting information. In controls, the multi-feature condition activated a distributed network including limbic, prefrontal, and medial temporal structures. TBI patients engaged this same network in the single-feature and baseline conditions. In multi-feature presentations, TBI patients alone activated additional frontal, parietal, and occipital regions. These results are consistent with neuroimaging studies using tasks assessing different cognitive domains, where increased spread of brain activity changes was associated with TBI. Our results also extend previous findings that brain activity for relatively moderate task demands in TBI patients is similar to that associated with of high task demands in controls

Multiple Effects of Prefrontal Lesions on Task-Switching

This study examined the performance of 41 patients with focal prefrontal cortical lesions and 38 healthy controls on a task-switching procedure. Three different conditions were evaluated: single tasks without switches and two switching tasks with the currently relevant task signalled either 1500 ms (Long Cue) or 200 ms (Short Cue) before the stimulus. Patients with Superior Medial lesions showed both a general slowing of reaction time (RT) and a significantly increased switch cost as measured by RT. No other prefrontal group showed this increased reaction time switch cost. Increased error rates in the switching conditions, on the other hand, were observed in patients with Inferior Medial lesions and, to a lesser extent, ones with Superior Medial lesions. Patients with left dorsolateral lesions (9/46v) showed slower learning of the task as indicated by a high error rate early on. Several different processes are involved in task-switching and these are selectively disrupted by lesions to specific areas of the frontal lobes

Effects of divided attention on episodic memory in chronic traumatic brain injury: A function of severity and strategy

Abstract Eleven patients with mild traumatic brain injury (MTBI) and 13 patients with moderate-to-severe TBI (STBI) were compared to 10 matched controls on episodic memory for pictorial scene-object associations (e.g. kitchen-bread) and a range of standardized neuropsychological tests of memory and frontal-lobe functions. We tested the hypothesis that deficits in episodic memory result from impaired attentional resources and/or strategic control by manipulating attentional load at encoding (focused versus divided attention) and environmental support at retrieval (free recall and recalled cued by scene versus recognition of object and scene). Patients with TBI were disproportionately affected by the divided attention manipulation, but this effect was modulated by injury severity and encoding strategy. Overall, MTBI patients were impaired only when items were encoded under divided attention, indicating memory deficits that were secondary to deficits in the executive control. STBI patients could be differentiated into two distinct functional subgroups based on whether they favored a strategy of attending to the encoding or digit-monitoring task. The subgroup favoring the digit-monitoring task demonstrated deficits in the focused attention condition, and disproportionate memory deficits in the divided attention condition. In contrast, the subgroup favoring the encoding task demonstrated intact performance across all memory measures, regardless of attentional load, and despite remarkable similarity to the other STBI subgroup on demographic, neuropsychological, and acute injury severity measures. We discuss these outcome differences in terms of the relationship between strategy and executive control and highlight the need for more sensitive anatomical and behavioral measurement at both acute and chronic stages of injury

Effects of divided attention on episodic memory in chronic traumatic brain injury: A function of severity and strategy

Abstract Eleven patients with mild traumatic brain injury (MTBI) and 13 patients with moderate-to-severe TBI (STBI) were compared to 10 matched controls on episodic memory for pictorial scene-object associations (e.g. kitchen-bread) and a range of standardized neuropsychological tests of memory and frontal-lobe functions. We tested the hypothesis that deficits in episodic memory result from impaired attentional resources and/or strategic control by manipulating attentional load at encoding (focused versus divided attention) and environmental support at retrieval (free recall and recalled cued by scene versus recognition of object and scene). Patients with TBI were disproportionately affected by the divided attention manipulation, but this effect was modulated by injury severity and encoding strategy. Overall, MTBI patients were impaired only when items were encoded under divided attention, indicating memory deficits that were secondary to deficits in the executive control. STBI patients could be differentiated into two distinct functional subgroups based on whether they favored a strategy of attending to the encoding or digit-monitoring task. The subgroup favoring the digit-monitoring task demonstrated deficits in the focused attention condition, and disproportionate memory deficits in the divided attention condition. In contrast, the subgroup favoring the encoding task demonstrated intact performance across all memory measures, regardless of attentional load, and despite remarkable similarity to the other STBI subgroup on demographic, neuropsychological, and acute injury severity measures. We discuss these outcome differences in terms of the relationship between strategy and executive control and highlight the need for more sensitive anatomical and behavioral measurement at both acute and chronic stages of injury

The Toronto prehospital hypertonic resuscitation-head injury and multi organ dysfunction trial (TOPHR HIT) - Methods and data collection tools

<p>Abstract</p> <p>Background</p> <p>Clinical trials evaluating the use of hypertonic saline in the treatment of hypovolemia and head trauma suggest no survival superiority over normal saline; however subgroup analyses suggest there may be a reduction in the inflammatory response and multiorgan failure which may lead to better survival and enhanced neurocognitive function. We describe a feasibility study of randomizing head injured patients to hypertonic saline and dextran vs. normal saline administration in the out of hospital setting.</p> <p>Methods/Design</p> <p>This feasibility study employs a randomized, placebo-controlled design evaluating normal saline compared with a single dose of 250 ml of 7.5% hypertonic saline in 6% dextran 70 in the management of traumatic brain injuries. The primary feasibility endpoints of the trial were: 1) baseline survival rates for the treatment and control group to aid in the design of a definitive multicentre trial, 2) randomization compliance rate, 3) ease of protocol implementation in the out-of-hospital setting, and 4) adverse event rate of HSD infusion.</p> <p>The secondary objectives include measuring the effect of HSD in modulating the immuno-inflammatory response to severe head injury and its effect on modulating the release of neuro-biomarkers into serum; evaluating the role of serum neuro-biomarkers in predicting patient outcome and clinical response to HSD intervention; evaluating effects of HSD on brain atrophy post-injury and neurocognitive and neuropsychological outcomes.</p> <p>Discussion</p> <p>We anticipate three aspects of the trial will present challenges to trial success; ethical demands associated with a waiver of consent trial, challenging follow up and comprehensive accurate timely data collection of patient identifiers and clinical or laboratory values. In addition all the data collection tools had to be derived de novo as none existed in the literature.</p> <p>Trial registration number</p> <p>NCT00878631</p

The Post-traumatic Confusional State: A Case Definition and Diagnostic Criteria

In response to the need to better define the natural history of emerging consciousness after traumatic brain injury (TBI) and to better describe the characteristics of the condition commonly labeled Post-traumatic Amnesia, a case definition and diagnostic criteria for the Post- traumatic Confusional State (PTCS) were developed. This project was completed by the Confusion Workgroup of the American Congress of Rehabilitation Medicine Brain Injury Interdisciplinary Special Interest group. The case definition was informed by an exhaustive literature review and expert opinion of workgroup members from multiple disciplines. The workgroup reviewed 2,466 abstracts and extracted evidence from 44 articles. Consensus was reached through teleconferences, face-to-face meetings, and three rounds of modified Delphi voting. The case definition provides detailed description of PTCS (1) core neurobehavioral features, (2) associated neurobehavioral features, (3) functional implications, (4) exclusion criteria, (5) lower boundary, and (6) criteria for emergence. Core neurobehavioral features include disturbances of attention, orientation, and memory as well as excessive fluctuation. Associated neurobehavioral features include emotional and behavioral disturbances, sleep-wake cycle disturbance, delusions, perceptual disturbances and confabulation. The lower boundary distinguishes PTCS from the minimally conscious state while upper boundary is marked by significant improvement in the four core and five associated features. Key research goals are establishment of cut-offs on assessment instruments and determination of levels of behavioral function that distinguish persons in PTCS from those who have emerged to the period of continued recovery