Mild Traumatic Brain Injury : Studies on outcome and prognostic factors

Objectives: To explore the prevalence and structure of self-reported disability after mild traumatic brain injury and the impact of traumatic brain pathology on such outcome. Material and methods: In study 1-3, symptoms data were collected by use of Rivermead Post-concussion Symptoms Questionnaire (RPQ) and data on global function by use of Glasgow Outcome Scale Extended (GOSE) from 2602 patients at 3 months after MTBI. RPQ data were subject to factor and Rasch-analyses Head CT data from 1262 patients were used in a prediction analysis that also included age and gender. In study 4, MRI and symptoms data were collected at 2-3 days and at 3-7 months follow-up after MTBI in 19 patients. Global function was assessed at follow-up by use of the Rivermead Head Injury Follow-Up Questionnaire (RHIFUQ) and GOSE. Results: I. Most respondents reported no remaining symptoms but 24% reported ≥3 and 10% ≥7 remaining symptoms. The factor analysis demonstrated that all symptoms are correlated but also identified subgroups of symptoms. II. Rasch-analysis of RPQ showed disordered category function, local dependency of items, poor targeting of persons to items and indications of 3 or more dimensions. There was no differential item functioning. III. Head CT pathology with no need for acute intervention was observed in 52 patients (4%) but was not associated with either frequency of remaining symptoms or global outcome at 3 months post injury. Female gender and age over 30 years were associated with less favourable outcome with respect to symptoms and GOSE. IV. Post-acute MRI indicated trauma-related pathology in one patient and follow-up MRI indicated loss of brain volume in 4 patients. Conclusions: A substantial proportion of patients with MTBI report remaining problems at three months after MTBI. RPQ is useful but not optimal to assess symptoms outcome after MTBI and calculation of a total sum score is not recommended. Female gender and older age are negative prognostic factors while brain pathology according to CT has no effect on self-reported outcome. Loss of brain volume after MTBI according to MRI may be a sensitive marker of traumatic brain pathology and deserves further studies

Mild Traumatic Brain Injury : Studies on outcome and prognostic factors

Objectives: To explore the prevalence and structure of self-reported disability after mild traumatic brain injury and the impact of traumatic brain pathology on such outcome. Material and methods: In study 1-3, symptoms data were collected by use of Rivermead Post-concussion Symptoms Questionnaire (RPQ) and data on global function by use of Glasgow Outcome Scale Extended (GOSE) from 2602 patients at 3 months after MTBI. RPQ data were subject to factor and Rasch-analyses Head CT data from 1262 patients were used in a prediction analysis that also included age and gender. In study 4, MRI and symptoms data were collected at 2-3 days and at 3-7 months follow-up after MTBI in 19 patients. Global function was assessed at follow-up by use of the Rivermead Head Injury Follow-Up Questionnaire (RHIFUQ) and GOSE. Results: I. Most respondents reported no remaining symptoms but 24% reported ≥3 and 10% ≥7 remaining symptoms. The factor analysis demonstrated that all symptoms are correlated but also identified subgroups of symptoms. II. Rasch-analysis of RPQ showed disordered category function, local dependency of items, poor targeting of persons to items and indications of 3 or more dimensions. There was no differential item functioning. III. Head CT pathology with no need for acute intervention was observed in 52 patients (4%) but was not associated with either frequency of remaining symptoms or global outcome at 3 months post injury. Female gender and age over 30 years were associated with less favourable outcome with respect to symptoms and GOSE. IV. Post-acute MRI indicated trauma-related pathology in one patient and follow-up MRI indicated loss of brain volume in 4 patients. Conclusions: A substantial proportion of patients with MTBI report remaining problems at three months after MTBI. RPQ is useful but not optimal to assess symptoms outcome after MTBI and calculation of a total sum score is not recommended. Female gender and older age are negative prognostic factors while brain pathology according to CT has no effect on self-reported outcome. Loss of brain volume after MTBI according to MRI may be a sensitive marker of traumatic brain pathology and deserves further studies

Behavioural problems in the first year after Severe traumatic brain injury : a prospective multicentre study

Objective: To investigate the occurrence of behavioural problems in patients with severe traumatic brain injury during the first year after injury and potential associations with outcome. An additional post hoc objective was to analyse the frequency of behaviours with need for intervention from staff. Design and setting: In a prospective population based cohort study 114 patients with severe traumatic brain injury were assessed at three weeks, three months and one year after injury. Main measures: Assessments included clinical examination and standardised instruments. Agitation was assessed with the Agitated Behaviour Scale, the course of recovery by the Rancho Los Amigo Scale and outcome by Glasgow Outcome Scale Extended. Results: Agitation were most common at 3 weeks post injury and 28% (n=68) of the patients showed at least one agitated behaviour requiring intervention from staff. Presence of significant agitation at 3 weeks after injury was not associated with poor outcome. At 3 months agitation was present in 11% (n=90) and apathy in 26 out of 81 assessed patients. At 3 months agitation and apathy were associated with poor outcome at one year. Conclusions: Most agitated behaviours in the early phase are transient and are not associated with poor outcome. Agitation and apathy are uncommon at three months but when present are associated with poor outcome at one year after injury. In the early phase after a severe traumatic brain injury agitated behaviour in need of interventions from staff occur in a substantial proportion of patients

Extended anatomical grading in diffuse axonal injury using MRI : Hemorrhagic lesions in the substantia nigra and mesencephalic tegmentum indicate poor long-term outcome

Clinical outcome after traumatic diffuse axonal injury (DAI) is difficult to predict. In this study, three magnetic resonance imaging (MRI) sequences were used to quantify the anatomical distribution of lesions, to grade DAI according to the Adams grading system, and to evaluate the value of lesion localization in combination with clinical prognostic factors to improve outcome prediction. Thirty patients (mean 31.2 years ±14.3 standard deviation) with severe DAI (Glasgow Motor Score [GMS] <6) examined with MRI within 1 week post-injury were included. Diffusion-weighted (DW), T2*-weighted gradient echo and susceptibility-weighted (SWI) sequences were used. Extended Glasgow outcome score was assessed after 6 months. Number of DW lesions in the thalamus, basal ganglia, and internal capsule and number of SWI lesions in the mesencephalon correlated significantly with outcome in univariate analysis. Age, GMS at admission, GMS at discharge, and low proportion of good monitoring time with cerebral perfusion pressure <60 mm Hg correlated significantly with outcome in univariate analysis. Multivariate analysis revealed an independent relation with poor outcome for age (p = 0.005) and lesions in the mesencephalic region corresponding to substantia nigra and tegmentum on SWI (p  = 0.008). We conclude that higher age and lesions in substantia nigra and mesencephalic tegmentum indicate poor long-term outcome in DAI. We propose an extended MRI classification system based on four stages (stage I—hemispheric lesions, stage II—corpus callosum lesions, stage III—brainstem lesions, and stage IV—substantia nigra or mesencephalic tegmentum lesions); all are subdivided by age (≥/<30 years)

Investigating cognitive reserve, symptom resolution and brain connectivity in mild traumatic brain injury

Abstract Background A proportion of patients with mild traumatic brain injury (mTBI) suffer long-term consequences, and the reasons behind this are still poorly understood. One factor that may affect outcomes is cognitive reserve, which is the brain's ability to maintain cognitive function despite injury. It is often assessed through educational level or premorbid IQ tests. This study aimed to explore whether there were differences in post-concussion symptoms and symptom resolution between patients with mTBI and minor orthopedic injuries one week and three months after injury. Additional aims were to explore the relationship between cognitive reserve and outcome, as well as functional connectivity according to resting state functional magnetic resonance imaging (rs-fMRI). Method Fifteen patients with mTBI and 15 controls with minor orthopedic injuries were recruited from the emergency department. Assessments, including Rivermead Post-Concussion Questionnaire (RPQ), neuropsychological testing, and rs-fMRI scans, were conducted on average 7 days (SD = 2) and 122 days (SD = 51) after injury. Results At the first time point, significantly higher rates of post-concussion symptoms (U = 40.0, p = 0.003), state fatigue (U = 56.5, p = 0.014), and fatigability (U = 58.5, p = 0.025) were observed among the mTBI group than among the controls. However, after three months, only the difference in post-concussion symptoms remained significant (U = 27.0, p = 0.003). Improvement in post-concussion symptoms was found to be significantly correlated with cognitive reserve, but only in the mTBI group (Spearman’s rho = -0.579, p = .038). Differences in the trajectory of recovery were also observed for fatigability between the two groups (U = 36.5, p = 0.015). Moreover, functional connectivity differences in the frontoparietal network were observed between the groups, and for mTBI patients, functional connectivity differences in an executive control network were observed over time. Conclusion The findings of this pilot study suggest that mTBI, compared to minor orthopedic trauma, is associated to both functional connectivity changes in the brain and concussion-related symptoms. While there is improvement in these symptoms over time, a small subgroup with lower cognitive reserve appears to experience more persistent and possibly worsening symptoms over time. This, however, needs to be validated in larger studies. Trial registration NCT05593172. Retrospectively registered

Cognitive Reserve, Early Cognitive Screening, and Relationship to Long-Term Outcome after Severe Traumatic Brain Injury

The objective was to investigate the relationship between early global cognitive functioning using the Barrow Neurological Institute Screen for Higher Cerebral Functions (BNIS) and cognitive flexibility (Trail Making Test (TMT), TMT B-A), with long-term outcome assessed by the Mayo-Portland Adaptability Index (MPAI-4) in severe traumatic brain injury (sTBI) controlling for the influence of cognitive reserve, age, and injury severity. Of 114 patients aged 18–65 with acute Glasgow Coma Scale 3–8, 41 patients were able to complete (BNIS) at 3 months after injury and MPAI-4 5–8 years after injury. Of these, 33 patients also completed TMT at 3 months. Global cognition and cognitive flexibility correlated significantly with long-term outcome measured with MPAI-4 total score (rBNIS = 0.315; rTMT = 0.355). Global cognition correlated significantly with the participation subscale (r = 0.388), while cognitive flexibility correlated with the adjustment (r = 0.364) and ability (r = 0.364) subscales. Adjusting for cognitive reserve and acute injury severity did not alter these relationships. The effect size for education on BNIS and TMT scores was large (d ≈ 0.85). Early screenings with BNIS and TMT are related to long-term outcome after sTBI and seem to measure complementary aspects of outcome. As early as 3 months after sTBI, educational level influences the scores on neuropsychological screening instruments