96 research outputs found
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Challenges and Pitfalls Associated with Diagnostic and Prognostic Applications of Functional Neuroimaging in Disorders of Consciousness
The diagnostic assessment of patients with disorder of consciousness is currently based on clinical testing at the bedside and prone to a high error rate in the assessment of the degree of conscious awareness. Investigation of more objective assessment strategies, such as the use of functional magnetic resonance imaging (fMRI) to detect conscious awareness, are becoming increasingly popular in the research community. However, inherent challenges to the use of fMRI threaten its validity as a diagnostic tool and will need to be resolved prior to its integration into the clinical setting. These challenges, which range from the heterogeneity of the patient sample to factors influencing data acquisition and biases in interpretation strategies, are discussed below. Recommendations aimed at mitigating some of the limitations are provided
Which behaviours are first to emerge during recovery of consciousness after severe brain injury?
Background. Early detection of consciousness after severe brain injury is critical for establishing an accurate prognosis and planning appropriate treatment.
Objectives. To determine which behavioral signs of consciousness emerge first and to estimate the time course to recovery of consciousness in patients with severe acquired brain injury.
Methods. Retrospective observational study using the Coma Recovery Scale-Revised and days to recovery of consciousness in 79 patients (51 males; 34 with traumatic brain injury; median [IQR] age 48 [26–61] years; median time since injury 26 [20–36] days) who transitioned from coma or unresponsive wakefulness syndrome (UWS)/vegetative state (VS) to the minimally conscious state (MCS) or emerged from MCS during inpatient rehabilitation.
Results. Visual pursuit was the most common initial sign of MCS (41% of patients; 95% CI [30–52]), followed by reproducible command-following (25% [16–35]) and automatic movements (24% [15–33]). Ten other behaviors emerged first in less than 16% of cases. Median [IQR] time to recovery of consciousness was 44 [33–59] days. Etiology did not significantly affect time to recovered consciousness.
Conclusion. Recovery of consciousness after severe brain injury is most often signaled by reemergence of visual pursuit reproducible command-following and automatic movements. Clinicians should use assessment measures that are sensitive to these behaviors because early detection of consciousness is critical for accurate prognostication and treatment planning
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Long-term Multidomain Patterns of Change After Traumatic Brain Injury: A TRACK-TBI LONG Study.
BACKGROUND AND OBJECTIVES: Traumatic brain injury (TBI) may be a chronic condition carrying risk of future sequelae; few prospective studies examine long-term postinjury outcomes. We examined the prevalence of functional, cognitive, and psychiatric change outcomes from 1 to 7 years postinjury. METHODS: Transforming Research and Clinical Knowledge in TBI LONG (TRACK-TBI LONG) participants were prospectively enrolled within 24 hours of injury and followed up to 1 year postinjury; a subset participated in long-term follow-up from 2 to 7 years postinjury. Reliable change thresholds for the Brief Test of Adult Cognition by Telephone General Composite (cognition) and Brief Symptom Inventory (BSI)-18 (psychiatric) were derived from orthopedic trauma controls (OTCs). Multiple assessments were completed (postinjury baseline assessment and 2 or 3 visits 2-7 years postinjury) within a sample subset. Change was assessed for functional outcome (Glasgow Outcome Scale-Extended [GOSE]) and self-report/informant report of decline. Prevalence ratios for outcomes classified as stable, improved, and declined were reported individually and collectively. The Fisher exact test and log-binomial regression models examined factors associated with decline and improvement. RESULTS: Of the sample (N = 1,264; mild TBI [mTBI], Glasgow Coma Scale [GCS] 13-15, n = 917; moderate-to-severe TBI [msTBI], GCS 3-12, n = 193; or OTC n = 154), stable was the most prevalent outcome. Functional outcome showed the highest rates of decline, regardless of TBI severity (mild = 29%; moderate/severe = 23%). When measures were collectively considered, rates of decline included mTBI (21%), msTBI (26%), and OTC (15%). Age and preinjury employment status were associated with functional decline (per 10 years; relative risk [RR] 1.16, 95% CI 1.07-1.25, p < 0.001; higher in retired/disabled/not working vs full-time/part-time; RR 1.81, 95% CI 1.33-2.45, respectively) in the mTBI group. Improvement in functional recovery 2-7 years postinjury was associated with higher BSI scores (per 5 points; RR 1.11, 95% CI 1.04-1.18, p = 0.002) and GOSE score of 5-7 (GOSE = 8 as reference; RR 2.64, 95% CI 1.75-3.97, p < 0.001). Higher BSI scores and identifying as Black (RR 2.28, 95% CI 1.59-3.25, p < 0.001) were associated with a greater likelihood of improved psychiatric symptoms in mTBI (RR 1.21, 95% CI 1.14-1.29, p < 0.001). A greater likelihood of cognitive improvement was observed among those with higher educational attainment in msTBI (per 4 years; RR 2.61, 95% CI 1.43-4.79, p = 0.002). DISCUSSION: Function across domains at 1-year postinjury, a common recovery benchmark, undergoes change across the subsequent 6 years. Results support consideration of TBI as a chronic evolving condition and suggest continued monitoring, rehabilitation, and support is required to optimize long-term independence and quality of life
Predictive utility of an adapted Marshall head CT classification scheme after traumatic brain injury
Objective: To study the predictive relationship among persons with traumatic brain injury (TBI) between an objective indicator of injury severity (the adapted Marshall computed tomography [CT] classification scheme) and clinical indicators of injury severity in the acute phase, functional outcomes at inpatient rehabilitation discharge, and functional and participation outcomes at 1 year after injury, including death.Participants: The sample involved 4895 individuals who received inpatient rehabilitation following acute hospitalization for TBI and were enrolled in the Traumatic Brain Injury Model Systems National Database between 1989 and 2014.Design: Head CT variables for each person were fit into adapted Marshall CT classification categories I through IV.Main Measures: Prediction models were developed to determine the amount of variability explained by the CT classification categories compared with commonly used predictors, including a clinical indicator of injury severity.Results: The adapted Marshall classification categories aided only in the prediction of craniotomy or craniectomy during acute hospitalization, otherwise making no meaningful contribution to variance in the multivariable models predicting outcomes at any time point after injury.Conclusion: Results suggest that head CT findings classified in this manner do not inform clinical discussions related to functional prognosis or rehabilitation planning after TBI
Diagnosing Level of Consciousness: Limits of the Glasgow Coma Scale Total Score
In nearly all clinical and research contexts, the initial severity of a traumatic brain injury (TBI) is measured
using the Glasgow Coma Scale (GCS) total score. The GCS total score however, may not accurately reflect
level of consciousness, a critical indicator of injury severity. We investigated the relationship between GCS
total scores and level of consciousness in a consecutive sample of 2455 adult subjects assessed with the
GCS 69,487 times as part of the multi-center Transforming Research and Clinical Knowledge in TBI (TRACKTBI) study. We assigned each GCS subscale score combination a level of consciousness rating based on published criteria for the following disorders of consciousness (DoC) diagnoses: coma, vegetative state/
unresponsive wakefulness syndrome, minimally conscious state, and post-traumatic confusional state, and present our findings using summary statistics and four illustrative cases. Participants had the following characteristics: mean (standard deviation) age 41.9 (17.6) years, 69% male, initial GCS 3–8 = 13%; 9–12 = 5%; 13–15 = 82%.
All GCS total scores between 4–14 were associated with more than one DoC diagnosis; the greatest variability
was observed for scores of 7–11. Further, a wide range of total scores was associated with identical DoC diagnoses. Importantly, a diagnosis of coma was only possible with GCS total scores of 3–6. The GCS total score does
not accurately reflect level of consciousness based on published DoC diagnostic criteria. To improve the classification of patients with TBI and to inform the design of future clinical trials, clinicians and investigators should
consider individual subscale behaviors and more comprehensive assessments when evaluating TBI severityTRACK-TB
Central curation of Glasgow Outcome Scale-Extended data: lessons learned from TRACK-TBI
The Glasgow Outcome Scale (GOS) in its original or extended (GOSE) form is the most widely used assessment of global disability in traumatic brain injury (TBI) research. Several publications have reported concerns about assessor scoring inconsistencies, but without documentation of contributing factors. We reviewed 6801 GOSE assessments collected longitudinally, across 18 sites in the 5-year, observational Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study. We recorded error rates (i.e., corrections to a section or an overall rating) based on site assessor documentation and categorized scoring issues, which then informed further training. In Cohort 1 (n=1261; 2/2014-5/2016), 24% of GOSEs had errors identified by central review. In Cohort 2 (n=1130; 6/2016-7/2018), acquired following curation of Cohort 1 data, feedback, and further training of site assessors, the error rate was reduced to 10%. GOSE sections associated with the most frequent interpretation and scoring difficulties included whether current functioning represented a change from pre-injury (466 corrected ratings in Cohort 1; 62 in Cohort 2), defining dependency in the home and community (163 corrections in Cohort 1; 3 in Cohort 2); and return to work/school (72 corrections in Cohort 1; 35 in Cohort 2). These results highlight the importance of central review in improving consistency across sites and over time. Establishing clear scoring criteria, coupled with ongoing guidance and feedback to data collectors, is essential to avoid scoring errors and resultant misclassification, which carry potential to result in “failure” of clinical trials that rely on the GOSE as their primary outcome measure
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
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Prior traumatic brain injury is a risk factor for in-hospital mortality in moderate to severe traumatic brain injury: a TRACK-TBI cohort study.
OBJECTIVES: An estimated 14-23% of patients with traumatic brain injury (TBI) incur multiple lifetime TBIs. The relationship between prior TBI and outcomes in patients with moderate to severe TBI (msTBI) is not well delineated. We examined the associations between prior TBI, in-hospital mortality, and outcomes up to 12 months after injury in a prospective US msTBI cohort. METHODS: Data from hospitalized subjects with Glasgow Coma Scale score of 3-12 were extracted from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study (enrollment period: 2014-2019). Prior TBI with amnesia or alteration of consciousness was assessed using the Ohio State University TBI Identification Method. Competing risk regressions adjusting for age, sex, psychiatric history, cranial injury and extracranial injury severity examined the associations between prior TBI and in-hospital mortality, with hospital discharged alive as the competing risk. Adjusted HRs (aHR (95% CI)) were reported. Multivariable logistic regressions assessed the associations between prior TBI, mortality, and unfavorable outcome (Glasgow Outcome Scale-Extended score 1-3 (vs. 4-8)) at 3, 6, and 12 months after injury. RESULTS: Of 405 acute msTBI subjects, 21.5% had prior TBI, which was associated with male sex (87.4% vs. 77.0%, p=0.037) and psychiatric history (34.5% vs. 20.7%, p=0.010). In-hospital mortality was 10.1% (prior TBI: 17.2%, no prior TBI: 8.2%, p=0.025). Competing risk regressions indicated that prior TBI was associated with likelihood of in-hospital mortality (aHR=2.06 (1.01-4.22)), but not with hospital discharged alive. Prior TBI was not associated with mortality or unfavorable outcomes at 3, 6, and 12 months. CONCLUSIONS: After acute msTBI, prior TBI history is independently associated with in-hospital mortality but not with mortality or unfavorable outcomes within 12 months after injury. This selective association underscores the importance of collecting standardized prior TBI history data early after acute hospitalization to inform risk stratification. Prospective validation studies are needed. LEVEL OF EVIDENCE: IV. TRIAL REGISTRATION NUMBER: NCT02119182
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