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traumatic brain injury.

LATEST MEDICAL RESEARCH

Updated: 02 February 2010

TEN YEAR RECOVERY FROM TBI: CHILDREN AND YOUNG ADULTS

A Swedish study (Horneman, G. 2009) followed 165 survivors of TBI and tested them 10 years after injury. The results showed poor performance in intellectual function, low results in verbal tests and tests of verbal learning and memory, visual ability and executive functioning. When compared to healthy controls, these deficits persisted. It again noted that it is difficult to predict the outcome in children and young adults until years after the injury.

NEW MARKER FOR TBI

Yet another biological marker for the presence of traumatic brain injury has been found. In a Chinese study (Huang, M. et al. 2009) the changes in plasma micro particle procoagulant activity in patients was correlated with brain injury and is thought to contribute to the inflammatory reaction after trauma. The higher presence of this product is associated with poorer clinical outcome.

CONTINUED DEBATE OVER THERAPEUTIC HYPOTHERMIA
For the past ten years the topic of whether or not lowering the body temperature of a recent victim of brain trauma, is or is not clinically helpful. This latest study (deDeyne, C.S. 2010) suggests that the clinical advantages of this procedure are not necessarily out weighted by the negative effects of cooling and re-warming a patient whose has been severely injured. The battle goes on and it is unclear where this one will end. Families of the patients who were offered this procedure need to make their own informed decision.

CAREFUL ABOUT SLEEP MEDICATIONS

The Journal of Head Trauma Rehabilitation reported in 2010 (Larson, E.B.) that a negative effect on cognition was reported for TBI patients who were treated for insomnia with Benzodiazepins after injury. Furthermore, GABA antagonist agonists were found to possibly interfere with neuro-rehabilitation after injury. These types of medications should be avoided in the recovery phase of TBI. Pharmaceutical help in aiding sleep should be tailored to avoid these families of medications.

THE PSYCHIATRIC INJURIES OF TBI

Although it is generally held that psychiatric conditions can be created or aggravated after TBI, there is a lot of research going on at the present time to quantify this. In the American Journal of Psychiatry, (Bryant R. A. et al. 2010) a study involving patients who had suffered mild traumatic brain injury (MmTBI) studied to see if new psychiatric disorders occurred after injury. Measurements three and twelve months post injury showed that 22% of the patients developed a psychiatric disorder they had not experience before injury, the most common being depression 9%, generalized anxiety disorder 9%, post traumatic stress disorder 6% and agoraphobia 6%. Other studies have shown higher rates.

GENETIC ASSOCIATION WITH TBI OUTCOME

It remains a mystery why certain individuals who suffer a mild or moderate TBI can have an excellent outcome, while others can suffer devastating effects. Comparing MRI or CT scans between the patients offers little to support the differences. Studies are now (Dardiotis, E. et al 2010) starting to accumulate evidence which implicates various genetic elements in the injury and recovery process of brain trauma. They note that "the extent of brain injury after TBI seems to be modulated to some degree by genetic variance." Further research on this important issue will be forthcoming. Patients should take comfort in these studies in cases where hope for recovery does not occur, as it is in some instances beyond the patients control.



DATA ON DECOMPRESSIVE CRANIOTOMY

The benefits of decompressive crainotomy (DC) in the treatment of traumatic brain injury patients with increased intracranial pressure (ICP) is controversial. A recent study Williams R. F. et al. 2009, showed that DC resulted in good functional outcome in over 50% of patients with severe TBI. The maximum benefit was observed in younger patients with demonstrable reduction in ICP after decompression. These are factors to consider when the choice of DC arises after injury.

PROBABILITY OF LATE ONSET SEIZURES

Late onset seizures following moderate to severe brain injury are of great concern. They can emerge a year or two or more after the initial injury. A study (Englander, J. et al. 2003) showed that the highest probability for post traumatic seizures included biparietal contusions (66%), dural penetration with bone and metal fragments (62.5%), multiple intracranial operations (36%), multiple subcortical contusions (33%), subdural hematoma with evacuation (27%), midline shift greater than 5mm (25%). The initial Glasgow Coma Scale was associated with the following probabilities for developing late post traumatic seizures at 24-months: a score of 3 to 8, 17%, a score of 9 to 12, 24%, a score of 13 to 15, 8%.

NEW IMAGING HELPFUL IN CHILD BRAIN INJURY CASES

Two new types of MRI of the brain - Diffusion Weighted Imaging (DWI) and Consequent Apparent Diffusion Coefficient (ADC) have been used as predictors of outcome in adults, and a recent study (Galloway, NR 2008), shows that these tools have excellent predictive capability in regards to children with traumatic brain injury. That found that ADC values in the peripheral white matter were significantly reduced in children with severe TBI with poor outcomes compared to those with severe TBI and good outcomes. They also found that the total brain ADC value alone had the greatest ability to predict outcome and correctly predicted outcome in 84% of cases. Thus, early identification of children in high risk for poor outcomes can be obtained using these tools and an assist in aggressive clinical management of these patients.

FACE RECOGNITION IMPAIRMENT WITH TBI

A review of the literature done in the journal Brain Injury (Radice-Meumann, D. et al 2007) shows that the TBI population often suffers from an impairment of their ability to determine the emotion of others from facial expressions. While this sounds odd, the results of this deficit result in poor interpersonal skills, which can affect social relationships, marriage, and rehabilitation. They suggest treatment approaches similar to those previously designed for autism to be considered with PT.

NO MALINGERING DETECTION IN WISCONSIN CARD SORT TEST

A large test of patients with mild traumatic brain injury and uninjured controls(Grebe, KW, 2009) showed that the widely used neuropsychological battery instrument tests, the “Wisconsin Card Sorting Test” failed to detect patients with a plan to perform below their ability or falsely on the tests. The scores were ineffective in discriminating malingering from non-malingering mild TBI patients.

STUDIES ON POST CONCUSSIVE SYMPTOMS

Study in Norway (Siqurdardottir, S. 2009) studied post concussive symptoms from 3 to 12 months post injury in adults with TBI. Of the whole sample, 28% of cases developed those concussive syndromes at 3 months and 24% at 12 months post injury. The mild and moderate group showed a decline of symptoms over time in contrast to the severe TBI group. Greater levels of anxiety at 3 months, as well as shortness of post traumatic amnesia duration were found to be important predictors of the severity of these symptoms at 12 months. Interestingly, one year after injury, no differences were found between the TBI groups mild, moderate and severe on the presence of post concussive symdrome (PCS).

The second Norwegian study (Roe, C. et al. 2009) found that post concussive syndrome cognitive difficulties persisted for 12 months in a large percentage of the patients and that the cognitive symptoms persisted and were considered a “considerable” problem even one-year after injury.

COOLING PROTECTS BRAIN IN INJURED CHILDREN

This is a well known phenomenon, a Chinese study from 2009 showed that moderate hypothermia (lowering the core temperature of the patient 10-degrees or so) showed improvements in intracranial temperature, intracranial pressure and other markers after severe brain injury. The temperature lowering was done for 72 hours after admission to the hospital and was considered safe in that clinical setting and successful.

Another study from 2009 shows that hypothermia when used with children suffering from brain injury reduces the damage caused to the brain post accident by “oxidative stress” which is a secondary form of injury that goes on in the brain following traumatic injury and which could have severe effects. The lowering of the temperature lowered the rate at which oxidated stress occurred and thus resulted in a better outcome for those treated with hypothermia.

BLAST VICTIMS AND VISUAL IMPAIRMENT

The study following Iraq veterans suffering from TBI from blast injuries showed ongoing visual problems in a significant number (over 80%) following injury. The visual dysfunctions included problems with convergence, accommodative and ocular motor dysfunction, visual field defects and night vision. The study is important in that it validates, in a group in which no one can attack, the presence of these troubling visual problems often found in non-military brain injury settings. Insurance companies commonly scoff at these types of complaints, which are very real and objective.

THE BENEFITS OF ALPHA LIPOIC ACID IN TBI

A Turkish study from 2009 showed that the ingestion of alpha-lipoic acid (LA) produced inflamation and other symptoms after brain injury. It also reversed swelling due to increased water content. It is thought to exert its influence by helping preserve the brain blood barrier permeability and by its antioxidant properties.

BLOOD TEST PREDICTS BRAIN INJURY OUTCOME

A team at University of Pittsburgh has found that measuring the initial blood magnesium level of patients with brain injury indicted outcome from the injury. They found that patients who had a low magnesium level upon arrival at the hospital had significantly worse outcome than those with a normal magnesium level. It is hoped that more hospitals will begin to take this important measurement in the future.

POSITIVE EFFECTS OF HEMOGLOBIN SOLUTION

It has been noted that resuscitation with a special hemoglobin oxygen-carrying solution may reduce the effects of secondary brain injury in patients who have had traumatic brain injury and bleeds. The solution called HBOC-201, is a salt solution that increases oxygen delivery to tissues. The studies are human should be taken soon.

THE DRUG USEFUL FOR AGGRESSION

A pallet study for the use of Quetiapine for treatment of aggression secondary to traumatic brain injury showed that it was effective in reducing irritability and aggression in such patients. Patients also reported an associated improvement in cognitive functioning.

ACCELERATED DAMAGE IN ELDERLY

The destructive cellular action known as Excitotoxicity occurs after TBI and results in brain cell death. A recent study in rats showed that older animals showed earlier onset of damage in wider areas then younger rats. This study shows, along with many others, that the effects of TBI on the elderly are often more significant than an equivalent injury in a middle aged person.

MOOD DISORDERS AND THE HIPPOCAMPUS

It was found that patients who developed mood disorder following traumatic brain injury has significantly lower hippocampal volume than patients without mood disturbance. Reduced hippocampus volumes were associated with poor vocational outcome in one year follow-up. The findings are consistent with the “double-hit” mechanism by which neural and glial elements affected by trauma are further damaged by the neuro-toxic effects of increased cortisol found in association with mood disorders. The need for volumetric studies of the hippocampus following moderate to severe brain injuries becoming more and more important.

SELECTIVE BRAIN COOLING PROTECTS AGAINST TBI

Therapeutic hypothermia is a promising treatment for patients with severe TBI. Using a head cap and neck band filled with cooling material, patients who underwent such cooling after admission, had a far higher rate of good neurological outcome than those who did not. The non-evasive procedure is a safe method of improving the prognosis in severe TBI patients and hopefully this treatment will begin to be offered in the United States soon.

MILD TBI CELL DEATH

The presence of apoptotic cell death after mild traumatic brain injury in rats has been established. Selective neuronal cell loss was evident in several regions of the brain and the data suggest a biological basis for the permanent symptoms found in some mild TBI patients. (Raghupathi, R et al. 2002).

LONG TERM OUTCOME FOLLOWING MILD TBI

Following patients who reported mild TBI for an average of eight (8) years post injury, revealed that “MTBI can have adverse long term neuropsychological outcomes on subtle aspects of complex attention and working memory.” (Danderploeg, RD 2005).

MILD TRAUMATIC BRAIN INJURY, LONG TERM SYMPTOMS

A European study from 2006 followed the progression of victims of MTBI and the results of follow-up neuropsychological testing showed “the idea that MTBI can have sustained consequences, and that the subjectively experienced symptoms and difficulties in every day situations are related to objectively measurable parameters in neuro-cognitive function.” (Sterr A, et al. 2006).

VISUOSPATIAL ATTENTION DEFICIT AND EXECUTIVE FUNCTIONS PROBLEMS AND MTBI

A group of patients who had suffered mild traumatic brain injury were given a battery of test to determine the nature and rate of their recovery. The researchers noted “these findings indicate that the regions of the brain associated with orientating and executive components of visuospatial attention may be the most susceptible to neuro damage resulting from MTBI. Moreover, the lack of recovery in the executive component indicates that the degree and time course for recovery may be regionally specific.” The findings show the deficits in executive functioning existed one month after trauma.

MILD TRAUMATIC BRAIN INJURY EQUALS PERMANENT DEFICITS IN MICE

Researches tested mice following mild traumatic brain injury for up to 90 days post injury. There findings showed “these results demonstrate that persistent deficits in these tests of cognitive learning abilities and emergence of depression-like behavior in injured mice are similar to those reported in human post-concussion syndrome.” (Milman A, et al. 2005).

DIFFUSION TENSOR IMAGING (DTI) ADVANCES

The type of MRI now being utilized is know as Diffusion Tensor Imaging, promises to be more sensitive than normal MRI, especially in detection of white matter brain injury. It has the ability to see and is more sensitive to diffuse axonal injury and the effects of stretched neurons. Persons with ongoing TBI symptoms in the face of normal MRI should consider DTI to rule out more subtle damage. (Wilde EA et al. 2006).

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