Latest Medical Research about Brain Injury
Updated: 10 November 2013
Gene Expression Following TBI
Epigenetics and gene expression are cutting edge concepts which are making their way into the realm of traumatic brain injury. A study (Staffa, K et al. 2012) looked at twelve cases of severe brain injury resulting in death and analyzed whether or not the brain tissue had gene expression different than controls without TBI. They found that several substances were expressed in the cerebellum indicating that the cerebellum is an important target to study further regarding gene expression after TBI. This means that adverse changes in a parent with TBI can be passed to children. (for more see blog)
Blast Wave Hurt Axon
Further expiration of the effects of a blast wave on the brain continue to shed light. Mice, after being exposed to a blast, showed cognitive and behavioral changes. It was noted that it was a shortening of the axon initial segment (AIS) in the cortex and hippocampus. This increases both the threshold and the ability of the firing neurons to perform normally and supports the conclusion that exposure to a single blast can lead to mild traumatic brain injury (mTBI) with accompanying cognitive impairment and subcellular changes in the molecular organization of neurons.
Barbiturate Coma After Severe TBI
The idea of putting patients into a barbiturate coma after serious TBI in order to reduce the intracranial pressure (ICP) has been around for years. It has been controversial, and a new study (Majdan, M et al. 2012 ) showed that in five European treatment centers, while high dose barbiturates decrease ICP in 69% of patients, it also caused longer periods of pressure instability, which is exceedingly dangerous. The analysis showed no significant effect on outcome at any stage after injury. Probably not worth doing.
Gender Effect on TBI Outcome?
A study utilizing the Chinese head trauma data bank (Gao, GY 2012) studied over 7000 patients to determine whether or not there was a statistical difference between males and females suffering from traumatic brain injury regarding outcome. There was not. Mortality rates and unfavorable outcomes, showed no gender difference.
Hope for Vision Loss after TBI
A recent study (Sabel BA, et al. 2010) has shown that retinal or cerebral visual injury, long considered irreversible, can be restored with vision rehabilitation techniques. They propose the name "residual vision activation theory" and suggest it can be started at all ages and in all types of visual field impairment after stroke or TBI.
Conflicting Data on Stromal Cell Implantation
In the Journal of Neurotrauma (Bonilla C, et al. 2010) a study tested the intravenous administration of bone marrow stromal cells after traumatic brain injury in rats. After two months of administration the rats were no better at functional abilities. A study of their brains in comparison with the normal group showed no changes in the brains of the mice who received the intravenous stromal cells. However, the same group of investigators in 2009 had implanted the stromal cells, rather than have them administered through IV and found that the rats showed progressive functional recovery and signs of increased brain volume and neurogenesis in the autopsy brains of the rats. This is consistent with earlier studies (Zurita M. 2004) in which the therapeutic effect of transplanted bone marrow stromal cells showed clear and progressive functional recovery of treated animals compared with controls. In that case, new spinal cord tissue was grown bridging the traumatic injury and restoring function.
Surgeons in India have had success with transplantation of stem cells into humans suffering from severe traumatic brain injury and coma. More than one patient in a coma has recovered consciousness and speech after the operation.
In addition, several new drugs and treatments are on the horizon which will give rise to increased neurogenesis or regrowth of brain cells after injury or trauma. Pre-implantation factor (PIF) has been shown to be neuro-regenerative in mice and further studies following a successful toxicity trial will be under way at several universities.
Current Status of Stem Cells for Spinal Cord Regeneration
Many attempts in the last fifteen years have been made to find a method for enhancing spinal cord regeneration after injury. These include use of embryonic or adult stem cells, Schwann cells, genetically modified fibroblast, bone stromal cells, and olfactory ensheathing cells. Out of all the types of cells, a recent study (Sobani ZA, et al. 2010) showed that olfactory ensheathing cells seem to be the most promising, followed by bone marrow stromal cells. However, in the United States direct transplantion of these cells for spinal cord regeneration is not yet out of the experimental stage.
A human trial carried out in Australia had cultured olfactory ensheathing cells transplanted into the spinal cords of six patients with paraplegia. No improvement was noted. However, a quadriplegia patient who was operated on 13 days after a quadriplegia break at C4-5 using cultured bone marrow stomal cells showed gradual improvement in six months following the surgery.
Nerve Repair with Fat Derived Stem Cells Successful
Peripheral nerves (those outside the brain or spinal cord) can often cause ongoing and devastating nerve pain in the extremities. Micro surgery often cannot address all of the cell death involved in some of these conditions. However, combining nerve repair with placement of fat derived stem cells in the dorsal root ganglia showed nerve regeneration and neuro-protection with significant reduction of symptoms. (Reid AJ, et al. 2001).
Important Finding on Coma Decisions
The horrible choices as to the true nature of injury and patients with vegetative or minimally conscious states is well known. Investigators using resting state EEG (Fingelkurts AA, et al. 2011) show that (1) the EEGs for non survivors were significantly lower than for survivors; (2) there was a higher probability of mostly delta and slow beta waves during first assessment for patients with bad outcome (i.e. those who died within the first six months); (3) patients with a good outcome had higher probability of mostly fast-beta and alpha oscillations. Therefore resting state EEGs may have a potentially prognostic value with regards to outcome from VS or MCS. This will also be potentially helpful in medical-legal end of life decision making.TRAUMATIC BRAIN INJURY AS CHRONIC DISEASE
A review of 25 years of treating survivors of brain injury in a university of Texas medical school study, shows that brain injury is a chronic ongoing process rather then a one time injury, as traditionally thought. The researchers hope to reclassify traumatic brain injury as a chronic disease, which will help researches with additional funding to investigate potential cures. They stress that neurological disorders can decrease life expectancy through sleep disorders, cardiac arrhythmia, or epilepsy. The disorders lead to gradual decline in cognitive functioning, a hosts of endocrine disorders, and psychiatric and psychological diseases.TRAUMATIC BRAIN IN JURY COMMON AMONG HOMELESS
A study of more than 900 homeless men and women in Toronto showed that an astonishing 58% of the homeless men and 42% of the homeless women have a history of traumatic brain injury. For many people, the first instance of brain injury occur at a young age, suggesting that it could have set off a chain of events leading to homelessness. The study again highlights the seriousness of brain injury to a life as a successful human being.SOLDIERS WITH BRAIN INJURY HAVE HIGHER EPILEPSY RISK DECADES LATER
New research in the publication Neurology, showed that 13% of post traumatic epilepsy reported in head-wounded veterans did not show up until more than 14 years after the brain injury. A study found that the types of seizure changed over time, often becoming more severe.MILD HEAD INJURY INCREASED RISK OF SLEEP DISORDER
A study (Ayalon, L 2007) showed that as many as 40% to 65% of people with mild traumatic brain injury suffer from insomnia.. The head injury patients underwent numerous sleep studies and found that 15 of 42 patients or 36% had circadian rhythm sleep disorder (CRSD) it was noted that these disorders can lead to psychological and cognitive problems and can interfere with rehabilitation.MORE EVIDENCE THAT PROGESTERONE AS TREATMENT FOR TRAUMATIC BRAIN INJURY
Researchers at Emory University (Stien, D.G. 2009) found that progesterone can protect damaged cells in the central and peripheral nervous system following traumatic brain injury. They found it can reduce swelling and the restriction of blood supply after an injury. It also protects neurons from dying after trauma. Because of its known safety, low costs and ready availability, progesterone should be widely used very soon.SLEEP APNEA AND HEAD INJURY A NEW RISK
It is well known that a large percentage of those with mild or moderate brain injury can suffer from sleep apnea. I has also been observed that people with obstructive sleep apnea have a marked increase in the risk of severe motor crashes. A group of sleep apnea sufferers suffered 250 crashes over 3 years compared to 123 crashes in the group without sleep apnea.TREATING SLEEP DISORDERS IN TBI DOES NOT ELIMINATE SYMPTOMS
Sleep disorders are common with TBI, but a recent study showed that after three months treatment with continuous positive air pressure (CPAP) reduced the severity of obstructive sleep apnea significantly. The participants suffering from TBI experienced no significant changes in the quality of life or cognitive performance after the treatment. Researchers believe that the other problems associated with traumatic brain injury may be continuing to effect the individuals even when they are largely eliminated. This is bad news for sufferers associated with TBI.PINPOINTING THE SOURCE OF EPILEPSY
Scientist are using a new kind of scan called magnetoencephalopathy (MEG) in association with MRI to generate a detailed map that allows them to locate precise areas of the brain dysfunction and have them removed to stop epilepsy. Chronic epilepsy can be fatal and the ability of MEG to pinpoint the source of the seizure more accurately than the traditional method of EEG is a breakthrough that should help many patients with chronic epilepsy. The costs benefit analysis of doing brain surgery for epilepsy is now greater on the benefit side.BIOMARKER IN BRAIN FOUND FOR IDENTIFYING POST TRAUMATIC STRESS DISORDER
Seventy-four U.S. vets who were diagnosed with PTSD were scanned by a magnetoencephalopathy (MEG), a new non-evasive type of brain scan with more than 90% accuracy. Researchers were able to differentiate PTSD from health control. In addition, the MEG can show how badly the patients are impacted by the PTSD, possibly opening up the door to showing how badly patients are impacted by other brain disorders.EEG SCREENING FOR ONSET OF ALZHEIMER
Using a non-evasive and relatively inexpensive EEG analysis and software, scientist have shown that an accurate diagnosis of early Alzheimer's can be made. A seven year NYU study revealed the program is 95% accurate in predicting cognitive decline. A brain wave called Theta was much more prominent in people likely to decline and was especially abnormal in the frontal regions of the brain. Especially the hippocampus.NEW TREATMENT FOR ACUTE BRAIN INJURY
Researchers at Clemson University in South Carolina have developed a gel, made partially of stem cells, that they are injecting into the brains of injured patients. People with combat wounds, car accident or gun shot wounds have been injected with the gel which has been shown to promote healing and limit the amount of secondary injury from the trauma. This is an exciting new method of reducing injury and improving outcome that has never been available before. The gel is expected to be ready for testing in humans in about three years.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).