Aase W. Engberg

Long-term global and regional brain volume changes following severe traumatic brain injury: A longitudinal study with clinical correlates

Traumatic brain injury (TBI) results in neurodegenerative changes that progress for months, perhaps even years post-injury. However, there is little information on the spatial distribution and the clinical significance of this late atrophy. In 24 patients who had sustained severe TBI we acquired 3D T1-weighted MRIs about 8 weeks and 12 months post-injury. For comparison, 14 healthy controls with similar distribution of age, gender and education were scanned with a similar time interval. For each subject, longitudinal atrophy was estimated using SIENA, and atrophy occurring before the first scan time point using SIENAX. Regional distribution of atrophy was evaluated using tensor-based morphometry (TBM). At the first scan time point, brain parenchymal volume was reduced by mean 8.4% in patients as compared to controls. During the scan interval, patients exhibited continued atrophy with percent brain volume change (%BVC) ranging between -0.6% and -9.4% (mean -4.0%). %BVC correlated significantly with injury severity, functional status at both scans, and with 1-year outcome. Moreover, %BVC improved prediction of long-term functional status over and above what could be predicted using functional status at approximately 8 weeks. In patients as compared to controls, TBM (permutation test, FDR 0.05) revealed a large coherent cluster of significant atrophy in the brain stem and cerebellar peduncles extending bilaterally through the thalamus, internal and external capsules, putamen, inferior and superior longitudinal fasciculus, corpus callosum and corona radiata. This indicates that the long-term atrophy is attributable to consequences of traumatic axonal injury. Despite progressive atrophy, remarkable clinical improvement occurred in most patients.

Psychosocial outcome following traumatic brain injury in adults: a long-term population-based follow-up.

Primary objective: On a national basis to conduct a 5, 10 and 15 year follow-up study of representative samples of survivors after traumatic brain injury (TBI) and to identify factors of importance for long-term survival and life satisfaction after TBI occurring in 1982, 1987 or 1992. Research design: Epidemiological, register-based questionnaire survey. Main outcomes, result and conclusions: Out of 389 survivors randomly chosen from a national complete hospital register, 173 had suffered a cranial fracture, 186 a cerebral lesion (brain contusion or traumatic haemorrhage) and 30 patients a chronic subdural haematoma. Out of 337 survivors found eligible for a questionnaire, 76% responded. Among the data registered according to the above mentioned areas, the main findings were that 23–31% of the cerebral lesion responders were unable to maintain earlier work/education at pre-injury level, against up to 14% of cranial fracture patients. Significantly more cerebral lesion patients than cranial fracture patients found emotional control more difficult, as well as increased difficulties with memory and concentration, maintenance of leisure time interests and general life satisfaction. In the long run, an important factor influencing survival among cerebral lesion patients seemed to be whether relations with family and friends could be maintained at the pre-injury level.

Psychosocial consequences of stroke: a long-term population-based follow-up.

Primary objective: To investigate psychosocial status among nationally representative groups of stroke patients at long intervals post-stroke. Methods and procedures: From a Danish national register of hospitalizations, three representative groups of surviving patients were selected who had suffered a stroke 5, 10 and 15 years previously. A follow-up postal questionnaire was sent to them comprising items concerning symptomatology, functioning and social conditions, together with the Nottingham Health Profile (NHP). Main outcomes and results: Longer follow-up intervals were associated with younger age at stroke and better functioning at discharge. At follow-up, the majority of patients reported difficulties with attention, memory and emotional control, irrespective of follow-up interval. Return to employment, social relations and leisure activities were affected, but were comparatively better at longer follow-up intervals, as was self-rated functioning and several NHP symptom scales. However, multi-variate analyses suggest that these positive changes with time appear to be mediated by attrition related to age at stroke and discharge functioning rather than time since stroke itself. Conclusions: Symptomatology, functioning and social conditions remain affected and perhaps stagnant in long-term survivors of stroke.

Subjective well-being and quality of life following traumatic brain injury in adults: A long-term population-based follow-up

Primary objective: To assess subjective well-being and quality-of-life in nationally representative samples of patients at long intervals following traumatic brain injuries. Methods and procedures: Patients with either cranial fractures or cerebral lesions were identified in a national computer-based register of hospital admissions and random samples were selected among those who had suffered the injury at 5, 10 or 15 years prior to the follow-up. Postal questionnaires were sent to them covering quality of life, e.g. return to employment, family relations and current subjective well-being in terms of symptomatology, e.g. somatic complaints, cognitive dysfunction. A response rate of 76% was obtained, comprising 114 patients with cranial fracture and 126 with cerebral lesions. Main outcomes and results: The group with cerebral lesions had markedly poorer quality of life and subjective well-being than the group with cranial fractures and this did not vary across time. In both groups, the most common symptoms concerned cognition. Among the cerebral lesion group, quality of life outcome was fairly well predicted by severity of injury, but subjective well-being was less well predicted. Conclusions: The negative consequences of traumatic cerebral lesions are marked and do not vary at long periods following injury.

Centralized rehabilitation after severe traumatic brain injury – a population‐based study

Objectives –  To present results from the first 3 years of centralized subacute rehabilitation after very severe traumatic brain injury (TBI), and to compare results of centralized versus decentralized rehabilitation.

Cognitive dysfunction in young men following head injury in childhood and adolescence: a population study

Objectives: To examine the prevalence of cognitive dysfunction among young men who had suffered a head injury during childhood or adolescence, in particular focusing upon the effects of age and the severity of the injury. Methods: By cross linkage of Danish national registers for hospital admissions and the draft board, 3091 young men were identified who had been injured before age 18 and tested at age 18 or shortly thereafter: 970 had suffered a single concussion and were in hospital for one day only; 521 had two concussions at separate times and were in hospital for one day only on each occasion; 961 had a cranial fracture; and 639 had a cerebral lesion. For all of these, scores on the draft board’s cognitive screening test were obtained, dichotomised as dysfunctional or non-dysfunctional. Prevalences of dysfunctional scores were compared with population base rates (about 20% of all Danish men appearing before the draft board had a score classified as dysfunctional). Results: For young men who had suffered a single concussion, cranial fracture, or cerebral lesion before 12 years of age, resulting in less than 12 days of hospital admission (n = 376), rates of cognitive dysfunction did not exceed those in the general population (odds ratios < 1.4, NS), but the odds ratios became significant and > 1.4 where the injury occurred after age 11. For those with a cerebral lesion resulting in over 11 days of hospital admission (n = 263), all odds ratios were significant and ≥ 2.0, irrespective of age at injury. For cases of two concussions, all odds ratios were > 1.4 but were not significant for all age groupings. Conclusions: For milder forms of single head injury before age 12 there is no evidence of enduring cognitive dysfunction. The apparent effect at later ages may reflect predisposing psychosocial factors. For more serious injury, and for cases with two concussions, the effect is marked and not clearly related to age. For the former, this suggests enduring neurological effects of the injury; for the latter, where the effect is unrelated to time between injuries, predisposing factors may again play a role.

Functional Oral Intake and Time to Reach Unrestricted Dieting for Patients With Traumatic Brain Injury

OBJECTIVES To investigate the status of functional oral intake for patients with severe traumatic brain injury (TBI) and time to return to unrestricted dieting; and to investigate whether severity of brain injury is a predictor for unrestricted dieting. DESIGN Observational retrospective cohort study. SETTING Subacute rehabilitation department, university hospital. PARTICIPANTS Patients age 16 to 65 years (N=173) with severe TBI (posttraumatic amnesia from 7d to >6 mo) admitted over a 5-year period. Patients are transferred to the brain injury unit as soon as they ventilate spontaneously. INTERVENTION Facial oral tract therapy. MAIN OUTCOME MEASURE Unrestricted dieting assessed by the Functional Oral Intake Scale (FOIS). RESULTS We found that 93% of all patients had problems with functional oral intake at admission. Within 126 days of rehabilitation, 64% recovered to unrestricted dieting before discharge. The chance of returning to total oral diet depends on the severity of the brain injury and can be predicted by Glasgow Coma Scale (GCS; measured the day after cessation of sedation; Wald chi(2)=42.78, P<.01), Rancho Los Amigos Scale (RLAS) level (Wald chi(2)=11.84, P=.01), FIM instrument (Wald chi(2)=44.40, P<.01), and FOIS score at admission (Wald chi(2)=82.93, P<.01). CONCLUSIONS Impairment in functional oral intake was found to be very common for patients with severe TBI admitted to a subacute rehabilitation department. For those who recovered during hospital rehabilitation, return to unrestricted dieting happened within 126 days of rehabilitation. The chance of returning to unrestricted dieting depends on the severity of the brain injury and can be predicted by GCS score, RLAS level, FIM score, and functional oral intake at admission. These results are important when planning rehabilitation, giving information to patients and relatives, and designing efficacy studies of facial oral tract therapy, which are highly recommended.

The Association of Functional Oral Intake and Pneumonia in Patients With Severe Traumatic Brain Injury

OBJECTIVES To investigate the incidence and onset time of pneumonia for patients with severe traumatic brain injury (TBI) in the early phase of rehabilitation and to identify parameters associated with the risk of pneumonia. DESIGN Observational retrospective cohort study. SETTING Subacute rehabilitation department in a university hospital in Denmark. PARTICIPANTS Patients (N=173) aged 16 to 65 years with severe TBI who were admitted during a 5-year period. Patients are transferred to the brain injury unit as soon as they ventilate spontaneously. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Pneumonia. RESULTS Twenty-seven percent of the patients admitted to the brain injury unit were in treatment for pneumonia; pneumonia developed in 12% of the patients during rehabilitation; the condition occurred within 19 days of admission in all but 1 patient. Of these patients, 81% received nothing by mouth. Three factors identified patients at highest risk of pneumonia: Glasgow Coma Scale score less than 9 (1 day after cessation of sedation); Rancho Los Amigos Scale score less than 3 (on admission); and no oral intake on admission. Having a tracheotomy tube and/or feeding tube was also associated with a higher occurrence of pneumonia. CONCLUSIONS Among patients with severe TBI, 27% had pneumonia at transfer from the intensive care unit. Pneumonia developed in only 12% of the participants during rehabilitation. Patients with a low level of consciousness and patients with a tracheotomy tube or feeding tube had a higher likelihood of pneumonia.

A population-based study of survival and discharge status for survivors after head injury

Objectives – Creation of a basis for the planning of rehabilitation after head injury in Denmark.

Occurrence and severity of agitated behavior after severe traumatic brain injury

Purpose To investigate the occurrence and severity of agitation in patients after severe traumatic brain injury (TBI), to identify predictors of agitation and to study interrater reliability for a translated version of the Agitated Behavior Scale (ABS). Design Prospective observational study. From November 1, 2006, through October 2007, 46 consecutive patients with TBI were included in the early rehabilitation phase following neurosurgical intervention. Agitated behavior was assessed by the ABS, which was implemented in clinical practice. Logistic regression analysis identified predictors of agitated behavior and Intra Class Correlation was used to analyze reliability. Findings Agitated behavior occurred in 41% of patients, of whom one third exhibited severely agitated behavior. The interrater reliability between three nurses was good to excellent. Conclusions Using ABS as a tool in care of patients with agitated behavior may be effective through working as a common language. Clinical Relevance We recommend the use of ABS as a routine assessment in early rehabilitation of patients with TBI.