Dhaval Shukla

Outcome measures for traumatic brain injury

Traumatic brain injury (TBI) is a major public health problem resulting in death and disabilities of young and productive people. Though the mortality of TBI has decreased substantially in recent years the disability due to TBI has not appreciably reduced. Various outcome scales have been proposed and used to assess disability after TBI. A few, commonly used are Glasgow Outcome Scale (GOS) with or without extended scores, Disability Rating Scale (DRS), Functional Independence Measure (FIM), Community Integration Questionnaire (CIQ), and the Functional Status Examination (FSE). These scales assess disability resulting from physical and cognitive impairments. For patients with good physical recovery a cognitive and neuropsychological outcome measure is required. Such measures include Neurobehavioural Function Inventory and specific neuropsychological tests like Rey Complex Figure for visuoconstruction and memory, Controlled Oral Word Association for verbal fluency, Symbol Digit Modalities (verbal) for sustained attention and Grooved Pegboard for fine motor dexterity. A more holistic and complete outcome measure is Quality of Life (QOL). Disease specific QOL measure for TBI, Quality of Life after Brain Injury (QOLIBRI) has also been recently proposed. The problems with outcome measures include poor operational definitions, lack of sensitivity or low ceiling effects, inability to evaluate patients who cannot report, lack of integration of morbidity and mortality categories, and limited domains of functioning assessed. GOSE-E satisfies most of the criteria of good outcome scale and in combination with neuropsychological tests is a near complete instrument for assessment of outcome after TBI.

Mild traumatic brain injuries in adults

Mild traumatic brain injury (mTBI) is the commonest form of TBI. Though the name implies, it may not be mild in certain cases. There is a lot of heterogeneity in nomenclature, classification, evaluation and outcome of mTBI. We have reviewed the relevant articles on mTBI in adults, particularly its definition, evaluation and outcome, published in the last decade. The aspects of mTBI like pediatric age group, sports concussion, and postconcussion syndrome were not reviewed. There is general agreement that Glasgow coma score (GCS) of 13 should not be considered as mTBI as the risk of intracranial lesion is higher than in patients with GCS 14–15. All patients with GCS of <15 should be evaluated with a computed tomography (CT) scan. Patients with GCS 15 and risk factors or neurological symptoms should also be evaluated with CT scan. The outcome of mTBI depends on the combination of preinjury, injury and postinjury factors. Overall outcome of mTBI is good with mortality around 0.1% and disability around 10%.

Recovery of resting brain connectivity ensuing mild traumatic brain injury

Brains reveal amplified plasticity as they recover from an injury. We aimed to define time dependent plasticity changes in patients recovering from mild traumatic brain injury (mTBI). Twenty-five subjects with mild head injury were longitudinally evaluated within 36 h, 3 and 6 months using resting state functional connectivity (RSFC). Region of interest (ROI) based connectivity differences over time within the patient group and in comparison with a healthy control group were analyzed at p < 0.005. We found 33 distinct ROI pairs that revealed significant changes in their connectivity strength with time. Within 3 months, the majority of the ROI pairs had decreased connectivity in mTBI population, which increased and became comparable to healthy controls at 6 months. Within this diffuse decreased connectivity in the first 3 months, there were also few regions with increased connections. This hyper connectivity involved the salience network and default mode network within 36 h, and lingual, inferior frontal and fronto-parietal networks at 3 months. Our findings in a fairly homogenous group of patients with mTBI evaluated during the 6 month window of recovery defines time varying brain connectivity changes as the brain recovers from an injury. A majority of these changes were seen in the frontal and parietal lobes between 3 and 6 months after injury. Hyper connectivity of several networks supported normal recovery in the first 6 months and it remains to be seen in future studies whether this can predict an early and efficient recovery of brain function.

Does isolated traumatic subarachnoid hemorrhage affect outcome in patients with mild traumatic brain injury

Background:The importance of isolated traumatic subarachnoid hemorrhage (SAH) in relation to functional outcome in patients with mild traumatic brain injury (TBI) has not been frequently studied. The aim of this study was to compare the impact of isolated SAH with normal computed tomographic (CT) scan on outcome of patients with mild TBI. Methods:This is a retrospective study of clinical records and CT scans of all patients with mild TBI (Glasgow Coma Scale score ≥13) evaluated from January 1, 2010, to March 15, 2010, at our institution. The patients were divided into 2 groups: isolated SAH and normal CT scan. The telephonic Glasgow Outcome Scale–Extended, Rivermead Post-Concussion Symptoms Questionnaire (RPCSQ), and Rivermead Head Injury Follow-up Questionnaire (RHFUQ) scores were used to assess outcome after 1 year of injury. Independent sample t test in SPSS was used to assess difference in outcome. Results:A total of 1149 patients with mild TBI were evaluated during study period. Among them, 34 (2.9%) patients had isolated SAH. Twenty-eight patients were male and 6 were female, with a mean age of 36.5 years. Subarachnoid hemorrhage was cortical in 19 (55.9%) patients, interhemispheric in 3 (8.8%) patients, Sylvian fissure in 2 (5.9%) patients, and basal cisternal in 1 (2.9%) patient. Nine (26.5%) patients had SAH at multiple locations. The mean RPCSQ and RHFUQ scores for patients with isolated SAH were 1.38 ± 2.40 and 1.11 ±3.305, respectively. The mean RPCSQ and RHFUQ scores for patients with normal CT scans were 0.40 ± 1.549 and 0.533 ± 1.59, respectively. There was no significant difference in the outcome scores between the SAH and the normal CT scan groups (RHFUQ, P = .45; RPCSQ, P = .248). Conclusion:In our study sample of patients with mild TBI, there is no difference in outcome of patients with isolated SAH compared with those with normal CT scans 1 year after injury.

Injection nerve palsy.

Objective: To study the clinical profile and outcome of surgery for injection nerve palsies. Materials and Methods: This is a retrospective study of patients with INP who were treated at our institute during May 2000 to May 2009. Clinical, electroneuromyography (ENMG), and operative findings were noted. Intraoperative nerve action potential monitoring was not used in any case. Outcome of patients who were followed was reviewed. Results: INP comprised 92 (11%) of 837 nerve injury patients. Seventy one patients were children less than 16 years. The nerves involved were sciatic in 80 patients, radial in 8, and others in four. Fifty seven patients had power, grade 0/5. ENMG studies revealed absent compound muscle action potential in 64 and absent sensory nerve action potential in 67 patients. Thirty nine (42.3%) of 92 patients underwent surgery. The mean duration since injury in these patients was 5.2 months (3 months to 11 months). All underwent neurolysis. Only 18 patients who underwent surgery had a follow up of more than 3 months. Ten (55.5%) patients had good or fair outcome after surgery. Except for grade of motor deficit prior to surgery, none of the variables were found to significantly affect the outcome. Conclusion: The outcome of INP is generally good and many patients recover spontaneously. The outcome of surgery is dependent on preoperative motor power.

Anterior communicating artery aneurysm presenting with vision loss.

Anterior communicating artery aneurysm rarely presents with symptoms of compression of anterior visual pathways. We report a case of 65 years old man, who had complete loss of vision in right eye and temporal hemianopsia in left eye due to giant anterior communicating artery aneurysm.

Traumatic brain injury: Does gender influence outcomes?

Background: Traumatic brain injury (TBI) is a major public health problem. Both genders are affected, but little is known about female TBI. The present study exclusively explores epidemiological, clinical, imaging, and death aspects of female TBI, and how it differs from males. Methods: It is a retrospective study. Data were documented from a tertiary institute during January 2010 to March 2010. All variables were documented on standard proforma. The data were analyzed using R statistics software. Age group was categorized into pediatric (<18 years), middle (19–60 years) and elderly (>61 years). Significance was tested using Chi-square test at the significance level ofP< 0.05. Results: Data of 1627 TBI patients were recorded. Of the total, female TBIs contributed nearly 20%. Compared to males, female patients reported higher percentages in manifesting symptoms (84.3% vs. 82.6%), injuries due to fall (32.1% vs. 24.4%), and surgical interventions (11.6% vs. 10.4%). Female patients were significantly higher in mild head injury group (76.8% vs. 69.5%, P - 0.016) and mortality (3.4% vs. 1.6%, P - 0.048). Number of patients and deaths was more among females than males in pediatric and elderly age group. Severities of injuries were more among female patients than male patients in middle and elder age groups. Conclusion: The study results observe that female TBI group differ significantly in the severity of injury and mortality.

Bicycle accident-related head injuries in India

Objectives: To describe the epidemiology of head injuries sustained due to bicycle accidents in India. Materials and Methods: Data were retrospectively collected over a period of six months (15 May 2011 to 15 November 2011). Demography of patients, Glasgow coma scale (GCS), clinical and imaging findings, and mortality and outcome using Glasgow outcome scale (GOS), Rivermead post-concussion symptom questionnaire (RPCSQ) and Rivermead head injury follow-up questionnaire (RHFUQ), were analyzed. Outcome was assessed by telephonic interview. Results: There were 108 patients (100 males) with mean age of 27.7 years. Seventy-four (68.5%) were from rural areas. Accidents due to vehicular collision accounted for 60 (55.6%) cases. None wore a helmet. The admission GCS was 14-15 in 68.5% cases, 13-3 in 31.5%. The risk of moderate to severe injuries was increased among working laborers (OR = 5), and patients with loss of consciousness (OR = 4). Sixty-three (49%) patients had abnormal computed tomography (CT) findings; most common finding was skull fracture 25 (23.1%). Four patients needed surgery. The GOS assessment at three to six months revealed favorable outcome in 66 patients (61.1%) and death in 8 (7.4%). The common post-concussion symptoms were headache, fatigue, and poor concentration. Conclusion: The majority of hospitalized cyclists were from a rural background and of the lower income group. After three months the majority of patients had good recovery with few persistent concussion symptoms.

Subclinical autonomic nervous system dysfunction in compressive cervical myelopathy.

Study Design. Laboratory evaluation of autonomic nervous system (ANS) in patients with cervical compressive myelopathy (CCM). Objective. To study the autonomic functions and heart rate variability (HRV) in patients with CCM and compare the findings after surgery. Summary of Background Data. ANS dysfunction is well known after traumatic spinal cord injury. There are very few studies of ANS dysfunction in noncompressive myelopathy and there are no studies on compressive myelopathies. Methods. After excluding patients on cervical traction or with medical comorbidities, 29 adult patients with CCM were evaluated. Conventional autonomic function tests and HRV were studied in these patients. The same tests were done on 29 age- and sex-matched healthy controls. Student t test was used to find the significance of study parameters on continuous scale. Chi-square/Fisher exact test was used to find the significance of study parameters on categorical scale between two groups. Significance was assessed at 5% level. Results. Patients with CCM as compared with controls, showed significant difference in following parameters; deep breathing, Valsalva ratio, 30:15 (longest RR interval (duration between two consecutive R waves of ECG) around 30th second and the minimum RR interval around 15 seconds after standing up), and orthostatic fall of blood pressure. Except 30:15, there was no significant change of other autonomic function tests after surgery. Among the HRV parameters, there was a trend in increase in total power and decrease in root-mean-square differences of successive RR intervals; however, it did not reach statistical significance. Conclusion. Patients with CCM have definite ANS dysfunction as compared to healthy age- and sex-matched controls. There is significant improvement in 30:15 ratio after surgery. HRV indices are also impaired and there is a trend for change in total power and root-mean-square differences of successive RR intervals suggesting loss of HRV.

Role of the thalamus in natural recovery of cognitive impairment in patients with mild traumatic brain injury

Abstract Introduction: Patients with mild traumatic brain injury (mTBI) may have normal neuroimaging but manifest with a broad-spectrum of cognitive-deficits, which may resolve eventually. The function of the thalamus in the process of natural-recovery remains elusive. The current study investigates the role of the thalamus in natural-recovery of cognitive-deficits in patients with mTBI. Methods: Twenty-one patients with mTBI were evaluated with an initial MRI scan, within 36 hours of injury and assessed with neuropsychological tests(NPT) at 3–4 weeks after injury. First and second follow-up MRI and NPT were performed at 3–4 months and 6–7 months, respectively. The volume and tensor measures of the thalamus and cognitive-scores were analysed at each assessment using repeated-measures of variance. The association of cognitive-scores with corresponding period imaging measures was analysed using bivariate-correlation. Results: Serial evaluation showed that all the cognitive-domains improved significantly. During this period there was a significant increase in mean thalamic volume (p = 0.049, effect-size = 0.18). After 3–4 months there was emergence of anisotropic thalamo-cortical connections. At 2–3 weeks and 6–7 months after injury, the alterations in diffusivity values were positively associated with improvement in memory-scores. Improvement in attention-scores correlated significantly with changes in tensor values at the 6–7 months after-injury. Conclusion: The correlation between improvement in cognitive-scores and changes in thalamic tensor and volume measures reflect the role of the thalamus in natural-recovery after mTBI.