Jennie Ponsford

Decompressive Craniectomy in Diffuse Traumatic Brain Injury

BACKGROUND It is unclear whether decompressive craniectomy improves the functional outcome in patients with severe traumatic brain injury and refractory raised intracranial pressure. METHODS From December 2002 through April 2010, we randomly assigned 155 adults with severe diffuse traumatic brain injury and intracranial hypertension that was refractory to first-tier therapies to undergo either bifrontotemporoparietal decompressive craniectomy or standard care. The original primary outcome was an unfavorable outcome (a composite of death, vegetative state, or severe disability), as evaluated on the Extended Glasgow Outcome Scale 6 months after the injury. The final primary outcome was the score on the Extended Glasgow Outcome Scale at 6 months. RESULTS Patients in the craniectomy group, as compared with those in the standard-care group, had less time with intracranial pressures above the treatment threshold (P<0.001), fewer interventions for increased intracranial pressure (P<0.02 for all comparisons), and fewer days in the intensive care unit (ICU) (P<0.001). However, patients undergoing craniectomy had worse scores on the Extended Glasgow Outcome Scale than those receiving standard care (odds ratio for a worse score in the craniectomy group, 1.84; 95% confidence interval [CI], 1.05 to 3.24; P=0.03) and a greater risk of an unfavorable outcome (odds ratio, 2.21; 95% CI, 1.14 to 4.26; P=0.02). Rates of death at 6 months were similar in the craniectomy group (19%) and the standard-care group (18%). CONCLUSIONS In adults with severe diffuse traumatic brain injury and refractory intracranial hypertension, early bifrontotemporoparietal decompressive craniectomy decreased intracranial pressure and the length of stay in the ICU but was associated with more unfavorable outcomes. (Funded by the National Health and Medical Research Council of Australia and others; DECRA Australian Clinical Trials Registry number, ACTRN012605000009617.).

Factors influencing outcome following mild traumatic brain injury in adults

This study aimed to investigate outcome in adults with mild traumatic brain injury (TBI) at 1 week and 3 months postinjury and to identify factors associated with persisting problems. A total of 84 adults with mild TBI were compared with 53 adults with other minor injuries as controls in terms of postconcussional symptomatology, behavior, and cognitive performance at 1 week and 3 months postinjury. At 1 week postinjury, adults with mild TBI were reporting symptoms, particularly headaches, dizziness, fatigue, visual disturbance, and memory difficulties. They exhibited slowing of information processing on neuropsychological measures, namely the WAIS-R Digit Symbol subtest and the Speed of Comprehension Test. By 3 months postinjury, the symptoms reported at 1 week had largely resolved, and no impairments were evident on neuropsychological measures. However, there was a subgroup of 24% of participants who were still suffering many symptoms, who were highly distressed, and whose lives were still significantly disrupted. These individuals did not have longer posttraumatic amnesia (PTA) duration. They were more likely to have a history of previous head injury, neurological or psychiatric problems, to be students, females, and to have been injured in a motor vehicle accident. The majority were showing significant levels of psychopathology. A range of factors, other than those directly reflecting the severity of injury, appear to be associated with outcome following mild TBI.

Outcome following traumatic brain injury: a comparison between 2 and 5 years after injury

This study examined long-term outcome in traumatically brain-injured individuals following discharge from a comprehensive rehabilitation programme. Of 254 traumatic brain injury (TBI) patients reviewed at 2 years, 103 have been followed up at 5 years using a structured interview format detailing neurological symptoms, mobility, independence in ADL, productivity status, relationship issues, communication and the presence of cognitive, behavioural and emotional changes. Visual difficulties, headache and fatigue were persistent in a significant number of patients. Between 2 and 5 years there was increased independence in personal, domestic and community ADL and the use of transport. Ten more patients had returned to driving. On the other hand there was a slightly higher incidence of cognitive, behavioural and emotional changes reported at 5 years. Thirty-two per cent of those working at 2 years were not employed at 5 years. Many students had also become unemployed. These findings suggest the need for intermittent lifelong intervention following TBI. Systems of rehabilitation need to be adapted to provide this.

Attentional deficits following closed-head injury.

Aimed to assess, in the light of current attentional theories, the nature of the attentional deficit in a group of severely traumatically head-injured subjects, relative to a group of orthopaedic rehabilitation patients, and to establish which neuropsychological measures best reflected the deficit. Three separate studies were conducted in order to meet these aims. The first study focused on selective attention; the second, on vigilance or sustained attention; the third, on the Supervisory Attentional System. Results provided no evidence for the presence of deficits of focused attention, sustained attention, or supervisory attentional control, but ample evidence for the presence of a deficit in speed of information processing. Those neuropsychological measures shown to be the best measures of this deficit included the Symbol Digit Modalities Test, simple and choice reaction-time tasks, colour naming and word reading scores on the Stroop, and the Paced Auditory Serial Addition Test.

A profile of outcome: 2 years after traumatic brain injury

A group of 175 traumatic brain injury (TBI) patients who had undergone intensive rehabilitation at Bethesda Hospital attended a follow-up interview 2 years after injury. The majority of patients had suffered severe TBI. Outcome was documented in ten areas: medical/physical, mobility, activities of daily living (ADLs) accommodation, marital status, leisure and recreation, employment/study, communication, cognition and behaviour. Whilst most patients were physically independent and competent in personal and domestic activities of daily living, a third of the group were still reliant on assistance with community skills and transport, and more than half of those who previously had a job, were not working at 2 years post-injury. Around two-thirds of the sample reported cognitive, behavioural and emotional changes. There is clearly a need for ongoing community-based support and assistance in dealing with practical difficulties and psychological problems as they are experienced after return to the community.

Impact of early intervention on outcome following mild head injury in adults

Background: The impact of mild head injury is variable and determinants of outcome remain poorly understood. Results of previous intervention studies have been mixed. Objectives: To evaluate the impact on outcome of the provision of information, measured in terms of reported symptoms, cognitive performance, and psychological adjustment three months postinjury. Methods: 202 adults with mild head injury were studied: 79 were assigned to an intervention group and were assessed one week and three months after injury; 123 were assigned to a non-intervention control group and were seen at three months only. Participants completed measures of preinjury psychological adjustment, concurrent life stresses, post-concussion symptoms, and tests of attention, speed of information processing, and memory. Subjects seen at one week were given an information booklet outlining the symptoms associated with mild head injury and suggested coping strategies. Those seen only at three months after injury did not receive this booklet. Results: Patients in the intervention group who were seen at one week and given the information booklet reported fewer symptoms overall and were significantly less stressed at three months after the injury. Conclusions: The provision of an information booklet reduces anxiety and reporting of ongoing problems.

Cognitive functioning ten years following traumatic brain injury and rehabilitation.

Many previous studies investigating long-term cognitive impairments following traumatic brain injury (TBI) have focused on extremely severely injured patients, relied on subjective reports of change and failed to use demographically relevant control data. The aim of this study was to investigate cognitive impairments 10 years following TBI and their association with injury severity. Sixty TBI and 43 control participants were assessed on tests of attention, processing speed, memory, and executive function. The TBI group demonstrated significant cognitive impairment on measures of processing speed (Symbol Digit Modalities Test [SDMT], Smith, 1973; Digit Symbol Coding, Wechsler, 1997), memory (Rey Auditory Verbal Learning Test [RAVLT]; Rey, 1958; Lezak, 1976), Doors and People tests; Baddeley, Emslie & Nimmo-Smith, 1994) and executive function (Hayling C [Burgess & Shallice, 1997] and SART errors, Robertson, Manly, Andrade, Baddeley & Yiend, 1997). Logistic Regression analyses indicated that the SDMT, Rey AVLT and Hayling C and SART errors most strongly differentiated the groups in the domains of attention/processing speed, memory and executive function, respectively. Greater injury severity was significantly correlated with poorer test performances across all domains. This study shows that cognitive impairments are present many years following TBI and are associated with injury severity.

Functional outcome 10 years after traumatic brain injury: Its relationship with demographic, injury severity, and cognitive and emotional status

Previous investigations of long-term outcome following traumatic brain injury (TBI) have yielded mixed results regarding the predictive power of injury severity and demographic factors. Furthermore, there has been limited investigation of the association between long-term outcome and current cognitive functioning and psychiatric state. The aim of this study was to investigate the association of injury severity, demographic factors, and concurrent cognitive and psychiatric functioning with functional outcome 10 years following mild to severe TBI. Outcome was rated using the Extended Glasgow Outcome Scale (GOSE) for 60 participants, who also completed neuropsychological measures of attention, speed of processing, memory and executive function and the Hospital Anxiety and Depression Scale (HADS). Outcome on the GOSE ranged from upper good recovery (32%) to lower severe disability (2%). Participants showing poorer outcome on the GOSE had significantly longer posttraumatic amnesia duration; less education; performed more poorly on cognitive measures of information processing speed, attention, memory, and executive function; and showed higher levels of anxiety on the HADS.

Predictors of Postconcussive Symptoms 3 Months After Mild Traumatic Brain Injury

OBJECTIVE There is continuing controversy regarding predictors of poor outcome following mild traumatic brain injury (mTBI). This study aimed to prospectively examine the influence of preinjury factors, injury-related factors, and postinjury factors on outcome following mTBI. METHOD Participants were 123 patients with mTBI and 100 trauma patient controls recruited and assessed in the emergency department and followed up 1 week and 3 months postinjury. Outcome was measured in terms of reported postconcussional symptoms. Measures included the ImPACT Post-Concussional Symptom Scale and cognitive concussion battery, including Attention, Verbal and Visual memory, Processing Speed and Reaction Time modules, pre- and postinjury SF-36 and MINI Psychiatric status ratings, VAS Pain Inventory, Hospital Anxiety and Depression Scale, PTSD Checklist-Specific, and Revised Social Readjustment Scale. RESULTS Presence of mTBI predicted postconcussional symptoms 1 week postinjury, along with being female and premorbid psychiatric history, with elevated HADS anxiety a concurrent indicator. However, at 3 months, preinjury physical or psychiatric problems but not mTBI most strongly predicted continuing symptoms, with concurrent indicators including HADS anxiety, PTSD symptoms, other life stressors and pain. HADS anxiety and age predicted 3-month PCS in the mTBI group, whereas PTSD symptoms and other life stressors were most significant for the controls. Cognitive measures were not predictive of PCS at 1 week or 3 months. CONCLUSIONS Given the evident influence of both premorbid and concurrent psychiatric problems, especially anxiety, on postinjury symptoms, managing the anxiety response in vulnerable individuals with mTBI may be important to minimize ongoing sequelae.

Coping and emotional adjustment following traumatic brain injury.

ObjectivesTo examine the association between coping style and emotional adjustment following traumatic brain injury. ParticipantsThirty three individuals who had sustained a traumatic brain injury (mean duration of posttraumatic amnesia = 32 days) between 1½ months and almost 7 years previously. Measures: Coping Scale for Adults, Hospital Anxiety and Depression Scale, Rosenberg Self-Esteem Scale, State-Trait Anger Expression Inventory, and the Sickness Impact Profile. ResultsApproximately 50% of the sample reported clinically significant levels of anxiety and depression. Coping characterized by avoidance, worry, wishful thinking, self-blame, and using drugs and alcohol was associated with higher levels of anxiety, depression, and psychosocial dysfunction and lower levels of self-esteem. Coping characterized by actively working on the problem and using humor and enjoyable activities to manage stress was associated with higher self-esteem. Lower premorbid intelligence (measured via the National Adult Reading Test) and greater self-awareness (measured via the Self-Awareness of Deficits Interview) were associated with an increased rate of maladaptive coping. ConclusionsThe strong association between the style of coping used to manage stress and emotional adjustment suggests the possibility that emotional adjustment might be improved by the facilitation of more adaptive coping styles. It is also possible that improving emotional adjustment may increase adaptive coping. The development and evaluation of interventions aimed at facilitating adaptive coping and decreasing emotional distress represent important and potentially fruitful contributions to enhancing long-term outcome following brain injury.