Joan Machamer

A Trial of Intracranial-Pressure Monitoring in Traumatic Brain Injury

BACKGROUND Intracranial-pressure monitoring is considered the standard of care for severe traumatic brain injury and is used frequently, but the efficacy of treatment based on monitoring in improving the outcome has not been rigorously assessed. METHODS We conducted a multicenter, controlled trial in which 324 patients 13 years of age or older who had severe traumatic brain injury and were being treated in intensive care units (ICUs) in Bolivia or Ecuador were randomly assigned to one of two specific protocols: guidelines-based management in which a protocol for monitoring intraparenchymal intracranial pressure was used (pressure-monitoring group) or a protocol in which treatment was based on imaging and clinical examination (imaging-clinical examination group). The primary outcome was a composite of survival time, impaired consciousness, and functional status at 3 months and 6 months and neuropsychological status at 6 months; neuropsychological status was assessed by an examiner who was unaware of protocol assignment. This composite measure was based on performance across 21 measures of functional and cognitive status and calculated as a percentile (with 0 indicating the worst performance, and 100 the best performance). RESULTS There was no significant between-group difference in the primary outcome, a composite measure based on percentile performance across 21 measures of functional and cognitive status (score, 56 in the pressure-monitoring group vs. 53 in the imaging-clinical examination group; P=0.49). Six-month mortality was 39% in the pressure-monitoring group and 41% in the imaging-clinical examination group (P=0.60). The median length of stay in the ICU was similar in the two groups (12 days in the pressure-monitoring group and 9 days in the imaging-clinical examination group; P=0.25), although the number of days of brain-specific treatments (e.g., administration of hyperosmolar fluids and the use of hyperventilation) in the ICU was higher in the imaging-clinical examination group than in the pressure-monitoring group (4.8 vs. 3.4, P=0.002). The distribution of serious adverse events was similar in the two groups. CONCLUSIONS For patients with severe traumatic brain injury, care focused on maintaining monitored intracranial pressure at 20 mm Hg or less was not shown to be superior to care based on imaging and clinical examination. (Funded by the National Institutes of Health and others; ClinicalTrials.gov number, NCT01068522.).

Outcome 3 to 5 years after moderate to severe traumatic brain injury

OBJECTIVE To investigate neuropsychologic, emotional, and functional status and quality of life (QOL) 3 to 5 years after moderate to severe traumatic brain injury (TBI). DESIGN Observational cohort. SETTING Level I trauma center. PARTICIPANTS Consecutive adult admissions with TBI involving intracranial abnormalities, prospectively followed up for 3 to 5 years, with 80% follow-up. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Neuropsychologic functioning (Paced Auditory Serial Addition Test, California Verbal Learning Test), emotional status (Center for Epidemiologic Studies Depression Scale, Brief Symptom Inventory), functional status (Functional Status Examination, Glasgow Outcome Scale, Medical Outcomes Study 36-Item Short-Form Health Survey, employment), and perceived QOL. RESULTS Significant functional limitations were observed in all areas. Recovery to preinjury levels ranged from 65% of cases in personal care to approximately 40% in cognitive competency, major activity, and leisure and recreation. Brain injury severity, measured by the modified Abbreviated Injury Scale, related to functional status and neuropsychologic functioning, but not to emotional or QOL measures. Length of impaired consciousness appeared to contribute to outcome more than did anatomic lesions. CONCLUSIONS The results provide representative estimates of long-term morbidity in patients with TBI involving intracranial lesions. The magnitude of morbidity was high. Although direct costs of TBI have received the most attention, the long-term consequences and their cost implications are much larger, unfold over time, and are borne by the survivors, their families, and the public subsidy system.

Cognitive outcome following traumatic brain injury

ObjectiveTo determine whether an association exists between traumatic brain injury (TBI) sustained in adulthood and cognitive impairment 6 months or longer after injury. DesignSystematic review of the published, peer-reviewed literature. ResultsFrom 430 articles, we identified 11 primary and 22 secondary studies that examined cognitive impairment by using performance measures for adults who were at least 6 months post-TBI. There was clear evidence of an association between penetrating brain injury and impaired cognitive function. Factors that modified this association included preinjury intelligence, volume of brain tissue lost, and brain region injured. There was also suggestive evidence that penetrating brain injury may exacerbate the cognitive effects of normal aging. We found clear evidence for long-term cognitive deficits associated with severe TBI. There was suggestive evidence that moderately severe brain injuries are associated with cognitive impairments. There was inadequate/insufficient evidence to determine whether an association exists between a single, mild TBI and cognitive deficits 6 months or longer postinjury. ConclusionIn adults, penetrating, moderate, and severe TBIs are associated with cognitive deficits 6 months or longer postinjury. There is insufficient evidence to determine whether mild TBI is associated with cognitive deficits 6 months or longer postinjury.

Magnesium sulfate for neuroprotection after traumatic brain injury: a randomised controlled trial

BACKGROUND Traumatic brain injuries represent an important and costly health problem. Supplemental magnesium positively affects many of the processes involved in secondary injury after traumatic brain injury and consistently improves outcome in animal models. We aimed to test whether treatment with magnesium favourably affects outcome in head-injured patients. METHODS In a double-blind trial, 499 patients aged 14 years or older admitted to a level 1 regional trauma centre between August, 1998, and October, 2004, with moderate or severe traumatic brain injury were randomly assigned one of two doses of magnesium or placebo within 8 h of injury and continuing for 5 days. Magnesium doses were targeted to achieve serum magnesium ranges of 1.0-1.85 mmol/L or 1.25-2.5 mmol/L. The primary outcome was a composite of mortality, seizures, functional measures, and neuropsychological tests assessed up to 6 months after injury. Analyses were done according to the intention-to-treat principle. This trial is registered with , number . FINDINGS Magnesium showed no significant positive effect on the composite primary outcome measure at the higher dose (mean=55 average percentile ranking on magnesium vs 52 on placebo, 95% CI for difference -7 to 14; p=0.70). Those randomly assigned magnesium at the lower dose did significantly worse than those assigned placebo (48 vs 54, 95% CI -10.5 to -2; p=0.007). Furthermore, there was higher mortality with the higher magnesium dose than with placebo. Other major medical complications were similar between groups, except for a slight excess of pulmonary oedema and respiratory failure in the lower magnesium target group. No subgroups were identified in which magnesium had a significantly positive effect. INTERPRETATION Continuous infusions of magnesium for 5 days given to patients within 8 h of moderate or severe traumatic brain injury were not neuroprotective and might even have a negative effect in the treatment of significant head injury.

One year psychosocial outcome in head injury.

Psychosocial outcome at one year post-injury was examined prospectively in 466 hospitalized head-injured subjects, 124 trauma controls, and 88 friend controls. The results indicate that head injury is associated with persistent psychosocial limitations. However, the presence and extent of limitations are related to the demographics of the population injured, to other system injuries sustained in the same accident, and particularly to the severity of the head injury. More severe head injuries are associated with limitations implying greater dependence on others including poorer Glasgow Outcome Scale (GOS) ratings, dependent living, unemployment, low income, and reliance on family and social subsidy systems. Head injury severity is more closely related to more objective indices of psychosocial outcome (e.g., employment) than to self-perceived psychosocial limitations, such as measured by the Sickness Impact Profile (SIP).

Rates of symptom reporting following traumatic brain injury

This study examines rates of reporting of new or worse post-traumatic symptoms for patients with a broad range of injury severity at 1 month and 1 year after traumatic brain injury (TBI), as compared with those whose injury spared the head, and assesses variables related to symptom reporting at 1 year post-injury. Seven hundred thirty two TBI subjects and 120 general trauma comparison (TC) subjects provided new or worse symptom information at 1 month and/or 1 year post-injury. Symptom reporting at 1 year post-injury was compared in subgroups based on basic demographics, preexisting conditions, and severity of brain injury. The TBI group reported significantly more symptoms at 1 month and 1 year after injury than TCs (each p < .001). Although symptom endorsement declined from 1 month to 1 year, 53% of people with TBI and 24% of TC continued to report 3 or more symptoms at 1 year post-injury. Symptom reporting in the TBI group was significantly related to age, gender, preinjury alcohol abuse, pre-injury psychiatric history, and severity of TBI. Symptom reporting is common following a traumatic injury and continues to be experienced by a substantial number of TBI subjects of all severity levels at 1 year post-injury.

Mild head injury: facts and artifacts.

While most would agree that mild traumatic brain injury (TBI) is associated with early neuropsychological problems, disagreement exists regarding their persistence and whether they are the cause of the disabilities experienced by some people. The aim of this study was to examine how the criteria used to define mild TBI and how the pre-injury characteristics of people affect their neuropsychological outcome. A total of 157 unselected hospitalized cases with Glasgow Coma Scale scores of 13-15 and 109 trauma controls were prospectively recruited and administered a number of cognitive measures at 1 month and 12 months after injury. The results indicated early impairments that decreased with time and the stringency of the definition of ‘mild’ TBI. The contribution of demographics was usually significant and often stronger than the mild TBI effect. Subtle variation of the demographics of the brain injured or the comparison subjects can be sufficient to mimic or mask mild brain injury effects.

Psychosocial outcome in patients with moderate to severe head injury: 2-year follow-up.

Psychosocial outcome and recovery of a group of 31 consecutive adult patients with moderate to severe head injuries were prospectively investigated over a 2-year period. A friend control group was used for comparison purposes. We conclude that moderate and severe head injuries have a significant long-term impact on psychosocial functioning. More specifically, although there is an increase over time in the number of subjects who resume former levels of activity, many moderate to severely head-injured people remain unable to work, support themselves financially, live independently and participate in pre-injury leisure activities at least up to 2 years post-injury. Initially, self-perceived limitations in everyday functioning are widespread, with physical functioning being of primary concern. Over time, there is improvement in both physical and psychosocial areas. However, in spite of improvement, difficulties in psychosocial functioning become dominant later due to greater improvement in the physical area. This study gives no evidence of general increase in emotional distress with increasing time since injury.

Social Functioning After Traumatic Brain Injury

ObjectiveTo determine the relationship between adult-onset traumatic brain injury (TBI) and social functioning including employment, social relationships, independent living, recreation, functional status, and quality of life 6 months or longer after injury. ParticipantsNot applicable. DesignSystematic review of the published, peer-reviewed literature. Primary MeasuresNot applicable. ResultsFourteen primary and 25 secondary studies were identified that allowed comparison to controls for adults who were at least 6 months post-TBI. TBI decreases the probability of employment after injury in those who were workers before their injury, lengthens the timing of their return if they do return to work, and decreases the likelihood that they will return to the same position. Those with moderate and severe TBI are clearly affected, but there was insufficient evidence of a relationship between unemployment and mild TBI. Penetrating head injury sustained in wartime is clearly associated with increased unemployment. TBI also adversely affects leisure and recreation, social relationships, functional status, quality of life, and independent living. Although there is a dose-response relationship between severity of injury and social outcomes, there is insufficient evidence to determine at what level of severity the adverse effects are demonstrated. ConclusionTBI clearly has adverse effects on social functioning for adults. While some consequences might arise from injuries to other parts of the body, those with moderate to severe TBI have more impaired functioning than do those with other injuries alone.

Emotional and behavioral adjustment after traumatic brain injury

OBJECTIVES To examine emotional and behavioral adjustment and recovery over 1 year after traumatic brain injury (TBI), and to determine whether the difficulties, if present, are due to neurologic insult. DESIGN Longitudinal evaluation of adjustment from 1 month to 1 year after injury. SETTING Level I trauma center at a university hospital. PATIENTS One hundred fifty-seven consecutively hospitalized adults with TBI and 125 trauma controls with other system injuries evaluated at 1 and 12 months after injury. MAIN OUTCOME MEASURES Katz Adjustment Scale (KAS). RESULTS The TBI group at 1 year follow-up demonstrated significant emotional and behavioral maladjustment, but such difficulties did not appear to be mediated by the brain injury, since the KAS scores for the TBI and trauma control groups were not significantly different. Those with moderate TBI reported greater difficulties than those with mild or severe injuries. Changes in adjustment over 1 year were common for both groups. Within the TBI group there was differential recovery: improvement in cognitive clarity, dysphoric mood, and emotional stability, but increased difficulties with anger management, antisocial behaviors, and self-monitoring. CONCLUSIONS These results raise questions about commonly held beliefs that those with mild TBI report greater distress, and clarify some misconceptions regarding change in emotional and behavioral functioning over time.