Judith Marcoux

Early outcome in patients with traumatic brain injury, pre-injury alcohol abuse and intoxication at time of injury

Primary objective: To investigate the relationship between pre-injury alcohol abuse and intoxication at time of injury on duration of post-traumatic amnesia (PTA) as well as on early functional and neurobehavioural outcomes in persons with traumatic brain injury (TBI) hospitalized in an acute care setting. Methods and procedure: Sixty persons with mild, moderate and severe TBI admitted to the intensive care unit were part of this retrospective study. Main outcomes: Duration of PTA, length of stay (LOS), Extended Glasgow Outcome Scale (GOS-E) score, the FIM™ score as well as early neuropsychological outcome measured by the Neurobehavioural Rating Scale Revised (NBRS-R). Results: 2-factor ANOVAs and chi-squares tests showed that PTA and LOS were significantly longer in the group of patients with pre-injury alcohol abuse, regardless of whether they were intoxicated or not at the time of injury. Moreover, the FIM™ total and cognitive scores were significantly higher for the group intoxicated on admission compared to the sober group. However, GOS-E scores and results on the NBRS-R were similar. Conclusions: Despite a longer PTA and LOS, global and neurobehavioural outcomes at discharge from acute care were not different for those with pre-injury alcohol abuse.

Primary or secondary decompressive craniectomy: different indication and outcome.

BACKGROUND Intracranial hypertension can cause secondary damage after a traumatic brain injury. Aggressive medical management might not be sufficient to alleviate the increasing intracranial pressure (ICP), and decompressive craniectomy (DC) can be considered. Decompressive craniectomy can be divided into categories, according to the timing and rationale for performing the procedure: primary (done at the time of mass lesion evacuation) and secondary craniectomy (done to treat refractory ICP). Most studies analyze primary and secondary DC together. Our hypothesis is that these two groups are distinct and the aim of this retrospective study is to evaluate the differences in order to better predict outcome after DC. METHODS Seventy patients had DC over a period of four years at our center. They were divided into two groups based on the timing of the DC. Primary DC (44 patients) was done within 24 hours of the injury for mass lesion evacuation. Secondary DC (26 patients) was done after 24 hours and purely for the treatment of refractory ICP. Pre-op characteristics and post-op outcomes were compared between the two groups. RESULTS There was a significant difference in the mechanism of injury, the pupil abnormalities and Marshall grade between primary and secondary DC. There was also a significant difference in outcome with primary DC showing 45.5% good outcome and 40.9% mortality and secondary DC showing 73.1% good outcome and 15.4% mortality. CONCLUSIONS Primary and secondary DC have different indications and patients characteristics. Outcome prediction following DC should be adjusted according to the surgical indication.

The mini-mental state examination and the montreal cognitive assessment after traumatic brain injury: An early predictive study

Abstract Primary objective: To compare results on the Montreal Cognitive Assessment (MoCA) to those on the Mini-Mental State Examination (MMSE) in patients with traumatic brain injury (TBI) and to predict the outcome at discharge from the acute care setting. Research design: A retrospective study. Methods and procedures: The MoCA and the MMSE were administered to 214 patients with TBI during their acute care hospitalization in a Level I trauma centre. Outcome was measured with the Disability Rating Scale (DRS). Main outcomes and results: A linear regression determined that the MoCA, the MMSE, TBI severity, education level and presence of diffuse injuries predicted 57% of the total variability of the DRS scores. The model without the MMSE had a R2 of 53.7% and the model without the MoCA had a R2 of 55.0%. The models without the MMSE or the MoCA had a R2 of 24.9%. Conclusions: These results indicated that the MoCA and the MMSE function as similar predictors of the DRS at discharge.

Acute evaluation of conversational discourse skills in traumatic brain injury

Abstract This study looked at performance on the conversational discourse checklist of the Protocole Montréal d’évaluation de la communication (D-MEC) in 195 adults with TBI of all severity hospitalized in a Level 1 Trauma Centre. To explore validity, results were compared to findings on tests of memory, mental flexibility, confrontation naming, semantic and letter category naming, verbal reasoning, and to scores on the Montreal Cognitive Assessment. The relationship to outcome as measured with the Disability Rating Scale (DRS), the Extended Glasgow Outcome Scale (GOS-E), length of stay, and discharge destinations was also determined. Patients with severe TBI performed significantly worse than mild and moderate groups (χ2KW2df = 24.435, p = .0001). The total D-MEC score correlated significantly with all cognitive and language measures (p < .05). It also had a significant moderate correlation with the DRS total score (r = −.6090, p < .0001) and the GOS-E score (r = .539, p < .0001), indicating that better performance on conversational discourse was associated with a lower disability rating and better global outcome. Finally, the total D-MEC score was significantly different between the discharge destination groups (F(3,90) = 20.19, p < .0001). Thus, early identification of conversational discourse impairment in acute care post-TBI was possible with the D-MEC and could allow for early intervention in speech-language pathology.

Early conversational discourse abilities following traumatic brain injury: An acute predictive study

Abstract Primary objective: To date, little information is available regarding communication and conversational discourse proficiency post-traumatic brain injury (TBI) in the acute care phase. The main goal of this study was to examine how conversational discourse impairment following TBI predicts early outcome. Factors which influence conversational discourse performance were also explored. Methods: The conversational discourse checklist of the Protocole Montréal d’évaluation de la communication (D-MEC) was administered in an acute tertiary care trauma centre to 195 adults within 3 weeks post-TBI. Outcome was measured with the Disability Rating Scale (DRS), the extended Glasgow Outcome Scale (GOS-E) and included discharge destinations from acute care. Main outcomes and results: Linear regression results showed that the D-MEC total score, age and initial GCS score accounted for 50% of the variation of the DRS scores. The DRS score was lower, signifying better outcome, when the total D-MEC score was higher, the subject was younger and when the initial GCS score was higher. Moreover, D-MEC performance significantly predicted the moderate and severe disability categories of the GOS-E and the probability of requiring rehabilitation (p < 0.05). Conclusion: These results provide additional information to guide healthcare professionals in predicting overall outcome acutely post-TBI.

The Montreal Cognitive Assessment in Persons with Traumatic Brain Injury

The objective of this study was to examine the performance of patients with traumatic brain injury (TBI) on the Montreal Cognitive Assessment (MoCA). The MoCA was administered to 214 patients with TBI during their acute care hospitalization in a Level 1 trauma center. The results showed that patients with severe TBI had lower scores on the MoCA compared with patients with mild and moderate TBI, F(2, 211) = 10.35, p = .0001. This difference was found for visuospatial/executive, attention, and orientation subtests (p < .05). Linear regression demonstrated that age, education, TBI severity, and the presence of neurological antecedents were the best predictors of cognitive impairments explaining 42% of the total variability of the MoCA. This information can enable clinicians to predict early cognitive impairments and plan cognitive rehabilitation earlier in the recovery process.

Olfactory and executive dysfunctions following orbito-basal lesions in traumatic brain injury

Abstract Objective: To study the acute relationship between olfactory function and traumatic brain injury (TBI), cognitive functions and outcome. Methods: Sixty-two patients with TBI were evaluated within the first 2 weeks following TBI. The Sniffin’Sticks identification test was used to assess olfaction. A neuropsychological evaluation was carried out to assess attention, verbal fluency, naming, memory, problem-solving and mental flexibility. The extended Glasgow Outcome Scale (GOSE) and the Disability Rating Scale (DRS) were rated at discharge from acute care. Results: Traumatic lesions located in the basal frontal area resulted in odour identification scores that were significantly lower than when lesions were elsewhere (p < 0.001). A significant positive correlation was shown between odour identification scores and mental flexibility scores (p = 0.004) and patients with hyposmia had worse performances on executive tests measuring problem-solving, verbal fluency and mental flexibility (p < 0.01). Moreover, the odour identification score and the DRS total score were related (p = 0.019). Conclusions: These findings add information regarding acute olfactory status following TBI and provide evidence on the importance of assessing olfaction very early post-TBI in order to plan intervention and determine what accident prevention advice will be required for home or work re-integration.

Neuroanatomical correlates of the clock drawing test in patients with traumatic brain injury.

Objective: The clock drawing test (CDT) is a quick and easy to administer test that has traditionally shown parietal lobe dysfunction. The aim of this study was to correlate performance on the CDT with the presence of acute traumatic cerebral injuries sustained after traumatic brain injury (TBI). Methods: A retrospective study was conducted on 170 patients with TBI of all severity admitted to an acute care setting. These patients sustained different types of injuries (epidural haematoma, subdural haematoma, subarachnoid haemorrhage, intraparenchymal haematoma and brain oedema) in different sites (frontal, temporal, parietal, occipital lobes, bilateral and right or left hemisphere). Results: The CDT total score was significantly lower for subjects presenting subarachnoid haemorrhage (4.80 ± 3.34 vs 7.04 ± 3.14, t168df = 4.477, p < 0.001) and for those presenting brain oedema (4.50 ± 3.06 vs 6.69 ± 3.38, t168df = 4.214, p < 0.001), parietal injury (5.15 ± 3.17 vs 6.42 ± 3.52, t168df = 2.416, p = 0.017) or bilateral injuries (5.28 ± 3.31 vs 6.62 ± 3.44, t168df = 2.569, p = 0.011) compared to those who did not. Conclusion: This study provides empirical evidence of the relationship between TBIs and results on the CDT, supporting previous studies done with other populations.

Traumatic brain injury in the elderly: A level 1 trauma centre study

Abstract Objective: To explore the characteristics and outcome of patients with TBI over 65 years old admitted to an acute care Level 1 Trauma centre in Montreal, Canada. Methods: Data were retrospectively collected on patients (n = 1812) who were admitted post-TBI to the McGill University Health Centre-Montreal General Hospital from 2000–2011. The cohort was composed of four groups over 65 years old (65–75; 76–85; 86–95; and 96 and more). Outcome measures used were the extended Glasgow Outcome Scale (GOSE) as well as discharge destination. Results: As the patients got older, the odds of having a poor outcome increased (OR = 2.344 for those 75–85 years old, 4.313 for those 86–95 years of age and 3.465 for those aged 96 years of age or older). Also, the proportion of patients going home or going home with out-patient rehabilitation decreased as age increased (p = 0.001 and p < 0.001, respectively). In contrast, the proportion of patients being discharged to long-term care facilities increased significantly as age increased (p < 0.001). Conclusion: This descriptive study provides a better understanding of characteristics and outcome of different age groups of patients with TBI all over 65 years old in Montreal, Canada.

Epidural Hematoma Treated Conservatively: When to Expect the Worst.

BACKGROUND The Brain Trauma Foundations 2006 surgical guidelines have objectively defined the epidural hematoma (EDH) patients who can be treated conservatively. Since then, the literature has not provided adequate clues to identify patients who are at higher risk for EDH progression (EDHP) and conversion to surgical therapy. The goal of our study was to identify those patients. METHODS We carried a retrospective review over a 5-year period of all EDH who were initially triaged for conservative management. Demographic data, injury severity and history, neurological status, use of anticoagulants or anti-platelets, radiological parameters, conversion to surgery and its timing, and Glasgow Outcome Scale were analyzed. Bivariate association and further logistic regression were used to point out the significant predictors of EDHP and conversion to surgery. RESULTS 125 patients (75% of all EDH) were included. The mean age was 39.1 years. The brain injury was mild in 62.4% of our sample and severe in 14.4%. Only 11.2% of the patients required surgery. Statistical comparison showed that younger age (p< 0.0001) and coagulopathy (p=0.009) were the only significant factors for conversion to surgery. There was no difference in outcomes between patients who had EDHP and those who did not. CONCLUSIONS Most traumatic EDH are not surgical at presentation. The rate of conversion to surgery is low. Significant predictors of EDHP are coagulopathy and younger age. These patients need closer observation because of a higher risk of EDHP. Outcome of surgical conversion was similar to successful conservative management.