Marissa McCarthy

Longitudinal outcome of patients with disordered consciousness in the NIDRR TBI model systems programs

Few studies address the course of recovery from prolonged disorders of consciousness (DOC) after severe traumatic brain injury (TBI). This study examined acute and long-term outcomes of persons with DOC admitted to acute inpatient rehabilitation within the National Institute on Disability and Rehabilitation Research (NIDRR) TBI Model Systems Programs (TBIMS). Of 9028 persons enrolled from 1988 to 2009, 396 from 20 centers met study criteria. Participants were primarily male (73%), Caucasian (67%), injured in motor vehicle collision (66%), with a median age of 28, and emergency department Glasgow Coma Scale (GCS) score of 3. Participant status was evaluated at acute rehabilitation admission and discharge and at 1, 2, and 5 years post-injury. During inpatient rehabilitation, 268 of 396 (68%) regained consciousness and 91 (23%) emerged from post-traumatic amnesia (PTA). Participants demonstrated significant improvements on GCS (z=16.135, p≤0.001) and Functional Independence Measure (FIM) (z=15.584, p≤0.001) from rehabilitation admission (median GCS=9; FIM=18) to discharge (median GCS=14; FIM=43). Of 337 with at least one follow-up visit, 28 (8%) had died by 2.1 years (mean) after discharge. Among survivors, 66 (21%) improved to become capable of living without in-house supervision, and 63 demonstrated employment potential using the Disability Rating Scale (DRS). Participants with follow-up data at 1, 2, and 5 years post-injury (n=108) demonstrated significant improvement across all follow-up evaluations on the FIM Cognitive and Supervision Rating Scale (p<0.01). Significant improvements were observed on the DRS and FIM Motor at 1 and 2 years post-injury (p<0.01). Persons with DOC at the time of admission to inpatient rehabilitation showed functional improvement throughout early recovery and in years post-injury.

Descriptive Characteristics and Rehabilitation Outcomes in Active Duty Military Personnel and Veterans With Disorders of Consciousness With Combat- and Noncombat-Related Brain Injury

OBJECTIVE To report the injury and demographic characteristics, medical course, and rehabilitation outcome for a consecutive series of veterans and active duty military personnel with combat- and noncombat-related brain injury and disorder of consciousness (DOC) at the time of rehabilitation admission. DESIGN Retrospective study. SETTING Rehabilitation center. PARTICIPANTS From January 2004 to October 2009, persons (N=1654) were admitted to the Polytrauma Rehabilitation System of Care. This study focused on the N=122 persons admitted with a DOC. Participants with a DOC were primarily men (96%), on active duty (82%), ≥12 years of education, and a median age of 25. Brain injury etiologies included mixed blast trauma (24%), penetrating (8%), other trauma (56%), and nontrauma (13%). Median initial Glasgow Coma Scale score was 3, and rehabilitation admission Glasgow Coma Scale score was 8. Individuals were admitted for acute neurorehabilitation approximately 51 days postinjury with a median rehabilitation length of stay of 132 days. INTERVENTIONS None. MAIN OUTCOME MEASURES Recovery of consciousness and the FIM instrument. RESULTS Most participants emerged to regain consciousness during neurorehabilitation (64%). Average gains ± SD on the FIM cognitive and motor subscales were 19 ± 25 and 7 ± 8, respectively. Common medical complications included spasticity (70%), dysautonomia (34%), seizure occurrence (30%), and intracranial infection (22%). Differential outcomes were observed across etiologies, particularly for those with blast-related brain injury etiology. CONCLUSIONS Despite complex comorbidities, optimistic outcomes were observed. Individuals with severe head injury because of blast-related etiologies have different outcomes and comorbidities observed. Health-services research with a focus on prevention of comorbidities is needed to inform optimal models of care, particularly for combat injured soldiers with blast-related injuries.

Incidence, Characterization, and Predictors of Sleep Apnea in Consecutive Brain Injury Rehabilitation Admissions.

Objective:To prospectively examine the incidence and risk factors for sleep apnea in consecutive brain injury rehabilitation admissions. Setting:Inpatient neurorehabilitation hospital. Participants:Participants (n = 86) were consecutive neurorehabilitation admissions. Design:Retrospective analysis of prospectively collected data. Main Measures:Polysomnography. Results:Half (49%) of the sample was diagnosed with sleep apnea. For the full sample, univariate logistic regression revealed age (odds ratio: 1.08; 95% confidence interval: 1.04-1.11) and hypertension (odds ratio: 7.77; 95% confidence interval: 2.81-21.47) as significant predictors of sleep apnea diagnosis. Results of logistic regression conducted within the traumatic brain injury group revealed age (odds ratio: 1.07; 95% confidence interval: 1.02-1.13) as the only significant predictor of apnea diagnosis after adjustment for other variables. Hierarchical generalized linear regression models for the prediction of apnea severity (ie, apnea-hypopnea index found that Functional Independence Measure Cognition Score (P = .01) and age (P < .01) were significant predictors. Following adjustment for all other terms, only age (P < .01) remained significant. Conclusion:Sleep apnea is prevalent in acute neurorehabilitation admissions and traditional risk profiles for sleep apnea may not effectively screen for the disorder. Given the progressive nature of obstructive sleep apnea and morbidity associated with even mild obstructive sleep apnea, early identification and intervention may address comorbidities influencing acute and long-term outcome.

Rehospitalization in the First Year Following Veteran and Service Member TBI: A VA TBI Model Systems Study

Objective:To determine the incidence and causes of rehospitalization following military or Veteran traumatic brain injury (TBI). Setting:Department of Veterans Affairs (VA) Veterans Health Administration Polytrauma Rehabilitation Centers (VHA PRCs). Participants:Consecutive sample of VHA TBI Model System participants (N = 401). Design:Prospective observational cohort study. Main Measures:Number and type of rehospitalizations in first year post-TBI. Results:Forty-one percent of 401 participants were rehospitalized. Rehospitalization status was associated with greater injury severity and receipt of TBI while active duty. Of those rehospitalized, 30% had 2 or more readmissions. Participants experiencing multiple rehospitalizations (2+) were more likely to have sustained their TBI during deployment than those with none or single rehospitalization. This group also sustained more severe injuries and spent more time in VA PRC inpatient rehabilitation. Common reasons for rehospitalization included inpatient rehabilitation (33%), unspecified (26%), orthopedic (10%), seizures (8%), infection (8%), and psychiatric (7%). Conclusion:This is the first study examining military and Veteran rehospitalization following TBI requiring inpatient rehabilitation at a VA PRC. Findings indicate frequent rehospitalizations in the first year postinjury, suggesting the need for preventive models of health maintenance following inpatient rehabilitation discharge. Greater surveillance of those with deployment-related TBI or active duty at the time of injury and greater TBI severity may be warranted.

Hemiballismus in a Polytrauma Patient with a Severe Traumatic Brain Injury and Damage to his Basal Ganglia: A Case Report

dysarthria. He was started on broad spectrum antibiotics and once deemed medically stable was transferred to acute rehab. Setting: Acute inpatient rehabilitation. Results or Clinical Course: During the acute rehab course, therapy focused on developing speech compensatory strategies using multiple modalities for facilitating functional communication such as slower speech and use of short phrases. Training in swallow compensatory strategies included techniques to improve anterior to posterior bolus transit and tongue base contraction strength for enhanced pharyngeal propulsion. Subsequently, the patient showed improvement of dysarthria with observed tongue tip elevations. He continued to have persistent oral dysphagia for which he was able to perform compensatory strategies and was upgraded to an oral diet. Discussion: Skull base osteomyelitis usually arises from the progression of otitis externa to adjacent temporal bone and soft tissue. Atypical rare cases, such as this one, can present without otitis externa as the inciting source. Research supporting the assessment and treatment of speech and swallowing difficulties in combination with medical treatment in these cases is not widely published. For this patient, the most effective treatment approach combined compensatory speech and swallowing therapeutic techniques with targeted exercises to maximize functional muscle return in conjunction with antibiotic therapy. Conclusions: This case demonstrates a patient with severe dysarthria and dysphagia in the setting of a rare case of skull base osteomyelitis who with targeted therapy had successful return to functional communication and to a full oral diet.

A 25-Year-Old Male Polytrauma Patient Who Sustained a Traumatic Brain Injury with Recovery only to Suffer a Later Anoxic Brain Injury: A Case Report

Disclosures: J. Solberg, No Disclosures: I Have Nothing To Disclose. Case Description: A 76-year-old man presented to the hospital with acute mental status changes five days after visiting Atlantic City. He had become progressively confused and developed chills and emesis while at home. In the Emergency Room, the patient was alert but confused with a temperature of 101.2 degrees Fahrenheit. A lumbar puncture indicated meningitis. Computed tomography of the head was noncontributory. Acute treatment included intravenous dexamethasone, antibiotics, and acyclovir. Serological testing of cerebrospinal fluid with immunoglobulin M (IgM) antibody enzyme-linked immunosorbent assay confirmed West Nile Virus. Within 24 hours of admission, the patient rapidly declined and became unresponsive mandating mechanical ventilation. Elevated intracranial pressure necessitated a lumbar drain on hospital day 2; however, the comatose state persisted. On day 10, there continued to be no improvement in mentation with above treatments and the patient was started on amantadine 100 milligrams, twice daily. Setting: Inpatient Critical Care Unit. Results or Clinical Course: Within 48 hours after starting amantadine the patient had intermittent eye opening and responded to noxious stimuli. By 72 hours after administration, the patient performed simple commands such as moving left and right to verbal command and raising requested amount of fingers. Discussion: This case illustrated the potential of amantadine improving alertness and functional recovery in a patient with meningoencephalitis-related coma. The patient remained unresponsive for over 5 days while receiving treatment with antiviral medications and maintaining a normal cerebral perfusion pressure. It was not until the administration of amantadine that the patient awoke from a comatose state. Conclusions: Amantadine is documented in the literature to induce wakefulness in traumatic brain injury and even degenerative brain disorders such as Creutzfeldt-Jakob disease. There may be a similar role in the treatment of functional impairment due to encephalitis; however, further study is indicated.

Poster 11 Use of Hyperbaric Oxygen Treatment in Severe Traumatic Brain Injury: A Case Report

near-complete neurologic recovery. Setting: A tertiary pediatric hospital. Results: Before rehabilitation admission, the Wee Functional Independence Measure revealed deficits in self-care, sphincter control, mobility transfers, locomotion, communication, and social cognition that improved to supervision or modified independent level before discharge. Neuropsychological testing, although improved from admission, revealed deficits with executive functioning, fine motor speed, and dexterity at discharge. Discussion: Given the significant neurologic decline after mild impact and the radiologic findings of a thin subdural hematoma with a large midline shift, his injury is consistent with second impact syndrome (SIS). This case is unique in that it represents one of the longest temporal intervals (3 weeks) between head injuries and one of the best neurologic outcomes after this type of injury. Conclusions: SIS is a rare but serious condition that can result in severe neurologic deficits and potentially death. Increased time between head injuries as well as prompt medical care and rehabilitation may result in better outcomes of SIS. In addition, heightened awareness to the seriousness of a concussion and prevention of a second concussion while the brain is healing is paramount in preventing SIS.