Wilhelm Schalén

Psychosocial outcome 5–8 years after severe traumatic brain lesions and the impact of rehabilitation services

This study addresses three questions. First, what is the long-term psychosocial outcome for severely head-injured patients? Second, is an increased survival rate associated with an increase in the number of patients with a poor quality of life? Third, do rehabilitation services affect the final outcome? The long-term outcome was assessed by means of questionnaires for self-ratings, interviews with patients and relatives and neurophysical examinations. One hundred and six patients initially judged as good recovery/moderate disability (GR/MD) 6 months post-injury participated in the study. Forty to 50% of these patients showed co-ordination disturbances; more than 20% had speech disorders and cranial nerve deficits. Twenty-eight per cent had psychiatric symptom scores on the Hopkins Symptom Checklist (HSCL) indicating need of treatment. Social function according to the Social Adjustment Scale--Self-Report (SAS--SR) showed that 40% had problems concerning interpersonal relations and 20-30% had problems within the field of leisure activities, but few problems were reported on work activities and economy. The Comprehensive Psychopathological Rating Scale (CPRS) revealed that hostile feelings, failing memory and fatiguability were common symptoms and were reported by relatives in 71%, 52% and 48%, respectively, but the mean distress levels were moderate. A correlation was seen between quality of life reported by relatives and the degree of mental and social disability according to the Bond Outcome Scale, but the correlation to neurophysical handicap was rather weak. The majority of patients were able to return to a productive social life. The proportion of patients with a poor long-term outcome did not increase after introduction of an aggressive management protocol for head injuries. Data indicated that improvements in facilities for rehabilitation may positively affect psychosocial adjustment.

Assessment of motor and process skills reflects brain-injured patients ability to resume independent living better than neuropsychological tests

Objective –  To compare recovery of cognitive functions and activities of daily living during the first year of rehabilitation after severe brain trauma.

Bedside biochemical monitoring of the penumbra zone surrounding an evacuated acute subdural haematoma

We describe a penumbra zone with increased biochemical vulnerability in cerebral cortex underlying an evacuated acute subdural haematoma. Two microdialysis catheters were placed in this zone and one catheter was placed in the opposite, less injured hemisphere. The microdialysis perfusates were analysed bedside for glucose, pyruvate, lactate, glutamate, and glycerol.

Severe traumatic brain lesions in Sweden. Part 2: Impact of aggressive neurosurgical intensive care.

During a 6 year period (1977-1982), 425 patients were treated in the Department of Neurosurgery, University Hospital of Lund, for severe traumatic brain lesions (coma greater than 6 hours). From 1983 a more aggressive management protocol was introduced including early recording of intracranial pressure (ICP) and 162 patients were included in the study 1983-1984. A dangerous increase in ICP in spite of adequate surgical treatment and moderately controlled hyperventilation was the incentive for barbiturate coma therapy in selected patients. In the first part of the study overall mortality was 48% whereas 39% of the patients reached good recovery/moderate disability 6 months after injury. During the second part of the study the corresponding figures were 35% and 54%, respectively (in both cases p less than or equal to 0.01). In the group of patients with focal intracranial mass lesions mortality decreased from 59% to 46% (p less than or equal to 0.05) and good recovery/moderate disability increased from 30% to 42% (p less than or equal to 0.05). Improvement in outcome was even more pronounced in patients with no-mass lesions, mortality decreased from 30% to 12% and good recovery/moderate disability increased from 56% to 80% (p less than or equal to 0.05 and p less than or equal to 0.01, respectively). No change occurred in age distribution or in the types of intracranial lesions that could explain these improvements. It is concluded that aggressive neurosurgical intensive care significantly improves outcome in patients with severe traumatic brain lesions.

Bedside diagnosis of mitochondrial dysfunction in aneurysmal subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (SAH) is frequently associated with delayed neurological deterioration (DND). Several studies have shown that DND is not always related to vasospasm and ischemia. Experimental and clinical studies have recently documented that it is possible to diagnose and separate cerebral ischemia and mitochondrial dysfunction bedside. The study explores whether cerebral biochemical variables in SAH patients most frequently exhibit a pattern indicating ischemia or mitochondrial dysfunction.

Clinical outcome and cognitive impairment in patients with severe head injuries treated with barbiturate coma

SummaryThis study reports on clinical outcome in 38 patients with severe head injuries (posttraumatic coma for 6 hours or more) treated with barbiturate coma because of intracranial hypertension. Eighteen patients died, 4 patients remained in a severely disabled or a chronic vegetative state, and 16 patients reached the levels good recovery/ moderate disability. Six of these patients returned to work or school full time, 4 for half time and 3 were in a rehabilitation program. Fourteen patients were subjected to a comprehensive neuropsychological assessment. All patients except one exhibited varying degrees of cognitive dysfunction and 6 patients had signs of personality change. The quality of life for the majority of surviving patients was relatively good but the positive effects of barbiturate coma therapy in the age groups over 40 years appeared to be limited.

Neuropsychological assessments in relation to CBF after severe head injuries

Objective – To determine whether neuropsychological outcome is related to cerebral blood flow (CBF) early in the recovery phase. Material and methods– Twelve consecutive patients (mean age of 30 years, range 15–48 years) with severe traumatic brain injuries were subjected to a neuropsychological test battery at admission to the rehabilitation unit and after 3, 6 and 12 months. CBF measurements were performed at admission and 6 and 12 months later with a high‐resolution, two‐dimensional regional cerebral blood flow system with 254 stationary detectors after 1 min of 133Xe inhalation (70–100 MBq/l). Results and conclusion– Mean CBF values were within normal range already in the early post‐acute phase and remained virtually unchanged during the first year of rehabilitation. A correlation was found between the individual CBF level and neuropsychological outcome 1 year after injury, particularly with regard to verbal memory capacity, reasoning capacity, and information processing speed.

Recirculation usually precedes malignant edema in middle cerebral artery infarcts

In patients with large middle cerebral artery (MCA) infarcts, maximum brain swelling leading to cerebral herniation and death usually occurs 2–5 days after onset of stroke. The study aimed at exploring the pattern of compounds related to cerebral energy metabolism in infarcted brain tissue.