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PubMed2003

Incidence, risk factors, and outcomes of fecal incontinence after acute brain injury: findings from the Traumatic Brain Injury Model Systems national database.

OBJECTIVE: To investigate the incidence, risk factors, and outcome in patients with fecal incontinence after acute brain injury. DESIGN: A retrospective study of the incidence of and risk factors contributing to fecal incontinence, and outcomes at admission to and discharge from inpatient rehabilitation and at 1-year follow-up. SETTING: Medical centers in the federally sponsored Traumatic Brain Injury Model Systems (TBIMS). PARTICIPANTS: A total of 1,013 consecutively enrolled rehabilitation inpatients from 17 TBIMS centers who were admitted to acute care within 24 hours of traumatic brain injury and seen at 1-year postinjury between 1990 and 2000. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Incidence of fecal incontinence, length of coma, length of posttraumatic amnesia (PTA), admission Glasgow Coma Scale (GCS) score, length of stay (LOS), FIM instrument scores, disposition at discharge and follow-up, and incidences of pelvic fracture, frontal contusion, and urinary tract infection (UTI). RESULTS: The incidence of fecal incontinence was 68% at admission to inpatient rehabilitation, 12.4% at rehabilitation discharge, and 5.2% at 1-year follow-up. Analysis of variance and chi-square analyses revealed statistically significant associations between the incidence of fecal incontinence at rehabilitation admission and admission GCS score, length of coma and PTA, LOS, and incidence of UTI and frontal contusion. Fecal incontinence at rehabilitation discharge was significantly associated with several variables, including age, discharge disposition, admission GCS score, length of coma, PTA, LOS, FIM scores, and incidence of pelvic fracture and frontal contusion. Significant associations were also found between fecal incontinence at 1-year follow-up and age, discharge and current 1-year disposition, admission GCS score, length of coma, LOS, FIM scores, and incidence of UTI (P<.05). Although logistic regression analyses were significant (P<.001), and predicted continence with 100% accuracy, demographics, injury characteristics, medical complications, and functional outcomes did not predict incontinence at discharge and at 1-year follow-up. CONCLUSIONS: Fecal incontinence is a significant problem after brain injury. Certain factors may increase its likelihood. Further studies evaluating mechanisms of fecal incontinence and treatment or control interventions would be useful.

Amnesia↗
PubMed2006

Initial experiences in management of blunt aortic injury taking associated brain injury into consideration.

BACKGROUND: Although endovascular stent-grafting (SG) has become acceptable for blunt aortic injury (BAI), open surgical repair (OR) does provide reliable, good long-term results. A current surgical strategy for BAI, taking account of associated brain injury, is presented and preferable initial management for BAI is proposed. METHODS AND RESULTS: The surgical strategy for BAI was established in 2001: SG is performed for patients with obvious brain injuries, but OR is performed for patients without brain injury, and conservative treatment should be used initially for patients with critical non-aortic injuries. Between 2001 and 2004 20 patients with BAI were admitted to hospital: 16 blunt aortic ruptures and 4 blunt aortic dissections. Of them 15 patients underwent surgery (SG, 9; OR, 6) and 5 patients were treated conservatively. One patient died from associated lung injury after SG, all patients treated conservatively died because of associated brain injuries or another rupture of BAI, and 2 elderly patients treated by OR died within 1 year from postoperative respiratory failure. CONCLUSION: This brain-injury conscious surgical strategy for BAI provided acceptable early results. OR should be chosen for young patients without brain injury, but endovascular SG seems to be a better initial treatment for elderly patients or patients with other comorbidities.

Adult↗
PubMed2000

Evaluation of attention process training and brain injury education in persons with acquired brain injury.

Fourteen patients with stable acquired brain injuries exhibiting attention and working memory deficits were given 10 weeks of attention process training (APT) and 10 weeks of brain injury education in a cross-over design. Structured interviews and neuropsychological tests were used prior to rehabilitation and after both treatments to determine the influence of the interventions on tasks of daily life and performance on attentional networks involving vigilance, orienting, and executive function. The overall results showed that most patients made improvements. Some of these gains were due to practice from repetitive administration of the tests. In addition, the type of intervention also influenced the results. The brain injury education seemed to be most effective in improving self-reports of psychosocial function. APT influenced self-reports of cognitive function and had a stronger influence on performance of executive attention tasks than was found with the brain injury education therapy. Vigilance and orienting networks showed little specific improvement due to therapy. However, vigilance level influenced the improvement with therapy on some tests of executive attention. We consider the implications of these results for future studies of the locus of attentional improvement and for the design of improved interventions.

Activities of Daily Living↗
PubMed2003

The family systems approach to treating families of persons with brain injury: a potential collaboration between family therapist and brain injury professional.

Although brain injury may have a great impact on the family as a whole, family reactions are not adequately addressed in rehabilitative programmes. When they are, treatment tends to be approached from a family education and support perspective and not from a family therapy perspective. The aim of the following paper is to illustrate the important role that a family systems approach can play in treating families of individuals with brain injury. In particular, clinical examples taken from the literature will be presented that illustrate how family roles can be modified as a consequence of a brain injury, and the importance of re-establishing or re-distributing these roles. It will be argued that an intimate collaboration between family therapist and brain injury professional is essential, and that the ideal professional make-up of clinicians working with families of persons with brain injury are those well-versed in both brain injury rehabilitation and family therapy.

Adult↗
PubMed1990

MK-801 pretreatment enhances N-methyl-D-aspartate-mediated brain injury and increases brain N-methyl-D-aspartate recognition site binding in rats.

Direct intracerebral administration of N-methyl-D-aspartate typically produces focal brain injury. (+)-5-Methyl-10,11-dihydro-5H-dibenzo[a,d]cyclohepten-5,10-immi ne maleate (MK-801), a non-competitive N-methyl-D-aspartate antagonist, can protect against N-methyl-D-aspartate-mediated brain injury when administered shortly before or after an intracerebral injection of N-methyl-D-aspartate. However, in this study we report that in perinatal rats if MK-801 (1 mg/kg) is administered intraperitoneally 24 h prior to a unilateral intrastriatal N-methyl-D-aspartate injection, N-methyl-D-aspartate-mediated brain injury is paradoxically enhanced. The severity of resulting brain injury is 15-25% greater in groups that received MK-801 in comparison with saline-treated controls (P less than 0.001, linear regression analysis). In contrast, the severity of brain injury resulting from intrastriatal injection of the glutamate agonist quisqualate is not altered by a similar 24 h MK-801 pretreatment. Furthermore, the enhanced toxicity of N-methyl-D-aspartate produced by a 24 h pretreatment with MK-801 is completely blocked if a second dose of MK-801 is administered 15 min after the intrastriatal injection of N-methyl-D-aspartate. To determine if MK-801 produced alterations in glutamate receptor pharmacology co-incident with the enhanced toxicity of N-methyl-D-aspartate, in vitro quantitative autoradiography for excitatory amino acid receptor subtypes was performed with [3H]glutamate and [3H]N-1-(2-thienyl)cyclohexyl-3,4-piperidine in seven-day-old rats killed 2 or 24 h after MK-801 (1 mg/kg) administration. A 2 h MK-801 pretreatment produced a 30-50% increase in [3H]glutamate binding at N-methyl-D-aspartate preferring recognition sites in all four brain regions examined (areas CA1 and CA3 of the hippocampus, corpus striatum, cingulate cortex) in comparison with saline-treated controls (P less than 0.05, ANOVA). [3H]N-1-(2-Thienyl)cyclohexyl-3,4-piperidine binding to the phencyclidine site associated with the N-methyl-D-aspartate receptor was reduced by 60-80% in all brain regions examined (P less than 0.001). Quisqualate-sensitive [3H]glutamate binding was not altered by a 2 h MK-801 pretreatment. In animals that received a 24 h MK-801 pretreatment.(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗
PubMed2000

Mannitol for acute traumatic brain injury.

BACKGROUND: Mannitol is sometimes dramatically effective in reversing acute brain swelling, but its effectiveness in the on-going management of severe head injury remains open to question. There is evidence that in prolonged dosage mannitol may pass from the blood into the brain, where it might cause reverse osmotic shifts that increase intracranial pressure. OBJECTIVES: To assess the effects of different mannitol therapy regimens, of mannitol compared to other intracranial pressure (ICP) lowering agents, and to quantify the effectiveness of mannitol administration given at other stages following acute traumatic brain injury. SEARCH STRATEGY: The review drew on the search strategy for the Injuries Group as a whole. We checked reference lists of trials and review articles, and contacted authors of trials. SELECTION CRITERIA: Randomised trials of mannitol, in patients with acute traumatic brain injury of any severity. The comparison group could be placebo-controlled, no drug, different dose, or different drug. Trials where the intervention was started more than eight weeks after injury, and cross-over trials were excluded. DATA COLLECTION AND ANALYSIS: The reviewers independently rated quality of allocation concealment and extracted the data. Relative risks (RR) and 95% confidence intervals (CI) were calculated for each trial on an intention to treat basis. MAIN RESULTS: Overall there were few eligible trials. There were no trials comparing different doses, or type of administration. One trial compared ICP-directed therapy to 'standard care' (RR for death= 0.83; 95% CI 0.47;1.46). One trial compared mannitol to pentobarbital (RR for death = 0.85; 95% CI 0. 52;1.38). No trials compared mannitol to other ICP lowering agents. One trial tested the effectiveness of pre-hospital administration of mannitol against placebo (RR for death=1.59; 95% CI 0.44;5.79). REVIEWER'S CONCLUSIONS: There are insufficient data to recommend one form of mannitol infusion over another. Mannitol therapy for raised ICP may have a beneficial effect on mortality when compared to pentobarbital treatment. ICP-directed treatment shows a small beneficial effect compared to treatment directed by neurological signs and physiological indicators. There are insufficient data on the effectiveness of pre-hospital administration of mannitol to preclude either a harmful or a beneficial effect on mortality.

Brain Injuries↗
PubMed2006

[Anti-inflammatory modulators in traumatic brain injury].

Traumatic brain injury leads to primary and secondary brain injuries. Primary brain injury results from mechanical forces applied to the head at the time of impact. Secondary brain injury occurs at some time after the primary impact. Numerous pathophysiological mechanisms have been postulated to explain the progressive tissue damage produced by secondary injuries. The endogenous neuroinflammatory response after traumatic brain injury contributes to the development of blood-brain barrier breakdown, cerebral oedema and neuronal cell death and this has led to various pharmacological therapies to try to limit this type of damage. Studies employing glutamate receptor antagonist for cerebral protection have yielded promising results in laboratory animals but failed to produce clinically significant improvements. The present review will summarize the mechanisms of post traumatic cerebral inflammation with a special focus on the anti-inflammatory drug targets.

Adrenal Cortex Hormones↗
PubMed1995

Defining assessment parameters in dual injuries: spinal cord injury and traumatic brain injury.

Assessment parameters for muscle testing in the individual with a spinal cord injury (SCI) have been clearly defined by the American Spinal Injury Association (ASIA). However, the ASIA standard requires the individual's participation in reporting sensory information and he/she must be able to perform specific tasks to complete the examination. In an individual with a dual injury, a SCI and a traumatic brain injury (TBI), neurological assessment can be impeded by the individual's inability to participate in the exam. Assessment needs to incorporate both cognitive and physical parameters that will appropriately assess both injuries. This article reviews the assessment parameters for both spinal cord injury and traumatic brain injury and provides assessment guidelines for bedside evaluation of functional ability. In addition, a review of the biomechanics of injury will provide a model for understanding dual injury.

Biomechanical Phenomena↗
PubMed1999

Cerebral hemodynamics after traumatic brain injury of immature brain.

These studies were designed to characterize the cerebral hemodynamic effects of fluid percussion brain injury (FPI) in the newborn pig equipped with a closed cranial window. Reductions in cerebral blood flow, pial artery diameter, and cerebral oxygenation following FPI were greater in newborn (1-3 days old) vs. juvenile (3-4 weeks old) pigs, suggesting that newborns were exquisitely sensitive to brain injury. Additionally, in piglets, there was decremented dilation to nitric oxide, cGMP, and cAMP dependent stimuli following FPI. The membrane potential of vascular muscle is an important contributor to vascular tone and the activity of K+ channels is an important regulator of membrane potential. Recent studies indicate that altered dilator responsiveness and cerebral hemodynamic control following FPI results from impaired K+ ATP sensitive (KATP) and calcium sensitive (Kca+2) channel function. Impaired KATP channel function results, at least in part, from protein kinase C activation by the peptide endothelin-1. These observations indicate that the effects of brain injury on cerebral hemodynamics in the newborn are multifaceted and multifactorial.

Animals↗
PubMed2005

Pediatric traumatic brain injury: do racial/ethnic disparities exist in brain injury severity, mortality, or medical disposition?

INTRODUCTION: Little is known regarding pediatric racial/ethnic disparities. We sought to determine if racial/ethnic disparities exist in the severity, mortality, or medical disposition of pediatric traumatic brain injury (TBI). METHODS: We analyzed data from a comprehensive trauma database assembled at a large independent children's hospital. Among all patients evaluated by the trauma service in the emergency department (ED), cases of TBI were identified (N=1035). Analyses contrasted non-Hispanic White children with all others (minority children). The relationship of race to patient characteristics, brain injury severity, mortality, and medical disposition (hospital admission, intensive care unit admission) was analyzed by using bivariable approaches and multivariate logistic regression. The latter controlled for age, overall injury severity, and insurance status. RESULTS: Although sociodemographic characteristics did not differ, the mechanism of injury was significantly different (P<.001); minority children were more likely to have been a pedestrian or cyclist struck by a vehicle. Minority children were less likely to require transfer to the ED for treatment and were more likely to be publicly insured (P<.001). No differences in brain injury severity, mortality, or medical disposition were observed with both bivariable and multivariable approaches. CONCLUSIONS: This study is one of the first to examine potential disparities in trauma and contributes to the small but growing literature in pediatric health disparities. Multiple explanations are explored, several with potential implications for reducing disparities in other health conditions. Identifying conditions in which evaluation and treatment appears to be free of disparities may provide insights for subsequent investigations and interventions.

Adolescent↗
PubMedDate not supplied

Magnetization transfer imaging of diffuse axonal injury following experimental brain injury in the pig: characterization by magnetization transfer ratio with histopathologic correlation.

PURPOSE: Our goal was to evaluate the use of the magnetization transfer ratio (MTR) in the detection of diffuse axonal injury (DAI) resulting from traumatic brain injury in a swine model. METHOD: DAI was created by applying a nonimpact, coronal plane, rotational acceleration to the heads of miniature swine (n = 4). GE imaging was performed with and without off-resonance MT saturation. Histologic correlation of axonal injury with MRI was performed 7 days postinjury. Thirty-one subcortical white matter regions and 10 deep white matter regions were selected for the direct comparison of histologic data and MTR measurements. RESULTS: Nineteen of 41 examined locations exhibited histologic evidence of axonal injury. The mean MTR in regions with axonal damage was significantly less than in regions without axonal damage. These changes were observed both in regions demonstrating high signal intensity on T2-weighted images (T2WI) (p <0.0001, n = 6) and in regions with no signal intensity change on T2WI (p < 0.05, n = 13). CONCLUSION: These results suggest that the measurement of MTR may have the potential for evaluation axonal damage in DAI following traumatic brain injury even when conventional T2WI does not demonstrate the lesion.

Animals↗
PubMed2002

Regional brain injury epidemiology as the basis for planning brain injury treatment. The Romagna (Italy) experience.

AIM: Neurosurgical services for traumatic brain injury (TBI) should be based upon the understanding of the epidemiology of TBI in the region as well as the clinical parameters. Our objective was to measure incidence and epidemiologic factors associated with TBI in the Romagna region of Northeastern Italy and correlate those parameters with neurosurgical imaging and related clinical features. METHODS: Guidelines for brain injury management in our region were derived following meetings of all physicians involved in the treatment of brain injury. An epidemiologic study was undertaken in 1998. The study population was all patients admitted for hospital care in the Region following a TBI with a discharge diagnosis of pertinent International Classification Disease, 9(th) revision, codes. Data on the extent, diagnoses, severity, external causes and hospital course were abstracted from the hospital record and computer entered for analyses. RESULTS: Using data for the population of Romagna of about 1000000 persons we identified, in the full year 1998, 2430 TBI patients or an incidence rate of 250 per 100000 resident population. There were, in addition, 460 nonresident patients who were admitted in the region. External causes of injury were generally similar to reports from other places in Western Europe, with the exception of a very low frequency of cases stemming from violence. Age specific incidence rates were highest among young children, persons aged 15-24, and those aged 65 and older. Computerized tomography scans were given to 1732 patients and intracranial traumatic lesions were identified in 497 (28.6%) patients or a rate of 38 /100000. We performed 128 craniotomies, an incidence rate of 11/100000. The case fatality rate (CFR) was 2.8% among admitted patients with the highest rate among those aged 75 or older. CONCLUSION: Incidence of TBI in Italy is similar to other published European series. The number of minor brain injuries admitted for hospital care remains high and can be significantly reduced with better use of CT scans in adults whenever possible. The workload for a neurosurgical unit servicing a population of 1 million is limited and does not justify the opening of new units for trauma care or the use of craniotomies outside the Neurosurgical Unit.

Adolescent↗