Post-traumatic amnesia: Consistency-of-recovery and duration-to-recovery following traumatic brain impairment

The aim of this research was to examine the nature and order of recovery of orientation and memory functioning during Post-Traumatic Amnesia (PTA) in relation to injury severity and PTA duration. The Westmead PTA Scale was used across consecutive testing days to assess the recovery of orientation and memory during PTA in 113 patients. Two new indices were examined: a Consistency-of-Recovery and a Duration-to-Recovery index. a predictable order of recovery was observed during PTA: orientation-to-person recovered sooner and more consistently than the following cluster; orientation-to-time, orientation-to-place, and the ability to remember a face and name. However, the type of memory functioning required for the recall face and name task recovered more consistently than that required for memorizing three pictures. An important overall finding was that the order-of-recovery'' of orientation and memory functioning was dependent upon both the elapsed days since injury, and the consistency of recovery. The newly developed indices were shown to be a valuable means of accounting for differences between groups in the elapsed days to recovery of orientation and memory. These indices also clearly increase the clinical utility of the Westmead PTA Scale and supply an objective means of charting (and potentially predicting) patients' recovery on the different components of orientation and memory throughout their period of hospitalization.

Rehabilitation outcomes for brain injured patients in Australia: functional status, length of stay and discharge destination

This study describes the rehabilitation length of stay (LOS), discharge destination and discharge functional status of 149 patients admitted with traumatic brain injury (TBI) to an Australian hospital over a 5-year period. Hospital charts of patients admitted between 1993-1998 were reviewed. Average LOS over the 5-year time period was 61.8 days and only decreased nominally over this time. Longer LOS was predicted by lower admission motor FIM scores and presence of comorbidities. Mean admission and discharge motor FIM scores were 58 and 79, which represented a gain of 21 points. Higher discharge motor FIM scores were predicted by higher admission motor FIM scores and younger age. FIM gain was predicted by cognitive status and age. Most patients, 88%, were discharged back to the community, with 30% changing their living setting or situation. Changing living status was predicted by living alone and having poorer functional status on admission.

The investigation of factors underlying deficits in self-awareness and self-regulation

Primary objective: To examine a theoretical model which suggests that a contribution of both psychological and neuropsychological factors underlie deficits in self-awareness and self-regulation. Research design: Multivariate design including correlations and analysis of variance (ANOVA). Methods: Sixty-one subjects with acquired brain injury (ABI) were administered standardized measures of self-awareness and self-regulation. Psychological factors included measures of coping-related denial, personality-related denial and personality change. Neuropsychological factors included an estimate of IQ and two measures of executive functioning that assess capacity for volition and purposive behaviour. Main outcomes and results: The findings indicated that the relative contribution of neuropsychological factors to an outcome of deficits in self-awareness and self-regulation had a more direct effect than psychological factors. In general, measures of executive functioning had a direct relationship, while measures of coping-related and personality-related denial had an indirect relationship with measures of self-awareness and self-regulation. Conclusion: The findings highlighted the importance of measuring both neuropsychological and psychological factors and demonstrated that the relative contribution of these variables varies according to different levels of self-awareness and self-regulation.

Electrocardiographic abnormalities in neurological diseases

OBJECTIVE: To evaluate electrocardiographic abnormalities in patients with neurologic diseases. METHODS: We studied 161 patients with neurologic disorders by analyzing the 12-lead electrocardiogram during the pathological process. An expert who did not know anything about the patients evaluated the traces. RESULTS: Neurological process included brain tumor (41%), stroke (27.3%), cerebral aneurysm (15.5%), subarachnoid hemorrhage (6.8%), subdural hemorrhage (5%), and head injury (4.4%). Electrocardiograms were normal in 61% of cases, and the most frequent abnormality was ventricular repolarization (23.7%). The presence of T waves (4.6%) and prolonged QT intervals (8.8%) was the most characteristic of brain injuries. CONCLUSION: We observed a lower incidence of electrocardiographic abnormalities than that described in the literature.

Post-traumatic mutism in children: clinical characteristics, pattern of recovery and clinicopathological correlations.

Among the numerous clinical syndromes observed after severe traumatic head injury, post-traumatic mutism is a disorder rarely reported in adults and not studied in any detail in children. We report seven children between the ages of 3 1/2 and 14 years who sustained severe head injury and developed post-traumatic mutism. We aim to give a precise clinical characterization of this disorder, discuss differential diagnosis and correlations with brain imaging and suggest its probable neurological substrate. After a coma lasting from 5 to 25 days, the seven patients who suffered from post-traumatic mutism went through a period of total absence of verbal production lasting from 5 to 94 days, associated with the recovery of non-verbal communication skills and emotional vocalization. During the first days after the recovery of speech, all patients were able to produce correct small sentences with a hypophonic and monotonous voice, moderate dysarthria, word finding difficulties but no signs of aphasia, and preserved oral comprehension. The neurological signs in the acute phase (III nerve paresis in three of seven patients, signs of autonomic dysfunctions in five of seven patients), the results of the brain imaging and the experimental animal data all suggest the involvement of mesencephalic structures as playing a key role in the aetiology of post-traumatic mutism.

Knowledge of Glasgow coma scale by air-rescue physicians.

OBJECTIVE: To assess the theoretical and practical knowledge of the Glasgow Coma Scale (GCS) by trained Air-rescue physicians in Switzerland. METHODS: Prospective anonymous observational study with a specially designed questionnaire. General knowledge of the GCS and its use in a clinical case were assessed. RESULTS: From 130 questionnaires send out, 103 were returned (response rate of 79.2%) and analyzed. Theoretical knowledge of the GCS was consistent for registrars, fellows, consultants and private practitioners active in physician-staffed helicopters. The clinical case was wrongly scored by 38 participants (36.9%). Wrong evaluation of the motor component occurred in 28 questionnaires (27.2%), and 19 errors were made for the verbal score (18.5%). Errors were made most frequently by registrars (47.5%, p = 0.09), followed by fellows (31.6%, p = 0.67) and private practitioners (18.4%, p = 1.00). Consultants made significantly less errors than the rest of the participating physicians (0%, p < 0.05). No statistically significant differences were shown between anesthetists, general practitioners, internal medicine trainees or others. CONCLUSION: Although the theoretical knowledge of the GCS by out-of-hospital physicians is correct, significant errors were made in scoring a clinical case. Less experienced physicians had a higher rate of errors. Further emphasis on teaching the GCS is mandatory.

Predictive value of Glasgow Coma Scale after brain trauma: change in trend over the past ten years.

BACKGROUND: Age and the Glasgow Coma Scale (GCS) score on admission are considered important predictors of outcome after traumatic brain injury. We investigated the predictive value of the GCS in a large group of patients whose computerised multimodal bedside monitoring data had been collected over the previous 10 years. METHODS: Data from 358 subjects with head injury, collected between 1992 and 2001, were analysed retrospectively. Patients were grouped according to year of admission. Glasgow Outcome Scores (GOS) were determined at six months. Spearman's correlation coefficients between GCS and GOS scores were calculated for each year. RESULTS: On average 34 (SD: 7) patients were monitored every year. We found a significant correlation between the GCS and GOS for the first five years (overall 1992-1996: r = 0.41; p<0.00001; n = 183) and consistent lack of correlations from 1997 onwards (overall 1997-2001: r = 0.091; p = 0.226; n = 175). In contrast, correlations between age and GOS were in both time periods significant and similar (r = -0.24 v r = -0.24; p<0.002). CONCLUSIONS: The admission GCS lost its predictive value for outcome in this group of patients from 1997 onwards. The predictive value of the GCS should be carefully reconsidered when building prognostic models incorporating multimodality monitoring after head injury.

Kernohan's notch and misdiagnosis of disorders of consciousness.

A 69-year-old man presented with a sudden headache followed by unconsciousness. There was no head injury. The Glasgow Coma Scale (GCS) score was 3/15 and there was a left mydriasis, unreactive to light. The CT-scan showed a left acute subdural haematoma causing a remarkable mass effect. A supratentorial hemispheric craniotomy was performed. Nevertheless, after several weeks at the intensive care unit (ICU), the patient was still unresponsive to external stimuli and did not show any motor activity. A comfort care attitude was decided on with the family and the patient was extubated. However, a few days later, the patient subsequently showed a surprisingly favourable course, with improved wakefulness. Indeed, the GCS score improved, and the treatment plan was modified so that the patient benefited from rehabilitation. The MRI showed a right cerebral peduncle lesion, consistent with a Kernohan-Woltman notch phenomenon (KWNP). Six months later, the patient was able to walk and live quite normally.

Notfälle in der Pädiatrie [Pediatric emergencies]

We describe the most frequent emergencies in pediatrics and discuss their differential diagnosis and therapy. Dyspnea, shock, coma, convulsions, infectious CNS affections, head injury and burns are reported in detail. The importance of correct diagnosis and correct clinical assessment is emphasized, as they influence therapy and further management of the patients.

Use of neuron-specific enolase for assessing the severity and outcome of neurological disorders in patients

Neuron-specific enolase (NSE) is a glycolytic enzyme present almost exclusively in neurons and neuroendocrine cells. NSE levels in cerebrospinal fluid (CSF) are assumed to be useful to estimate neuronal injury and clinical outcome of patients with serious clinical manifestations such as those observed in stroke, head injury, anoxic encephalopathy, encephalitis, brain metastasis, and status epilepticus. We compared levels of NSE in serum (sNSE) and in CSF (cNSE) among four groups: patients with meningitis (N = 11), patients with encephalic injuries associated with impairment of consciousness (ENC, N = 7), patients with neurocysticercosis (N = 25), and normal subjects (N = 8). Albumin was determined in serum and CSF samples, and the albumin quotient was used to estimate blood-brain barrier permeability. The Glasgow Coma Scale score was calculated at the time of lumbar puncture and the Glasgow Outcome Scale (GOS) score was calculated at the time of patient discharge or death. The ENC group had significantly higher cNSE (P = 0.01) and albumin quotient (P = 0.005), but not sNSE (P = 0.14), levels than the other groups (Kruskal-Wallis test). Patients with lower GOS scores had higher cNSE levels (P = 0.035) than patients with favorable outcomes. Our findings indicate that sNSE is not sensitive enough to detect neuronal damage, but cNSE seems to be reliable for assessing patients with considerable neurological insult and cases with adverse outcome. However, one should be cautious about estimating the severity of neurological status as well as outcome based exclusively on cNSE in a single patient.

Psychopathy and Aggression: Examining the Role of Empathy

Empirical research has consistently demonstrated a positive association between psychopathic traits and physical aggression (Campbell, Porter, & Santor, 2004; Gretton, Hare, & Catchpole, 2004; Raine et aI., 2006; Spain, Douglas, Poythress, & Epstein, 2004). Moreover, research has also found that the emotional/interpersonal (Factor 1) psychopathy traits tend to be more closely associated with goal oriented, proactive aggression, whereas the social deviance (Factor 2) psychopathy characteristics have been more closely linked to reactive aggression, which is perpetrated in response to threat or provocation (Flight & Forth, 2007). Blair (2004; 2005; 2006) has recently proposed the Integrated Emotions Systems Model (lES), which posits that the association between Factor 1 psychopathy traits and proactive aggression is due to amygdala dysfunction leading to failed moral socialization. Consequently, individuals who exhibit Factor 1 psychopathy traits do not experience affective empathy in response to distress cues exhibited by others, thus, preventing the inhibition of proactive aggression. The current investigation sought to test this model by examining the associations among the emotional/interpersonal (Factor 1) psychopathy traits, proactive aggression, and affective empathy. After accounting for head injury, Factor 2 psychopathy traits, reactive aggression, and cognitive empathy, it was hypothesized that 1) Factor 1 psychopathy traits would predict proactive aggression, and 2) that affective empathy is a common cause of Factor 1 psychopathy traits, proactive aggression, and of the relationship between these two constructs. This hypothesis assumed that (a) affective empathy would uniquely predict Factor 1 psychopathy traits, (b) that affective empathy would uniquely predict proactive aggression, and (c) that affective empathy would account for the relationship between Factor I psychopathy traits and proactive aggression. The total sample consisted of 137 male undergraduate students. Participants completed measures of psychopathy (SRP III; Paulhus, Hemphill, & Hare, in press), aggression (PCS; Marsee, Kimonis, & Frick, 2004; RPQ; Raine et at, 2006), dispositional cognitive and affective empathy (BES; Jolliffe & Farrington, 2006; TES; Spreng, McKinnon, Mar, & Levine, 2009), and situational cognitive and affective empathy in response to neutral and empathy eliciting video clips. Physiological indices (heart rate & electrodermal activity) of affective empathy were also obtained while participants viewed the neutral and empathy eliciting videos. Findings indicated that Factor I psychopathy traits predicted proactive aggression. In addition, results demonstrated that affective empathy predicted both Factor I psychopathy traits and proactive aggression. However, the association between affective empathy and proactive aggression appeared to be dependent on the conceptualization and measurement of affective empathy. Conversely, affective empathy did not appear to account for the relationship between Factor I psychopathy traits and proactive aggression. Overall, results demonstrated partial support for the IES model. Implications of the results, limitations of the study and future research directions are discussed.

Douleur, affectivité, personnalité et fonctionnement attentionnel suite à un traumatisme craniocérébral léger

L’objectif principal de la présente thèse est d’étudier la nature multifactorielle des difficultés attentionnelles que présentent les personnes ayant subi un traumatisme craniocérébral léger (TCCL). Plus spécifiquement, nous avons voulu cerner l’impact des symptômes de douleur, ainsi que de facteurs émotifs et de personnalité, sur le fonctionnement attentionnel de personnes ayant eu un TCCL. Afin d’atteindre cet objectif, cette thèse présente trois articles. Dans le premier article, l’impact cognitif/neuropsychologique de la douleur chronique (DC) et de ses variables psychologiques concomitantes a été examiné par le biais d’une recension des écrits. Le deuxième article présente une étude expérimentale portant sur les relations entre des variables liées à la douleur et à l’affectivité, et le fonctionnement attentionnel de personnes ayant subi un TCCL étant à différents stades de récupération, comparativement à un groupe témoin normal. Enfin, un troisième article décrit une étude expérimentale qui a été menée afin d’explorer les associations entre certains facteurs de personnalité (neuroticisme, extraversion) et l’efficacité attentionnelle chez des participants normaux, ainsi que chez des personnes ayant subi un TCCL. Les résultats des articles présentés dans cette thèse démontrent que le TCCL en soi peut nuire au fonctionnement attentionnel, puisque des déficits de l’attention peuvent être observés sur des tâches neuropsychologiques qui mesurent les temps de réaction avec précision. Des variables concomitantes au TCCL peuvent aussi avoir un impact négatif sur l’attention sélective; la présence de symptômes de douleur nuit à la performance sur des tâches d’attention et certains traits de personnalité sont associés à l’efficacité attentionnelle ou aux symptômes post-commotionnels. Cette thèse montre donc que divers facteurs peuvent contribuer aux difficultés d’attention des personnes ayant subi un TCCL. Le neuropsychologue devrait utiliser des tâches sensibles aux atteintes, parfois plus subtiles, que présentent les personnes ayant eu un TCCL lorsqu’il tente de comprendre les difficultés attentionnelles de cette clientèle. De plus, les variables associées à la douleur et certains traits de personnalité devraient être systématiquement évalués lors de l’examen neuropsychologique post-TCCL.

Étude de l'association entre la sévérité des traumatismes crâniens et les inégalités sociales.

Introduction : La réduction des inégalités sociales de santé est un objectif de santé publique au Canada. Les liens entre les facteurs socio-économiques et les traumatismes en général ont été abondamment mesurés et illustrés notamment en pédiatrie, mais l’association entre les traumatismes crâniens et les inégalités sociales n’est pas assez investiguée dans la littérature. L’intérêt de ce travail en santé publique nous permettra de mieux connaitre les liens entre la défavorisation et les traumatismes crâniens particulièrement la sévérité. Objectif : L’objectif général de cette étude est d’examiner la relation entre les traumatismes crâniens et le statut socio-économique. Méthode : L’échantillon comprend 2269 patients ayant consulté le service d’urgence de l’Hôpital du Sacré Coeur de Montréal entre le 17 Mars 2008 et le 11 Janvier 2012, âgés de 14 ans et plus et habitant Montréal et Laval. Des analyses de régression logistiques ont été appliquées pour examiner la relation entre le quintile du statut socio-économique (mesuré à l’aide d’un proxy écologique) et la sévérité du traumatisme crânien (mesuré à l’aide de la tomodensitométrie). Résultat : A Montréal et à Laval, la cote d’avoir un scan normal est plus élevée chez les patients de quintile de revenu plus pauvre Q1 par rapport au quintile de revenu plus riche Q5, avec les valeurs respectives de 1,104 et 1,522 pour les régions de Montréal et Laval. A Laval lorsqu’on passe du quintile le plus pauvre Q1 au quintile le plus riche Q5, les cotes diminuent de 1,522 pour Q1; 1,302 pour le quintile de revenu bas; 1,126 pour le quintile de revenu moyen; 1,176 pour le quintile élevé à 1 pour le quintile le plus riche (quintile de référence). Conclusion : Bien que la relation entre les traumatismes et le statut socio-économique soit non significative, plusieurs questions se posent à travers ce mémoire notamment les causes différentes du traumatisme crânien en fonction du statut socio-économique et le territoire de résidence. D’autres recherches plus approfondies seraient utiles pour mieux informer les programmes de santé publique. Mots Clés : Traumatisme crânien, Statut socio-économique, Santé publique, Inégalités sociales, Chutes, Accidents de la route, Causes de traumatisme, Quintile de revenu

Evaluación e intervención interdisciplinaria del dolor en Unidades de Cuidado Intensivo

El dolor es un problema importante para los pacientes hospitalizados en las UCI porque genera malestar y distrés. Además, la investigación ha demostrado que en algunos pacientes críticos el dolor agudo puede persistir después de alta y convertirse en crónico. La gestión eficaz del dolor en pacientes críticos requiere un enfoque interdisciplinario, que incorpore la visión y trabajo de expertos que representan una amplia variedad de especialidades clínicas. Así, la utilización de la intervención psicológica en el tratamiento del dolor es una parte integral de un enfoque global. Basado en una revisión de la evidencia científica, se identifican y señalan: (1) los tipos de dolor más comunes; (2) las características del dolor; (3) las patologías más frecuentes asociadas con la presencia de dolor; (4) los procedimientos que generan dolor en la UCI; (5) los métodos de evaluación del dolor; (6) la intervención del mismo y; (7) la contribución del psicólogo en la evaluación y manejo del dolor con el paciente, los familiares y los profesionales de la salud. La revisión realizada indica que los procesos psicológicos influyen tanto en la experiencia del dolor como en los resultados del tratamiento, por lo tanto la integración de los principios psicológicos en el tratamiento del dolor parecen tener potencial mejora de los resultados beneficiando la salud del paciente.

Neuropsicología del trauma craneoencefálico en Cali, Colombia

Objetivo: realizar un análisis comparativo entre un grupo control y pacientes con trauma craneoencefálico, TCE, para determinar si existen diferencias neuropsicológicas a los seis meses de evolución y así orientar programas de intervención acordes con las necesidades de esta población. Materiales y métodos: se evaluó un total de setenta y nueve pacientes con antecedente de TCE con mínimo de seis meses de evolución y setenta y nueve sujetos en grupo control, el cual presentó una escolaridad promedio de once años frente a nueve años del grupo de TCE; ambos grupos con una media de treinta y cuatro años de edad, sin antecedentes neurológicos y/o psiquiátricos. La media del Glasgow en el grupo de TCE se ubicó en un rango moderado con una puntuación de once. Se aplicó la evaluación neuropsicológica breve en español Neuropsi a los dos grupos. Resultados: los grupos muestran diferencias significativas (p≤0,05) en las tareas de orientación, atención, memoria, lenguaje, lectura y escritura. Conclusiones: el TCE deja secuelas neuropsicológicas significativas, aún seis meses después de ocurrido el evento traumático. Estos hallazgos sugieren que los pacientes con TCE requieren de tratamiento después de superar la etapa inicial.