Traumatic Brain Injury

What are the long-term clinical effects of wartime traumatic brain injuries (TBIs)? Most are mild, but in general all are incompletely described, say researchers from University of Washington in Seattle and Washington University in St. Louis, Missouri. However, their own study found that service members with even mild concussive TBI often “experienced evolution, not resolution” of symptoms.

The researchers compared the results of 1-year and 5-year clinical evaluations of 50 active-duty U.S. military with acute to subacute concussive blast injury and 44 deployed but uninjured service members. The evaluations included neurobehavioral and neuropsychological performance and mental health burden.

At 5 years, global disability, satisfaction with life, neurobehavioral symptom severity, psychiatric symptom severity, and sleep impairment were significantly worse in patients with concussive blast TBI. Of the patients with concussive blast TBI, 36 (72%) showed decline, compared with only 5 of the combat-deployed group (11%). The researchers also found symptoms of PTSD and depression worsened in the concussive TBI patients. Performance on cognitive measures was no different between the 2 groups. A combination of factors, including neurobehavioral symptom severity, walking ability, and verbal fluency at 1 year after injury, was highly predictive of poor outcomes 5 years later.

“This is one of the first studies to connect the dots from injury to longer term outcomes and it shows that even mild concussions can lead to long-term impairment and continued decline in satisfaction with life,” said lead author Christine L. Mac Donald, PhD. “Most physicians believe that patients will stabilize 6 to 12 months postinjury, but this study challenges that.”

The researchers also found that, although 80% of service members with concussions had sought mental health treatment, only 19% reported that those programs were helpful. The findings advocate for new treatment strategies, the researchers say, to “combat the long-term and extremely costly effect” of these wartime injuries.

What are the long-term clinical effects of wartime traumatic brain injuries (TBIs)? Most are mild, but in general all are incompletely described, say researchers from University of Washington in Seattle and Washington University in St. Louis, Missouri. However, their own study found that service members with even mild concussive TBI often “experienced evolution, not resolution” of symptoms.

The researchers compared the results of 1-year and 5-year clinical evaluations of 50 active-duty U.S. military with acute to subacute concussive blast injury and 44 deployed but uninjured service members. The evaluations included neurobehavioral and neuropsychological performance and mental health burden.

At 5 years, global disability, satisfaction with life, neurobehavioral symptom severity, psychiatric symptom severity, and sleep impairment were significantly worse in patients with concussive blast TBI. Of the patients with concussive blast TBI, 36 (72%) showed decline, compared with only 5 of the combat-deployed group (11%). The researchers also found symptoms of PTSD and depression worsened in the concussive TBI patients. Performance on cognitive measures was no different between the 2 groups. A combination of factors, including neurobehavioral symptom severity, walking ability, and verbal fluency at 1 year after injury, was highly predictive of poor outcomes 5 years later.

“This is one of the first studies to connect the dots from injury to longer term outcomes and it shows that even mild concussions can lead to long-term impairment and continued decline in satisfaction with life,” said lead author Christine L. Mac Donald, PhD. “Most physicians believe that patients will stabilize 6 to 12 months postinjury, but this study challenges that.”

The researchers also found that, although 80% of service members with concussions had sought mental health treatment, only 19% reported that those programs were helpful. The findings advocate for new treatment strategies, the researchers say, to “combat the long-term and extremely costly effect” of these wartime injuries.

What are the long-term clinical effects of wartime traumatic brain injuries (TBIs)? Most are mild, but in general all are incompletely described, say researchers from University of Washington in Seattle and Washington University in St. Louis, Missouri. However, their own study found that service members with even mild concussive TBI often “experienced evolution, not resolution” of symptoms.

The researchers compared the results of 1-year and 5-year clinical evaluations of 50 active-duty U.S. military with acute to subacute concussive blast injury and 44 deployed but uninjured service members. The evaluations included neurobehavioral and neuropsychological performance and mental health burden.

At 5 years, global disability, satisfaction with life, neurobehavioral symptom severity, psychiatric symptom severity, and sleep impairment were significantly worse in patients with concussive blast TBI. Of the patients with concussive blast TBI, 36 (72%) showed decline, compared with only 5 of the combat-deployed group (11%). The researchers also found symptoms of PTSD and depression worsened in the concussive TBI patients. Performance on cognitive measures was no different between the 2 groups. A combination of factors, including neurobehavioral symptom severity, walking ability, and verbal fluency at 1 year after injury, was highly predictive of poor outcomes 5 years later.

“This is one of the first studies to connect the dots from injury to longer term outcomes and it shows that even mild concussions can lead to long-term impairment and continued decline in satisfaction with life,” said lead author Christine L. Mac Donald, PhD. “Most physicians believe that patients will stabilize 6 to 12 months postinjury, but this study challenges that.”

The researchers also found that, although 80% of service members with concussions had sought mental health treatment, only 19% reported that those programs were helpful. The findings advocate for new treatment strategies, the researchers say, to “combat the long-term and extremely costly effect” of these wartime injuries.

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BOSTON—Women athletes are 50% more likely to have a sports-related concussion than male athletes, according to research presented at the 69th Annual Meeting of the American Academy of Neurology.

“The findings from this study highlight the need for more research on the gender differences in concussion,” said James Noble, MD, Assistant Professor of Clinical Neurology at Columbia University in New York.

Little is known about the occurrence, severity, and recovery of sports-related concussion, especially among female athletes, since previous studies typically focused on male athletes. Gender-balanced studies have been limited by small sample size, incomplete or variable follow-up, or referral bias to tertiary concussion care centers. As a result, Dr. Noble and colleagues sought to determine gender differences in the incidence, symptomatology, neuropsychologic testing, and return-to-play length of sports-related concussion in collegiate varsity athletes.

For the study, Dr. Noble and colleagues followed 1,203 athletes at Columbia University from 2000 to 2014. In all, 822 of the participants were men, and 381 participants were women. All participants played sports such as soccer, basketball, and football.

Researchers assessed participants’ thinking skills and processing speed before and after a concussion. In addition, investigators tracked symptoms and when participants returned to play after a concussion.

A total of 228 athletes had at least one concussion, including 23% of the women (n = 88) and 17% of the men (n = 140). In addition, women who played soccer and basketball were more likely to have a concussion than their male counterparts. Finally, athletes who had had a previous concussion were three times more likely to have another concussion, compared with athletes who had never had a concussion.

The investigators also noted that women recovered from concussion about as quickly as men. Both men and women had a median return-to-play time of 10 days. Concussion symptoms were similar for men and women, although amnesia occurred more frequently in men (44% vs 31%), and insomnia occurred more frequently in women (42% vs 29%).

BOSTON—Women athletes are 50% more likely to have a sports-related concussion than male athletes, according to research presented at the 69th Annual Meeting of the American Academy of Neurology.

“The findings from this study highlight the need for more research on the gender differences in concussion,” said James Noble, MD, Assistant Professor of Clinical Neurology at Columbia University in New York.

Little is known about the occurrence, severity, and recovery of sports-related concussion, especially among female athletes, since previous studies typically focused on male athletes. Gender-balanced studies have been limited by small sample size, incomplete or variable follow-up, or referral bias to tertiary concussion care centers. As a result, Dr. Noble and colleagues sought to determine gender differences in the incidence, symptomatology, neuropsychologic testing, and return-to-play length of sports-related concussion in collegiate varsity athletes.

For the study, Dr. Noble and colleagues followed 1,203 athletes at Columbia University from 2000 to 2014. In all, 822 of the participants were men, and 381 participants were women. All participants played sports such as soccer, basketball, and football.

Researchers assessed participants’ thinking skills and processing speed before and after a concussion. In addition, investigators tracked symptoms and when participants returned to play after a concussion.

A total of 228 athletes had at least one concussion, including 23% of the women (n = 88) and 17% of the men (n = 140). In addition, women who played soccer and basketball were more likely to have a concussion than their male counterparts. Finally, athletes who had had a previous concussion were three times more likely to have another concussion, compared with athletes who had never had a concussion.

The investigators also noted that women recovered from concussion about as quickly as men. Both men and women had a median return-to-play time of 10 days. Concussion symptoms were similar for men and women, although amnesia occurred more frequently in men (44% vs 31%), and insomnia occurred more frequently in women (42% vs 29%).

BOSTON—Women athletes are 50% more likely to have a sports-related concussion than male athletes, according to research presented at the 69th Annual Meeting of the American Academy of Neurology.

“The findings from this study highlight the need for more research on the gender differences in concussion,” said James Noble, MD, Assistant Professor of Clinical Neurology at Columbia University in New York.

Little is known about the occurrence, severity, and recovery of sports-related concussion, especially among female athletes, since previous studies typically focused on male athletes. Gender-balanced studies have been limited by small sample size, incomplete or variable follow-up, or referral bias to tertiary concussion care centers. As a result, Dr. Noble and colleagues sought to determine gender differences in the incidence, symptomatology, neuropsychologic testing, and return-to-play length of sports-related concussion in collegiate varsity athletes.

For the study, Dr. Noble and colleagues followed 1,203 athletes at Columbia University from 2000 to 2014. In all, 822 of the participants were men, and 381 participants were women. All participants played sports such as soccer, basketball, and football.

Researchers assessed participants’ thinking skills and processing speed before and after a concussion. In addition, investigators tracked symptoms and when participants returned to play after a concussion.

A total of 228 athletes had at least one concussion, including 23% of the women (n = 88) and 17% of the men (n = 140). In addition, women who played soccer and basketball were more likely to have a concussion than their male counterparts. Finally, athletes who had had a previous concussion were three times more likely to have another concussion, compared with athletes who had never had a concussion.

The investigators also noted that women recovered from concussion about as quickly as men. Both men and women had a median return-to-play time of 10 days. Concussion symptoms were similar for men and women, although amnesia occurred more frequently in men (44% vs 31%), and insomnia occurred more frequently in women (42% vs 29%).

BOSTON—Proposed diagnostic criteria for probable or possible chronic traumatic encephalopathy (CTE), a progressive neurodegenerative disease associated with repetitive brain trauma, include a history of head impacts and various core clinical and supportive features.

The preliminary criteria, which were presented by Andrew Budson, MD, Professor of Neurology at Boston University School of Medicine, at the 69th Annual Meeting of the American Academy of Neurology, primarily were designed for research purposes, but can serve as a guide for neurologists for the diagnosis of traumatic encephalopathy syndrome. CTE is a neuropathologic diagnosis, whereas traumatic encephalopathy syndrome is a clinical diagnosis. In addition to presenting the general criteria, Dr. Budson shared diagnostic subtypes, potential biomarkers, and treatment options.

General Criteria

There are five general criteria that patients must meet to receive a diagnosis of traumatic encephalopathy syndrome, said Dr. Budson. First, there must be a history of impacts to the head based on types of injuries (eg, mild or severe traumatic brain injury, concussions, or subconcussive trauma) and sources of exposure, such as military service or involvement in contact sports for a minimum of six years, including at least two years at the college level or higher.

Second, patients must not have another neurologic disorder that likely accounts for the clinical features. Third, clinical features must be present for at least 12 months. The fourth requirement is that at least one core clinical feature (ie, cognitive, behavioral, or mood features) must be present and considered a change from baseline. Finally, at least two of nine supportive features must be present.

Core Clinical and Supportive Features

Of the core clinical features, difficulties in cognition must be reported by the patient, an informant, or a clinician and substantiated by standardized tests. Core behavioral clinical features include emotionally explosive behavior or physical and verbal abuse. Core mood clinical features include feeling overly sad, depressed, or hopeless.

In addition to core clinical features, two of the following supportive features must be present: impulsivity, anxiety, apathy, paranoia, suicidality, headache, motor signs (eg, dysarthria, dysgraphia, or other features of parkinsonism), documented decline for at least a year, or delayed onset of clinical features after a significant head impact exposure (usually at least two years).

Syndrome Subtypes

Patients may have one of four possible traumatic encephalopathy syndrome diagnostic subtypes. A behavioral/mood variant is more common among younger patients, whereas a cognitive variant is more common in older populations, said Dr. Budson. Patients also may have a mixed variant or dementia. Patients with the dementia subtype must have a progressive course of cognitive core clinical features, with or without behavior or mood features. In addition, patients with dementia must have cognitive impairment that interferes with their ability to function independently during normal daily activities.

Biomarkers and Treatment

Cavum septum pellucidum, cavum vergae, or fenestrations on neuroimaging are potential CTE biomarkers, said Dr. Budson. Normal beta amyloid CSF levels, elevated CSF p-tau/tau ratio, negative amyloid imaging, as well as cortical atrophy beyond that expected for age could also be signs of CTE. Potential experimental biomarkers include positive tau imaging and cortical thinning based on MRI.

Once physicians have made a diagnosis of probable or possible CTE, there are several treatments that may benefit patients, although no medications are approved for the treatment of CTE. Cholinesterase inhibitors may help to treat memory impairment, said Dr. Budson. For patients with depression and anxiety, selective serotonin reuptake inhibitors may be helpful. For patients with violent or explosive behavior, atypical neuroleptics may be efficacious. Memantine may benefit patients with moderate or severe dementia. Finally, to manage agitation, a combination of dextromethorphan and quinidine may be a treatment option. 

—Erica Tricarico

Suggested Reading

Montenigro PH, Baugh CM, Daneshvar DH, et al. Clinical subtypes of chronic traumatic encephalopathy: literature review and proposed research diagnostic criteria for traumatic encephalopathy syndrome. Alzheimers Res Ther. 2014;6(5):68.

BOSTON—Proposed diagnostic criteria for probable or possible chronic traumatic encephalopathy (CTE), a progressive neurodegenerative disease associated with repetitive brain trauma, include a history of head impacts and various core clinical and supportive features.

The preliminary criteria, which were presented by Andrew Budson, MD, Professor of Neurology at Boston University School of Medicine, at the 69th Annual Meeting of the American Academy of Neurology, primarily were designed for research purposes, but can serve as a guide for neurologists for the diagnosis of traumatic encephalopathy syndrome. CTE is a neuropathologic diagnosis, whereas traumatic encephalopathy syndrome is a clinical diagnosis. In addition to presenting the general criteria, Dr. Budson shared diagnostic subtypes, potential biomarkers, and treatment options.

General Criteria

There are five general criteria that patients must meet to receive a diagnosis of traumatic encephalopathy syndrome, said Dr. Budson. First, there must be a history of impacts to the head based on types of injuries (eg, mild or severe traumatic brain injury, concussions, or subconcussive trauma) and sources of exposure, such as military service or involvement in contact sports for a minimum of six years, including at least two years at the college level or higher.

Second, patients must not have another neurologic disorder that likely accounts for the clinical features. Third, clinical features must be present for at least 12 months. The fourth requirement is that at least one core clinical feature (ie, cognitive, behavioral, or mood features) must be present and considered a change from baseline. Finally, at least two of nine supportive features must be present.

Core Clinical and Supportive Features

Of the core clinical features, difficulties in cognition must be reported by the patient, an informant, or a clinician and substantiated by standardized tests. Core behavioral clinical features include emotionally explosive behavior or physical and verbal abuse. Core mood clinical features include feeling overly sad, depressed, or hopeless.

In addition to core clinical features, two of the following supportive features must be present: impulsivity, anxiety, apathy, paranoia, suicidality, headache, motor signs (eg, dysarthria, dysgraphia, or other features of parkinsonism), documented decline for at least a year, or delayed onset of clinical features after a significant head impact exposure (usually at least two years).

Syndrome Subtypes

Patients may have one of four possible traumatic encephalopathy syndrome diagnostic subtypes. A behavioral/mood variant is more common among younger patients, whereas a cognitive variant is more common in older populations, said Dr. Budson. Patients also may have a mixed variant or dementia. Patients with the dementia subtype must have a progressive course of cognitive core clinical features, with or without behavior or mood features. In addition, patients with dementia must have cognitive impairment that interferes with their ability to function independently during normal daily activities.

Biomarkers and Treatment

Cavum septum pellucidum, cavum vergae, or fenestrations on neuroimaging are potential CTE biomarkers, said Dr. Budson. Normal beta amyloid CSF levels, elevated CSF p-tau/tau ratio, negative amyloid imaging, as well as cortical atrophy beyond that expected for age could also be signs of CTE. Potential experimental biomarkers include positive tau imaging and cortical thinning based on MRI.

Once physicians have made a diagnosis of probable or possible CTE, there are several treatments that may benefit patients, although no medications are approved for the treatment of CTE. Cholinesterase inhibitors may help to treat memory impairment, said Dr. Budson. For patients with depression and anxiety, selective serotonin reuptake inhibitors may be helpful. For patients with violent or explosive behavior, atypical neuroleptics may be efficacious. Memantine may benefit patients with moderate or severe dementia. Finally, to manage agitation, a combination of dextromethorphan and quinidine may be a treatment option. 

—Erica Tricarico

Suggested Reading

Montenigro PH, Baugh CM, Daneshvar DH, et al. Clinical subtypes of chronic traumatic encephalopathy: literature review and proposed research diagnostic criteria for traumatic encephalopathy syndrome. Alzheimers Res Ther. 2014;6(5):68.

BOSTON—Proposed diagnostic criteria for probable or possible chronic traumatic encephalopathy (CTE), a progressive neurodegenerative disease associated with repetitive brain trauma, include a history of head impacts and various core clinical and supportive features.

The preliminary criteria, which were presented by Andrew Budson, MD, Professor of Neurology at Boston University School of Medicine, at the 69th Annual Meeting of the American Academy of Neurology, primarily were designed for research purposes, but can serve as a guide for neurologists for the diagnosis of traumatic encephalopathy syndrome. CTE is a neuropathologic diagnosis, whereas traumatic encephalopathy syndrome is a clinical diagnosis. In addition to presenting the general criteria, Dr. Budson shared diagnostic subtypes, potential biomarkers, and treatment options.

General Criteria

There are five general criteria that patients must meet to receive a diagnosis of traumatic encephalopathy syndrome, said Dr. Budson. First, there must be a history of impacts to the head based on types of injuries (eg, mild or severe traumatic brain injury, concussions, or subconcussive trauma) and sources of exposure, such as military service or involvement in contact sports for a minimum of six years, including at least two years at the college level or higher.

Second, patients must not have another neurologic disorder that likely accounts for the clinical features. Third, clinical features must be present for at least 12 months. The fourth requirement is that at least one core clinical feature (ie, cognitive, behavioral, or mood features) must be present and considered a change from baseline. Finally, at least two of nine supportive features must be present.

Core Clinical and Supportive Features

Of the core clinical features, difficulties in cognition must be reported by the patient, an informant, or a clinician and substantiated by standardized tests. Core behavioral clinical features include emotionally explosive behavior or physical and verbal abuse. Core mood clinical features include feeling overly sad, depressed, or hopeless.

In addition to core clinical features, two of the following supportive features must be present: impulsivity, anxiety, apathy, paranoia, suicidality, headache, motor signs (eg, dysarthria, dysgraphia, or other features of parkinsonism), documented decline for at least a year, or delayed onset of clinical features after a significant head impact exposure (usually at least two years).

Syndrome Subtypes

Patients may have one of four possible traumatic encephalopathy syndrome diagnostic subtypes. A behavioral/mood variant is more common among younger patients, whereas a cognitive variant is more common in older populations, said Dr. Budson. Patients also may have a mixed variant or dementia. Patients with the dementia subtype must have a progressive course of cognitive core clinical features, with or without behavior or mood features. In addition, patients with dementia must have cognitive impairment that interferes with their ability to function independently during normal daily activities.

Biomarkers and Treatment

Cavum septum pellucidum, cavum vergae, or fenestrations on neuroimaging are potential CTE biomarkers, said Dr. Budson. Normal beta amyloid CSF levels, elevated CSF p-tau/tau ratio, negative amyloid imaging, as well as cortical atrophy beyond that expected for age could also be signs of CTE. Potential experimental biomarkers include positive tau imaging and cortical thinning based on MRI.

Once physicians have made a diagnosis of probable or possible CTE, there are several treatments that may benefit patients, although no medications are approved for the treatment of CTE. Cholinesterase inhibitors may help to treat memory impairment, said Dr. Budson. For patients with depression and anxiety, selective serotonin reuptake inhibitors may be helpful. For patients with violent or explosive behavior, atypical neuroleptics may be efficacious. Memantine may benefit patients with moderate or severe dementia. Finally, to manage agitation, a combination of dextromethorphan and quinidine may be a treatment option. 

—Erica Tricarico

Suggested Reading

Montenigro PH, Baugh CM, Daneshvar DH, et al. Clinical subtypes of chronic traumatic encephalopathy: literature review and proposed research diagnostic criteria for traumatic encephalopathy syndrome. Alzheimers Res Ther. 2014;6(5):68.

Nearly 3 million emergency department (ED) visits, hospitalizations, and deaths were related to traumatic brain injury (TBI) in 2013, according to researchers from the National Center for Injury Prevention and Control. The age-adjusted rate of ED visits was higher in 2013 than in 2007 (787.1 vs 534.4), a change driven largely by people aged ≥ 75 years, who accounted for 18% of the increase in the number of TBI-related ED visits.

Related: Ideas for Helping TBI Patients

The most common mechanisms of injury in the study were falls, being struck by or against an object, and motor-vehicle crashes. Particular age groups were disproportionately affected by specific mechanisms. The researchers say about half of all fall-related TBI visits/hospitalizations/deaths were among babies, toddlers, and adults aged > 75 years.

Those data suggest an urgent need for more and stronger fall-prevention efforts, say the researchers. In older adults, TBIs are more likely to lead to hospitalizations that can be complicated by comorbidities. Moreover, the researchers say, older adults are more likely to use anticoagulants, which can increase the likelihood of intracranial hemorrhage.

Related: Making Fall Prevention “Routine”

Prevention strategies that have proved effective in randomized controlled trials include multicomponent exercise programs, tai chi, vitamin D supplements, cataract surgery, and making the home environment safer. The CDC also has developed the Stopping Elderly Accidents Deaths and Injuries (STEADI) program, which incorporates empirically supported clinical guidelines and scientifically tested interventions to help primary care providers address fall risk and use effective interventions.

Nearly 3 million emergency department (ED) visits, hospitalizations, and deaths were related to traumatic brain injury (TBI) in 2013, according to researchers from the National Center for Injury Prevention and Control. The age-adjusted rate of ED visits was higher in 2013 than in 2007 (787.1 vs 534.4), a change driven largely by people aged ≥ 75 years, who accounted for 18% of the increase in the number of TBI-related ED visits.

Related: Ideas for Helping TBI Patients

The most common mechanisms of injury in the study were falls, being struck by or against an object, and motor-vehicle crashes. Particular age groups were disproportionately affected by specific mechanisms. The researchers say about half of all fall-related TBI visits/hospitalizations/deaths were among babies, toddlers, and adults aged > 75 years.

Those data suggest an urgent need for more and stronger fall-prevention efforts, say the researchers. In older adults, TBIs are more likely to lead to hospitalizations that can be complicated by comorbidities. Moreover, the researchers say, older adults are more likely to use anticoagulants, which can increase the likelihood of intracranial hemorrhage.

Related: Making Fall Prevention “Routine”

Prevention strategies that have proved effective in randomized controlled trials include multicomponent exercise programs, tai chi, vitamin D supplements, cataract surgery, and making the home environment safer. The CDC also has developed the Stopping Elderly Accidents Deaths and Injuries (STEADI) program, which incorporates empirically supported clinical guidelines and scientifically tested interventions to help primary care providers address fall risk and use effective interventions.

Nearly 3 million emergency department (ED) visits, hospitalizations, and deaths were related to traumatic brain injury (TBI) in 2013, according to researchers from the National Center for Injury Prevention and Control. The age-adjusted rate of ED visits was higher in 2013 than in 2007 (787.1 vs 534.4), a change driven largely by people aged ≥ 75 years, who accounted for 18% of the increase in the number of TBI-related ED visits.

Related: Ideas for Helping TBI Patients

The most common mechanisms of injury in the study were falls, being struck by or against an object, and motor-vehicle crashes. Particular age groups were disproportionately affected by specific mechanisms. The researchers say about half of all fall-related TBI visits/hospitalizations/deaths were among babies, toddlers, and adults aged > 75 years.

Those data suggest an urgent need for more and stronger fall-prevention efforts, say the researchers. In older adults, TBIs are more likely to lead to hospitalizations that can be complicated by comorbidities. Moreover, the researchers say, older adults are more likely to use anticoagulants, which can increase the likelihood of intracranial hemorrhage.

Related: Making Fall Prevention “Routine”

Prevention strategies that have proved effective in randomized controlled trials include multicomponent exercise programs, tai chi, vitamin D supplements, cataract surgery, and making the home environment safer. The CDC also has developed the Stopping Elderly Accidents Deaths and Injuries (STEADI) program, which incorporates empirically supported clinical guidelines and scientifically tested interventions to help primary care providers address fall risk and use effective interventions.

OJAI, CA—Soldiers with posttraumatic headaches are “complicated patients,” said Alan G. Finkel, MD, Director of the Carolina Headache Institute in Chapel Hill, North Carolina. No drugs are approved for the treatment of posttraumatic complications, and persistent posttraumatic headaches may interfere with return to military service.

Characteristics of posttraumatic headaches—such as whether they are continuous, nummular, or holocephalic—may provide prognostic clues and suggest possible therapies, Dr. Finkel said at the 10th Annual Winter Conference of the Headache Cooperative of the Pacific. In addition, neurologists can address sleep, mood, and concussion symptoms when managing patients with posttraumatic headache.

Occupational Outcomes

Posttraumatic headaches most commonly are classified as migraine. Other classifications include tension-type headache and trigeminal autonomic cephalalgia. A patient may report multiple types of headache. Dr. Finkel and his research colleagues hypothesized that among patients with posttraumatic headache, the headache diagnosis may not be sufficient to predict occupational outcomes and that other headache characteristics might be more important.

To assess associations between headache characteristics and the outcome of leaving military service for medical reasons, Dr. Finkel and colleagues analyzed data from a retrospective cohort study. The cohort included 95 patients who were referred for headache evaluation at the Brain Injury Center at Womack Army Medical Center, Fort Bragg, North Carolina, between August 2008 and December 2009. The study was published online ahead of print February 27 in Headache.

About 14% of the patients had a history of headache, and about 40% had a prior history of concussion. The most common injury cited was blast injury (53.7%).

People were able to report as many as three headaches (ie, one continuous and two noncontinuous). The 95 patients reported 166 headaches. About 75% of the patients reported a continuous headache. Approximately 72% of patients reported a headache of a migraine type. The most clinically important headache was migraine for 61% of patients, tension-type headache for 4%, and trigeminal autonomic cephalalgias, including hemicrania continua, for 24%.

“The presence of a continuous headache was very likely to predict leaving service, and the headache diagnosis or the presence of a migraine diagnosis did not,” Dr. Finkel said.

Patients with continuous headache were approximately four times more likely to leave military service, compared with patients without continuous headache. Prior history of regular headache also appeared to predict the probability of discharge. Among patients with prior history of headache, continuous holocephalic headache, as well as the tendency to medicate and stay active with the most clinically important headache (as opposed to lying down or continuing activities without medication), also increased the likelihood of severance.

The study’s limitations included its retrospective design, the possibility of recall bias, and the lack of controls, Dr. Finkel noted.

Assessment Tools

When evaluating patients, instruments such as the Neurobehavioral Symptom Inventory and concussion checklists can be useful. “Get some tested baselines that you can then compare longitudinally,” he said.

The Balance Error Scoring System and the King–Devick test can assess concussion symptoms. “While you are making an assessment for persistent posttraumatic headache, make some comments in your chart about … whether or not they have concussive symptoms,” Dr. Finkel said. Neurologists also can assess problems with emotions and mood, which may be treatable. A combination of dextromethorphan hydrobromide and quinidine sulfate is approved for the treatment of emotional incontinence, which is associated with traumatic brain injury. Dr. Finkel uses the Pain Catastrophizing Scale and Posttraumatic Stress Disorder (PTSD) Checklist to evaluate pain-related anxiety. Neurologists also can ask patients about sleep, which may play an important role in patients’ recovery.

Treatment Options

In a clinic-based sample of 100 soldiers with chronic posttraumatic headache after mild head trauma, topiramate appeared to be an effective prophylactic.

Investigators plan to conduct a placebo-controlled trial of prazosin in patients with chronic postconcussive headache. Prazosin, an alpha one antagonist, may be prescribed to improve sleep and reduce nightmares. It may be a treatment option if a patient with chronic headache is hypervigilant and has insomnia, said Dr. Finkel. When prescribing prazosin, it is important to tell patients about the risk of fainting on the first night after taking the drug.

Defense Recommendation

The Department of Defense in February 2016 published a clinical recommendation for the primary care management of headache following concussion or mild traumatic brain injury. The recommendation describes red flags, establishes four categories into which symptoms might fall (ie, migraine, tension-type, cervicogenic, and neuropathic), and provides treatment guidance for each headache category.

If therapy alleviates holocephalic headaches, but focal pain persists, neurologists can try injecting onabotulinum toxin to treat the focal pain, Dr. Finkel said. In a case series of 64 patients with concussion-related headaches who were treated with onabotulinum toxin, 64% reported feeling better. The presence of PTSD did not appear to affect treatment outcomes, Dr. Finkel said.

Exercise and Expectation

Cardinal symptoms of concussion, including headache and PTSD, can improve with exercise, Dr. Finkel said. Evaluating patients on a treadmill can determine whether postconcussive symptoms recur at elevated heart rates. Patients can progressively increase the intensity of exercise until they are ready to resume activity.

When posttraumatic headache persists, neurologists should consider patients’ expectations. Research suggests that the language used to convey a diagnosis (eg, mild head injury, mild traumatic brain injury, or concussion) can affect what symptoms people anticipate. And patients’ perceptions of the illness may play a role in the persistence of postconcussion symptoms. Telling patients that they have a traumatic brain injury or expressing uncertainty about the diagnosis or prognosis is doing them a disservice, he said. “Tell them they are going to get better,” Dr. Finkel said.

—Jake Remaly

Suggested Reading

Erickson JC. Treatment outcomes of chronic post-traumatic headaches after mild head trauma in US soldiers: an observational study. Headache. 2011;51(6):932-944.

Finkel AG, Ivins BJ, Yerry JA, et al. Which matters more? A retrospective cohort study of headache characteristics and diagnosis type in soldiers with mTBI/concussion. Headache. 2017 Feb 27 [Epub ahead of print].

Finkel AG, Yerry JA, Klaric JS, et al. Headache in military service members with a history of mild traumatic brain injury: A cohort study of diagnosis and classification. Cephalalgia. 2016 May 20 [Epub ahead of print].

Whittaker R, Kemp S, House A. Illness perceptions and outcome in mild head injury: a longitudinal study. J Neurol Neurosurg Psychiatry. 2007;78(6):644-646.

Yerry JA, Kuehn D, Finkel AG. Onabotulinum toxin A for the treatment of headache in service members with a history of mild traumatic brain injury: a cohort study. Headache. 2015;55(3):395-406.

OJAI, CA—Soldiers with posttraumatic headaches are “complicated patients,” said Alan G. Finkel, MD, Director of the Carolina Headache Institute in Chapel Hill, North Carolina. No drugs are approved for the treatment of posttraumatic complications, and persistent posttraumatic headaches may interfere with return to military service.

Characteristics of posttraumatic headaches—such as whether they are continuous, nummular, or holocephalic—may provide prognostic clues and suggest possible therapies, Dr. Finkel said at the 10th Annual Winter Conference of the Headache Cooperative of the Pacific. In addition, neurologists can address sleep, mood, and concussion symptoms when managing patients with posttraumatic headache.

Occupational Outcomes

Posttraumatic headaches most commonly are classified as migraine. Other classifications include tension-type headache and trigeminal autonomic cephalalgia. A patient may report multiple types of headache. Dr. Finkel and his research colleagues hypothesized that among patients with posttraumatic headache, the headache diagnosis may not be sufficient to predict occupational outcomes and that other headache characteristics might be more important.

To assess associations between headache characteristics and the outcome of leaving military service for medical reasons, Dr. Finkel and colleagues analyzed data from a retrospective cohort study. The cohort included 95 patients who were referred for headache evaluation at the Brain Injury Center at Womack Army Medical Center, Fort Bragg, North Carolina, between August 2008 and December 2009. The study was published online ahead of print February 27 in Headache.

About 14% of the patients had a history of headache, and about 40% had a prior history of concussion. The most common injury cited was blast injury (53.7%).

People were able to report as many as three headaches (ie, one continuous and two noncontinuous). The 95 patients reported 166 headaches. About 75% of the patients reported a continuous headache. Approximately 72% of patients reported a headache of a migraine type. The most clinically important headache was migraine for 61% of patients, tension-type headache for 4%, and trigeminal autonomic cephalalgias, including hemicrania continua, for 24%.

“The presence of a continuous headache was very likely to predict leaving service, and the headache diagnosis or the presence of a migraine diagnosis did not,” Dr. Finkel said.

Patients with continuous headache were approximately four times more likely to leave military service, compared with patients without continuous headache. Prior history of regular headache also appeared to predict the probability of discharge. Among patients with prior history of headache, continuous holocephalic headache, as well as the tendency to medicate and stay active with the most clinically important headache (as opposed to lying down or continuing activities without medication), also increased the likelihood of severance.

The study’s limitations included its retrospective design, the possibility of recall bias, and the lack of controls, Dr. Finkel noted.

Assessment Tools

When evaluating patients, instruments such as the Neurobehavioral Symptom Inventory and concussion checklists can be useful. “Get some tested baselines that you can then compare longitudinally,” he said.

The Balance Error Scoring System and the King–Devick test can assess concussion symptoms. “While you are making an assessment for persistent posttraumatic headache, make some comments in your chart about … whether or not they have concussive symptoms,” Dr. Finkel said. Neurologists also can assess problems with emotions and mood, which may be treatable. A combination of dextromethorphan hydrobromide and quinidine sulfate is approved for the treatment of emotional incontinence, which is associated with traumatic brain injury. Dr. Finkel uses the Pain Catastrophizing Scale and Posttraumatic Stress Disorder (PTSD) Checklist to evaluate pain-related anxiety. Neurologists also can ask patients about sleep, which may play an important role in patients’ recovery.

Treatment Options

In a clinic-based sample of 100 soldiers with chronic posttraumatic headache after mild head trauma, topiramate appeared to be an effective prophylactic.

Investigators plan to conduct a placebo-controlled trial of prazosin in patients with chronic postconcussive headache. Prazosin, an alpha one antagonist, may be prescribed to improve sleep and reduce nightmares. It may be a treatment option if a patient with chronic headache is hypervigilant and has insomnia, said Dr. Finkel. When prescribing prazosin, it is important to tell patients about the risk of fainting on the first night after taking the drug.

Defense Recommendation

The Department of Defense in February 2016 published a clinical recommendation for the primary care management of headache following concussion or mild traumatic brain injury. The recommendation describes red flags, establishes four categories into which symptoms might fall (ie, migraine, tension-type, cervicogenic, and neuropathic), and provides treatment guidance for each headache category.

If therapy alleviates holocephalic headaches, but focal pain persists, neurologists can try injecting onabotulinum toxin to treat the focal pain, Dr. Finkel said. In a case series of 64 patients with concussion-related headaches who were treated with onabotulinum toxin, 64% reported feeling better. The presence of PTSD did not appear to affect treatment outcomes, Dr. Finkel said.

Exercise and Expectation

Cardinal symptoms of concussion, including headache and PTSD, can improve with exercise, Dr. Finkel said. Evaluating patients on a treadmill can determine whether postconcussive symptoms recur at elevated heart rates. Patients can progressively increase the intensity of exercise until they are ready to resume activity.

When posttraumatic headache persists, neurologists should consider patients’ expectations. Research suggests that the language used to convey a diagnosis (eg, mild head injury, mild traumatic brain injury, or concussion) can affect what symptoms people anticipate. And patients’ perceptions of the illness may play a role in the persistence of postconcussion symptoms. Telling patients that they have a traumatic brain injury or expressing uncertainty about the diagnosis or prognosis is doing them a disservice, he said. “Tell them they are going to get better,” Dr. Finkel said.

—Jake Remaly

Suggested Reading

Erickson JC. Treatment outcomes of chronic post-traumatic headaches after mild head trauma in US soldiers: an observational study. Headache. 2011;51(6):932-944.

Finkel AG, Ivins BJ, Yerry JA, et al. Which matters more? A retrospective cohort study of headache characteristics and diagnosis type in soldiers with mTBI/concussion. Headache. 2017 Feb 27 [Epub ahead of print].

Finkel AG, Yerry JA, Klaric JS, et al. Headache in military service members with a history of mild traumatic brain injury: A cohort study of diagnosis and classification. Cephalalgia. 2016 May 20 [Epub ahead of print].

Whittaker R, Kemp S, House A. Illness perceptions and outcome in mild head injury: a longitudinal study. J Neurol Neurosurg Psychiatry. 2007;78(6):644-646.

Yerry JA, Kuehn D, Finkel AG. Onabotulinum toxin A for the treatment of headache in service members with a history of mild traumatic brain injury: a cohort study. Headache. 2015;55(3):395-406.

OJAI, CA—Soldiers with posttraumatic headaches are “complicated patients,” said Alan G. Finkel, MD, Director of the Carolina Headache Institute in Chapel Hill, North Carolina. No drugs are approved for the treatment of posttraumatic complications, and persistent posttraumatic headaches may interfere with return to military service.

Characteristics of posttraumatic headaches—such as whether they are continuous, nummular, or holocephalic—may provide prognostic clues and suggest possible therapies, Dr. Finkel said at the 10th Annual Winter Conference of the Headache Cooperative of the Pacific. In addition, neurologists can address sleep, mood, and concussion symptoms when managing patients with posttraumatic headache.

Occupational Outcomes

Posttraumatic headaches most commonly are classified as migraine. Other classifications include tension-type headache and trigeminal autonomic cephalalgia. A patient may report multiple types of headache. Dr. Finkel and his research colleagues hypothesized that among patients with posttraumatic headache, the headache diagnosis may not be sufficient to predict occupational outcomes and that other headache characteristics might be more important.

To assess associations between headache characteristics and the outcome of leaving military service for medical reasons, Dr. Finkel and colleagues analyzed data from a retrospective cohort study. The cohort included 95 patients who were referred for headache evaluation at the Brain Injury Center at Womack Army Medical Center, Fort Bragg, North Carolina, between August 2008 and December 2009. The study was published online ahead of print February 27 in Headache.

About 14% of the patients had a history of headache, and about 40% had a prior history of concussion. The most common injury cited was blast injury (53.7%).

People were able to report as many as three headaches (ie, one continuous and two noncontinuous). The 95 patients reported 166 headaches. About 75% of the patients reported a continuous headache. Approximately 72% of patients reported a headache of a migraine type. The most clinically important headache was migraine for 61% of patients, tension-type headache for 4%, and trigeminal autonomic cephalalgias, including hemicrania continua, for 24%.

“The presence of a continuous headache was very likely to predict leaving service, and the headache diagnosis or the presence of a migraine diagnosis did not,” Dr. Finkel said.

Patients with continuous headache were approximately four times more likely to leave military service, compared with patients without continuous headache. Prior history of regular headache also appeared to predict the probability of discharge. Among patients with prior history of headache, continuous holocephalic headache, as well as the tendency to medicate and stay active with the most clinically important headache (as opposed to lying down or continuing activities without medication), also increased the likelihood of severance.

The study’s limitations included its retrospective design, the possibility of recall bias, and the lack of controls, Dr. Finkel noted.

Assessment Tools

When evaluating patients, instruments such as the Neurobehavioral Symptom Inventory and concussion checklists can be useful. “Get some tested baselines that you can then compare longitudinally,” he said.

The Balance Error Scoring System and the King–Devick test can assess concussion symptoms. “While you are making an assessment for persistent posttraumatic headache, make some comments in your chart about … whether or not they have concussive symptoms,” Dr. Finkel said. Neurologists also can assess problems with emotions and mood, which may be treatable. A combination of dextromethorphan hydrobromide and quinidine sulfate is approved for the treatment of emotional incontinence, which is associated with traumatic brain injury. Dr. Finkel uses the Pain Catastrophizing Scale and Posttraumatic Stress Disorder (PTSD) Checklist to evaluate pain-related anxiety. Neurologists also can ask patients about sleep, which may play an important role in patients’ recovery.

Treatment Options

In a clinic-based sample of 100 soldiers with chronic posttraumatic headache after mild head trauma, topiramate appeared to be an effective prophylactic.

Investigators plan to conduct a placebo-controlled trial of prazosin in patients with chronic postconcussive headache. Prazosin, an alpha one antagonist, may be prescribed to improve sleep and reduce nightmares. It may be a treatment option if a patient with chronic headache is hypervigilant and has insomnia, said Dr. Finkel. When prescribing prazosin, it is important to tell patients about the risk of fainting on the first night after taking the drug.

Defense Recommendation

The Department of Defense in February 2016 published a clinical recommendation for the primary care management of headache following concussion or mild traumatic brain injury. The recommendation describes red flags, establishes four categories into which symptoms might fall (ie, migraine, tension-type, cervicogenic, and neuropathic), and provides treatment guidance for each headache category.

If therapy alleviates holocephalic headaches, but focal pain persists, neurologists can try injecting onabotulinum toxin to treat the focal pain, Dr. Finkel said. In a case series of 64 patients with concussion-related headaches who were treated with onabotulinum toxin, 64% reported feeling better. The presence of PTSD did not appear to affect treatment outcomes, Dr. Finkel said.

Exercise and Expectation

Cardinal symptoms of concussion, including headache and PTSD, can improve with exercise, Dr. Finkel said. Evaluating patients on a treadmill can determine whether postconcussive symptoms recur at elevated heart rates. Patients can progressively increase the intensity of exercise until they are ready to resume activity.

When posttraumatic headache persists, neurologists should consider patients’ expectations. Research suggests that the language used to convey a diagnosis (eg, mild head injury, mild traumatic brain injury, or concussion) can affect what symptoms people anticipate. And patients’ perceptions of the illness may play a role in the persistence of postconcussion symptoms. Telling patients that they have a traumatic brain injury or expressing uncertainty about the diagnosis or prognosis is doing them a disservice, he said. “Tell them they are going to get better,” Dr. Finkel said.

—Jake Remaly

Suggested Reading

Erickson JC. Treatment outcomes of chronic post-traumatic headaches after mild head trauma in US soldiers: an observational study. Headache. 2011;51(6):932-944.

Finkel AG, Ivins BJ, Yerry JA, et al. Which matters more? A retrospective cohort study of headache characteristics and diagnosis type in soldiers with mTBI/concussion. Headache. 2017 Feb 27 [Epub ahead of print].

Finkel AG, Yerry JA, Klaric JS, et al. Headache in military service members with a history of mild traumatic brain injury: A cohort study of diagnosis and classification. Cephalalgia. 2016 May 20 [Epub ahead of print].

Whittaker R, Kemp S, House A. Illness perceptions and outcome in mild head injury: a longitudinal study. J Neurol Neurosurg Psychiatry. 2007;78(6):644-646.

Yerry JA, Kuehn D, Finkel AG. Onabotulinum toxin A for the treatment of headache in service members with a history of mild traumatic brain injury: a cohort study. Headache. 2015;55(3):395-406.

RIVIERA BEACH, FL—If a neurologist is at a sporting event during which a player sustains a head injury, audience members or officials may look to him or her for guidance, according to an overview delivered at the 44th Annual Meeting of the Southern Clinical Neurological Society. Understanding how to diagnose and manage concussion may be a vital skill for neurologists, regardless of specialty.

What Is Concussion?

Loss of consciousness previously was considered necessary for a diagnosis of concussion. Later, it was taken as a marker of serious injury. Neither of these principles is accepted any longer. Data indicate that at least 90% of concussions are not associated with loss of consciousness, and studies have not shown that loss of consciousness portends a worse prognosis or protracted recovery from the injury, said Dr. Kosa.

The pathophysiology of concussion is not certain. The current proposal is that concussion entails disruption of neuronal cell membranes resulting from disruption of normal ion channels (eg, calcium, potassium, and sodium), leading to a loss of normal neuronal homeostasis. This situation can cause a cascade of events, including mitochondrial dysfunction that causes neuronal energy failure, loss of normal glucose metabolism, activation of NMDA receptors from increased levels of glutamate, production of lactic acid, and generation of free radicals, all of which damage the neurons and supporting cells. Most cells survive the concussive injury, but can be functionally compromised. Severe injuries can lead to neuronal cell death.

What Are the Possible Sequelae of Concussion?

Concussion increases the risk of second impact syndrome, which can occur if the patient sustains another injury at between 24 hours and 10 days after a concussion. Research on second impact syndrome is limited, but the syndrome is understood to entail rapid and massive brain edema that leads to brain herniation and likely death or severe disability. The syndrome occurs within minutes of the second impact and is thought to be enabled by the period of vulnerability that follows an initial concussion. The syndrome occurs mostly in young patients, but has been described in boxers. For this reason, neurologists should be especially cautious when deciding whether to let a child with concussion return to play, said Dr. Kosa. The Centers for Disease Control and Prevention (CDC) estimate that second impact syndrome causes four to six deaths in patients under age 18 annually.

Concussion may be accompanied by traumatic brain injury (TBI). In 2010, the CDC reported 2.5 million hospital encounters related to TBI. Among these encounters, 87% of patients were treated in the emergency department and released, 11% were hospitalized and discharged, and 2% died. The highest incidence of TBI is in young children, and causes include sports accidents, bicycle accidents, skateboard accidents, vehicular accidents, and falls. The CDC estimates that between 3.2 million and 5.3 million people in the United States have permanent TBI-related disability, which results in great economic, physical, and emotional burdens.

Patients with repeated mild TBI may be at risk of chronic traumatic encephalopathy (CTE). This disorder has been described in football players, veterans, and boxers. Symptoms develop later in the patient’s life, and four stages have been described. The first stage includes headaches, inattention, and poor concentration. Stage two consists of significant mood disturbance with depression, along with explosive bouts of anger and short-term memory impairment. The third stage includes further cognitive or memory impairment that manifests as prominent executive dysfunction, where reasoning and organization or planning are most affected. In stage four, the patient has dementia; the cognitive and memory impairment has progressed to the point where the patient depends on others for activities of daily living.

McKee et al observed that CTE was associated with cerebral atrophy, mammillary body atrophy, dilation of the lateral ventricles, fenestrations of the septum pellucidum, and tau deposition. Researchers and clinicians, however, have not arrived at a consensus about the pathologic and clinical criteria for CTE. Furthermore, Cantu et al stated that it is not yet possible to determine the causality or risk factors of CTE with certainty. The hypothesis that repeated concussion or subconcussive impacts leads to the development of CTE has not been scientifically proven to date, they added.

What Should Be Done on the Field?

If a player at a sporting event sustains a head injury, he or she should be removed from play immediately and not allowed to return to the game. If he or she has not directly observed the injury, the neurologist should get information about it from witnesses. The neurologist should perform a focused physical examination, searching for evidence of decreased level of consciousness, confusion, focal weakness or incoordination, visual disturbance, cervical spine injury, or facial fractures. The Sport Concussion Assessment Tool (SCAT) can assist the clinician in concussion evaluation and treatment in a standardized and methodical way to determine whether and when a player can safely return to play.

A patient with an abnormal examination may need to be transferred to the local emergency department for further testing. CT imaging should not be performed automatically, because it may expose the patient to radiation unnecessarily. Two sets of criteria offer guidance about CT imaging. The New Orleans criteria state that a patient should undergo CT if he or she has a headache, has vomited, is older than 60, had been using alcohol or other drugs, had a seizure, has visible trauma above the clavicle, or has a short-term memory deficit. The Canadian CT Head Rule lists similar criteria, including a Glasgow Coma Scale score at two hours of less than 15, any sign of a basal skull fracture, and amnesia for events that took place 30 minutes before the injury.

Anticoagulants increase the risk of immediate or delayed hemorrhage after head injury. If a patient has intracranial hemorrhage on CT and has been using anticoagulants, the clinician should rapidly reverse the anticoagulant effect with the appropriate agent. A repeat head CT 24 hours later should be considered in those thought to be at high risk for intracranial hemorrhage and whose initial CT imaging is negative for bleed. “Err on the side of admitting these patients, at least for observation,” said Dr. Kosa. Before the patient is discharged from the emergency room, he or she should receive education about postconcussion symptoms that should prompt another visit to the emergency department. Educational materials are available on the CDC’s website.

When Can a Patient Return to Play?

The consensus statement on concussion in sport adopted at the Third International Conference on Concussion in Sport includes guidelines for graduated return to play. At first, the patient should undergo symptom-limited physical and cognitive rest until he or she recovers. Next, the patient may start light aerobic exercise such as walking, swimming, or cycling. The goal is to increase heart rate, but the patient should reduce activity if symptoms occur. Then, the patient may engage in sport-specific exercise. If recovery proceeds well, the patient may begin noncontact training drills and, later, full contact practice. Only when the patient has full confidence and coaching or training staff has assessed his or her functional skills can the athlete return to play.

What Concussion Research Is Under Way?

Investigations currently under way aim to improve understanding of concussion, as well as to aid diagnosis and treatment. Researchers are looking for a reliable biomarker of concussion that can be detected with an easy, cost-effective, and preferably noninvasive test. Saliva, tears, urine, blood, and CSF are among the candidate samples being studied. CSF is the most reliable fluid to test because of its proximity to the brain and its low susceptibility to extracerebral confounders, but it is the most invasive option. Groups are examining potential serum biomarkers such as S100b, neuron-specific enolase, myelin basic protein, glial fibrillary acidic protein, and cleaved tau.

In addition, McKee and colleagues are working to define clear pathologic criteria defining the various stages of CTE. They also are seeking a way of distinguishing CTE from Alzheimer’s disease, amyotrophic lateral sclerosis, and other neurodegenerative diseases in postmortem brain tissue. The group’s ultimate goal is to identify features that may assist in the diagnosis of CTE in living people using advanced neuroimaging.

—Erik Greb

Suggested Reading

Giza CC, Kutcher JS, Ashwal S, et al. Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013;80(24):2250-2257.

McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport--the 3rd International Conference on concussion in sport, held in Zurich, November 2008. J Clin Neurosci. 2009;16(6):755-763.

Omalu BI, Hamilton RL, Kamboh MI, et al. Chronic traumatic encephalopathy (CTE) in a National Football League Player: Case report and emerging medicolegal practice questions. J Forensic Nurs. 2010;6(1):40-46.

RIVIERA BEACH, FL—If a neurologist is at a sporting event during which a player sustains a head injury, audience members or officials may look to him or her for guidance, according to an overview delivered at the 44th Annual Meeting of the Southern Clinical Neurological Society. Understanding how to diagnose and manage concussion may be a vital skill for neurologists, regardless of specialty.

What Is Concussion?

Loss of consciousness previously was considered necessary for a diagnosis of concussion. Later, it was taken as a marker of serious injury. Neither of these principles is accepted any longer. Data indicate that at least 90% of concussions are not associated with loss of consciousness, and studies have not shown that loss of consciousness portends a worse prognosis or protracted recovery from the injury, said Dr. Kosa.

The pathophysiology of concussion is not certain. The current proposal is that concussion entails disruption of neuronal cell membranes resulting from disruption of normal ion channels (eg, calcium, potassium, and sodium), leading to a loss of normal neuronal homeostasis. This situation can cause a cascade of events, including mitochondrial dysfunction that causes neuronal energy failure, loss of normal glucose metabolism, activation of NMDA receptors from increased levels of glutamate, production of lactic acid, and generation of free radicals, all of which damage the neurons and supporting cells. Most cells survive the concussive injury, but can be functionally compromised. Severe injuries can lead to neuronal cell death.

What Are the Possible Sequelae of Concussion?

Concussion increases the risk of second impact syndrome, which can occur if the patient sustains another injury at between 24 hours and 10 days after a concussion. Research on second impact syndrome is limited, but the syndrome is understood to entail rapid and massive brain edema that leads to brain herniation and likely death or severe disability. The syndrome occurs within minutes of the second impact and is thought to be enabled by the period of vulnerability that follows an initial concussion. The syndrome occurs mostly in young patients, but has been described in boxers. For this reason, neurologists should be especially cautious when deciding whether to let a child with concussion return to play, said Dr. Kosa. The Centers for Disease Control and Prevention (CDC) estimate that second impact syndrome causes four to six deaths in patients under age 18 annually.

Concussion may be accompanied by traumatic brain injury (TBI). In 2010, the CDC reported 2.5 million hospital encounters related to TBI. Among these encounters, 87% of patients were treated in the emergency department and released, 11% were hospitalized and discharged, and 2% died. The highest incidence of TBI is in young children, and causes include sports accidents, bicycle accidents, skateboard accidents, vehicular accidents, and falls. The CDC estimates that between 3.2 million and 5.3 million people in the United States have permanent TBI-related disability, which results in great economic, physical, and emotional burdens.

Patients with repeated mild TBI may be at risk of chronic traumatic encephalopathy (CTE). This disorder has been described in football players, veterans, and boxers. Symptoms develop later in the patient’s life, and four stages have been described. The first stage includes headaches, inattention, and poor concentration. Stage two consists of significant mood disturbance with depression, along with explosive bouts of anger and short-term memory impairment. The third stage includes further cognitive or memory impairment that manifests as prominent executive dysfunction, where reasoning and organization or planning are most affected. In stage four, the patient has dementia; the cognitive and memory impairment has progressed to the point where the patient depends on others for activities of daily living.

McKee et al observed that CTE was associated with cerebral atrophy, mammillary body atrophy, dilation of the lateral ventricles, fenestrations of the septum pellucidum, and tau deposition. Researchers and clinicians, however, have not arrived at a consensus about the pathologic and clinical criteria for CTE. Furthermore, Cantu et al stated that it is not yet possible to determine the causality or risk factors of CTE with certainty. The hypothesis that repeated concussion or subconcussive impacts leads to the development of CTE has not been scientifically proven to date, they added.

What Should Be Done on the Field?

If a player at a sporting event sustains a head injury, he or she should be removed from play immediately and not allowed to return to the game. If he or she has not directly observed the injury, the neurologist should get information about it from witnesses. The neurologist should perform a focused physical examination, searching for evidence of decreased level of consciousness, confusion, focal weakness or incoordination, visual disturbance, cervical spine injury, or facial fractures. The Sport Concussion Assessment Tool (SCAT) can assist the clinician in concussion evaluation and treatment in a standardized and methodical way to determine whether and when a player can safely return to play.

A patient with an abnormal examination may need to be transferred to the local emergency department for further testing. CT imaging should not be performed automatically, because it may expose the patient to radiation unnecessarily. Two sets of criteria offer guidance about CT imaging. The New Orleans criteria state that a patient should undergo CT if he or she has a headache, has vomited, is older than 60, had been using alcohol or other drugs, had a seizure, has visible trauma above the clavicle, or has a short-term memory deficit. The Canadian CT Head Rule lists similar criteria, including a Glasgow Coma Scale score at two hours of less than 15, any sign of a basal skull fracture, and amnesia for events that took place 30 minutes before the injury.

Anticoagulants increase the risk of immediate or delayed hemorrhage after head injury. If a patient has intracranial hemorrhage on CT and has been using anticoagulants, the clinician should rapidly reverse the anticoagulant effect with the appropriate agent. A repeat head CT 24 hours later should be considered in those thought to be at high risk for intracranial hemorrhage and whose initial CT imaging is negative for bleed. “Err on the side of admitting these patients, at least for observation,” said Dr. Kosa. Before the patient is discharged from the emergency room, he or she should receive education about postconcussion symptoms that should prompt another visit to the emergency department. Educational materials are available on the CDC’s website.

When Can a Patient Return to Play?

The consensus statement on concussion in sport adopted at the Third International Conference on Concussion in Sport includes guidelines for graduated return to play. At first, the patient should undergo symptom-limited physical and cognitive rest until he or she recovers. Next, the patient may start light aerobic exercise such as walking, swimming, or cycling. The goal is to increase heart rate, but the patient should reduce activity if symptoms occur. Then, the patient may engage in sport-specific exercise. If recovery proceeds well, the patient may begin noncontact training drills and, later, full contact practice. Only when the patient has full confidence and coaching or training staff has assessed his or her functional skills can the athlete return to play.

What Concussion Research Is Under Way?

Investigations currently under way aim to improve understanding of concussion, as well as to aid diagnosis and treatment. Researchers are looking for a reliable biomarker of concussion that can be detected with an easy, cost-effective, and preferably noninvasive test. Saliva, tears, urine, blood, and CSF are among the candidate samples being studied. CSF is the most reliable fluid to test because of its proximity to the brain and its low susceptibility to extracerebral confounders, but it is the most invasive option. Groups are examining potential serum biomarkers such as S100b, neuron-specific enolase, myelin basic protein, glial fibrillary acidic protein, and cleaved tau.

In addition, McKee and colleagues are working to define clear pathologic criteria defining the various stages of CTE. They also are seeking a way of distinguishing CTE from Alzheimer’s disease, amyotrophic lateral sclerosis, and other neurodegenerative diseases in postmortem brain tissue. The group’s ultimate goal is to identify features that may assist in the diagnosis of CTE in living people using advanced neuroimaging.

—Erik Greb

Suggested Reading

Giza CC, Kutcher JS, Ashwal S, et al. Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013;80(24):2250-2257.

McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport--the 3rd International Conference on concussion in sport, held in Zurich, November 2008. J Clin Neurosci. 2009;16(6):755-763.

Omalu BI, Hamilton RL, Kamboh MI, et al. Chronic traumatic encephalopathy (CTE) in a National Football League Player: Case report and emerging medicolegal practice questions. J Forensic Nurs. 2010;6(1):40-46.

RIVIERA BEACH, FL—If a neurologist is at a sporting event during which a player sustains a head injury, audience members or officials may look to him or her for guidance, according to an overview delivered at the 44th Annual Meeting of the Southern Clinical Neurological Society. Understanding how to diagnose and manage concussion may be a vital skill for neurologists, regardless of specialty.

What Is Concussion?

Loss of consciousness previously was considered necessary for a diagnosis of concussion. Later, it was taken as a marker of serious injury. Neither of these principles is accepted any longer. Data indicate that at least 90% of concussions are not associated with loss of consciousness, and studies have not shown that loss of consciousness portends a worse prognosis or protracted recovery from the injury, said Dr. Kosa.

The pathophysiology of concussion is not certain. The current proposal is that concussion entails disruption of neuronal cell membranes resulting from disruption of normal ion channels (eg, calcium, potassium, and sodium), leading to a loss of normal neuronal homeostasis. This situation can cause a cascade of events, including mitochondrial dysfunction that causes neuronal energy failure, loss of normal glucose metabolism, activation of NMDA receptors from increased levels of glutamate, production of lactic acid, and generation of free radicals, all of which damage the neurons and supporting cells. Most cells survive the concussive injury, but can be functionally compromised. Severe injuries can lead to neuronal cell death.

What Are the Possible Sequelae of Concussion?

Concussion increases the risk of second impact syndrome, which can occur if the patient sustains another injury at between 24 hours and 10 days after a concussion. Research on second impact syndrome is limited, but the syndrome is understood to entail rapid and massive brain edema that leads to brain herniation and likely death or severe disability. The syndrome occurs within minutes of the second impact and is thought to be enabled by the period of vulnerability that follows an initial concussion. The syndrome occurs mostly in young patients, but has been described in boxers. For this reason, neurologists should be especially cautious when deciding whether to let a child with concussion return to play, said Dr. Kosa. The Centers for Disease Control and Prevention (CDC) estimate that second impact syndrome causes four to six deaths in patients under age 18 annually.

Concussion may be accompanied by traumatic brain injury (TBI). In 2010, the CDC reported 2.5 million hospital encounters related to TBI. Among these encounters, 87% of patients were treated in the emergency department and released, 11% were hospitalized and discharged, and 2% died. The highest incidence of TBI is in young children, and causes include sports accidents, bicycle accidents, skateboard accidents, vehicular accidents, and falls. The CDC estimates that between 3.2 million and 5.3 million people in the United States have permanent TBI-related disability, which results in great economic, physical, and emotional burdens.

Patients with repeated mild TBI may be at risk of chronic traumatic encephalopathy (CTE). This disorder has been described in football players, veterans, and boxers. Symptoms develop later in the patient’s life, and four stages have been described. The first stage includes headaches, inattention, and poor concentration. Stage two consists of significant mood disturbance with depression, along with explosive bouts of anger and short-term memory impairment. The third stage includes further cognitive or memory impairment that manifests as prominent executive dysfunction, where reasoning and organization or planning are most affected. In stage four, the patient has dementia; the cognitive and memory impairment has progressed to the point where the patient depends on others for activities of daily living.

McKee et al observed that CTE was associated with cerebral atrophy, mammillary body atrophy, dilation of the lateral ventricles, fenestrations of the septum pellucidum, and tau deposition. Researchers and clinicians, however, have not arrived at a consensus about the pathologic and clinical criteria for CTE. Furthermore, Cantu et al stated that it is not yet possible to determine the causality or risk factors of CTE with certainty. The hypothesis that repeated concussion or subconcussive impacts leads to the development of CTE has not been scientifically proven to date, they added.

What Should Be Done on the Field?

If a player at a sporting event sustains a head injury, he or she should be removed from play immediately and not allowed to return to the game. If he or she has not directly observed the injury, the neurologist should get information about it from witnesses. The neurologist should perform a focused physical examination, searching for evidence of decreased level of consciousness, confusion, focal weakness or incoordination, visual disturbance, cervical spine injury, or facial fractures. The Sport Concussion Assessment Tool (SCAT) can assist the clinician in concussion evaluation and treatment in a standardized and methodical way to determine whether and when a player can safely return to play.

A patient with an abnormal examination may need to be transferred to the local emergency department for further testing. CT imaging should not be performed automatically, because it may expose the patient to radiation unnecessarily. Two sets of criteria offer guidance about CT imaging. The New Orleans criteria state that a patient should undergo CT if he or she has a headache, has vomited, is older than 60, had been using alcohol or other drugs, had a seizure, has visible trauma above the clavicle, or has a short-term memory deficit. The Canadian CT Head Rule lists similar criteria, including a Glasgow Coma Scale score at two hours of less than 15, any sign of a basal skull fracture, and amnesia for events that took place 30 minutes before the injury.

Anticoagulants increase the risk of immediate or delayed hemorrhage after head injury. If a patient has intracranial hemorrhage on CT and has been using anticoagulants, the clinician should rapidly reverse the anticoagulant effect with the appropriate agent. A repeat head CT 24 hours later should be considered in those thought to be at high risk for intracranial hemorrhage and whose initial CT imaging is negative for bleed. “Err on the side of admitting these patients, at least for observation,” said Dr. Kosa. Before the patient is discharged from the emergency room, he or she should receive education about postconcussion symptoms that should prompt another visit to the emergency department. Educational materials are available on the CDC’s website.

When Can a Patient Return to Play?

The consensus statement on concussion in sport adopted at the Third International Conference on Concussion in Sport includes guidelines for graduated return to play. At first, the patient should undergo symptom-limited physical and cognitive rest until he or she recovers. Next, the patient may start light aerobic exercise such as walking, swimming, or cycling. The goal is to increase heart rate, but the patient should reduce activity if symptoms occur. Then, the patient may engage in sport-specific exercise. If recovery proceeds well, the patient may begin noncontact training drills and, later, full contact practice. Only when the patient has full confidence and coaching or training staff has assessed his or her functional skills can the athlete return to play.

What Concussion Research Is Under Way?

Investigations currently under way aim to improve understanding of concussion, as well as to aid diagnosis and treatment. Researchers are looking for a reliable biomarker of concussion that can be detected with an easy, cost-effective, and preferably noninvasive test. Saliva, tears, urine, blood, and CSF are among the candidate samples being studied. CSF is the most reliable fluid to test because of its proximity to the brain and its low susceptibility to extracerebral confounders, but it is the most invasive option. Groups are examining potential serum biomarkers such as S100b, neuron-specific enolase, myelin basic protein, glial fibrillary acidic protein, and cleaved tau.

In addition, McKee and colleagues are working to define clear pathologic criteria defining the various stages of CTE. They also are seeking a way of distinguishing CTE from Alzheimer’s disease, amyotrophic lateral sclerosis, and other neurodegenerative diseases in postmortem brain tissue. The group’s ultimate goal is to identify features that may assist in the diagnosis of CTE in living people using advanced neuroimaging.

—Erik Greb

Suggested Reading

Giza CC, Kutcher JS, Ashwal S, et al. Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013;80(24):2250-2257.

McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport--the 3rd International Conference on concussion in sport, held in Zurich, November 2008. J Clin Neurosci. 2009;16(6):755-763.

Omalu BI, Hamilton RL, Kamboh MI, et al. Chronic traumatic encephalopathy (CTE) in a National Football League Player: Case report and emerging medicolegal practice questions. J Forensic Nurs. 2010;6(1):40-46.

A gel that mimics the texture and mass of the brain, developed by U.S. Army Research Laboratory scientists, may help reveal what happens to the brain during an explosion.

The researchers used pressure-sensitive nanomaterials. The fluorescence intensity of the gel increases or decreases with the amount of pressure applied. Based on how the nanoclusters fluoresce under each pressure, the researchers will be able to gauge what would happen in a “brain situation,” 1 of the researchers says in a Health.mil article. The researchers are planning to create a pressure scale to graph information about the effects of blast pressure from the changes in color.

The laboratory has a working relationship with Japanese medical researchers who are also studying the effects of blast waves. The Japanese team will test the U.S. Army’s samples with a laser-induced shockwave and share the results of that experiment with the U.S. Army.

A gel that mimics the texture and mass of the brain, developed by U.S. Army Research Laboratory scientists, may help reveal what happens to the brain during an explosion.

The researchers used pressure-sensitive nanomaterials. The fluorescence intensity of the gel increases or decreases with the amount of pressure applied. Based on how the nanoclusters fluoresce under each pressure, the researchers will be able to gauge what would happen in a “brain situation,” 1 of the researchers says in a Health.mil article. The researchers are planning to create a pressure scale to graph information about the effects of blast pressure from the changes in color.

The laboratory has a working relationship with Japanese medical researchers who are also studying the effects of blast waves. The Japanese team will test the U.S. Army’s samples with a laser-induced shockwave and share the results of that experiment with the U.S. Army.

A gel that mimics the texture and mass of the brain, developed by U.S. Army Research Laboratory scientists, may help reveal what happens to the brain during an explosion.

The researchers used pressure-sensitive nanomaterials. The fluorescence intensity of the gel increases or decreases with the amount of pressure applied. Based on how the nanoclusters fluoresce under each pressure, the researchers will be able to gauge what would happen in a “brain situation,” 1 of the researchers says in a Health.mil article. The researchers are planning to create a pressure scale to graph information about the effects of blast pressure from the changes in color.

The laboratory has a working relationship with Japanese medical researchers who are also studying the effects of blast waves. The Japanese team will test the U.S. Army’s samples with a laser-induced shockwave and share the results of that experiment with the U.S. Army.

Controlling a Prosthesis With a Brain-Computer Interface

A brain-computer interface (BCI) that uses surface scalp electrodes can help a patient control a lower-extremity prosthesis and thus improve his or her daily life, researchers reported.  

A BCI allows a person to control a computer using his or her thoughts. The person is trained to use a specific thought such as flexing a knee for control. The thought generates electrical activity in the nerve cells and brainwaves. A chip can be implanted in the brain to monitor electrical activity, or electrodes can be placed on the scalp to monitor brainwaves. In people with paralysis or amputation, a BCI can help control the movement of muscles, limbs, and prosthetics.

"In general, using a prosthesis is an unnatural act that requires training [and] extra effort and can have a certain amount of awkwardness to it," said Douglas P. Murphy, MD, Associate Professor of Physical Medicine and Rehabilitation at Virginia Commonwealth University in Richmond. Dr. Murphy and colleagues sought to establish the feasibility of manipulating a prosthetic knee with a BCI. The use of a prosthesis can be difficult when climbing stairs or ramps, for example. The goal of all prosthetic research is to establish the same ease, comfort, and ability that the patient had with his or her natural leg, and controlling a prosthesis with thought is a big step in that direction, said Dr. Murphy.

Dr. Murphy's team worked with a person whose leg had been amputated above the knee (ie, a transfemoral amputee). Using surface scalp electrodes to transmit brainwave data to a computer software program, the participant learned how to activate a knee-unlocking switch through mental imaging. Surface scalp electrodes transmitted brainwave data to a software program that was keyed to activate the switch when the event-related desynchronization (ERD) in the EEG recording reached a certain threshold.  

"In our first attempt at using BCI with a lower extremity prosthesis, we wanted to test a simple system before moving on to more complicated ones to test the feasibility of the concept," said Dr. Murphy. "Thus, we chose control of the simplest prosthetic knee, which is the manual locking knee. When locked, the knee is rigid and straight, and when unlocked, the knee swings freely. Someone with an above-knee amputation would have to physically unlock the knee to sit and could lock or unlock in standing or walking, depending on his or her needs. We were interested to see if our participant could literally think his way to unlocking his prosthetic."

The participant learned to activate the knee-unlocking switch on his prosthesis that turned on a motor and unlocked his prosthetic knee. He walked up and down parallel bars while demonstrating his ability to unlock the knee to swing his leg and to sit down. Throughout the study, the participant was able to successfully unlock his knee between 50% and 100% of the time, and he responded to a questionnaire about his reactions to using the BCI with his prosthesis.

"The ultimate goal of this research is to provide the individual with a prosthesis that more easily and more successfully meets his or her needs for movement and walking," said Dr. Murphy. "The system should be comfortable [and] easy to use and serve useful purposes. The patient's subjective experience should reflect these goals. Our subject gave a good example of how this system could help him. He likes to hike with his children. Sometimes he is carrying his daughter and coming down a hill. With BCI control, he could adjust his prosthesis for descending the hill easily. This is the type of daily life activity we believe can be improved with BCI."

Based on this study, the BCI-controlled prosthesis would give patients a hands-free system of control, as well as a prosthesis that is responsive to more of their needs and takes less energy to use in complex environments. This system is in the early stages of development, and research is continuing.  

College Students Take Longer to Recover From a Concussion

College students take significantly more time to recover from a concussion than the general national average of seven to 14 days, investigators reported.

The Centers for Disease Control and Prevention estimates that between 1.6 million and 3.8 million concussions occur in the United States each year. On average, a person takes seven to 14 days to recover from a concussion. "This duration is in the pediatric and sports-specific populations, however. No prior study has evaluated the outcome of concussions in a collegiate student population," said Prakash Jayabalan, MD, PhD, Assistant Professor of Physical Medicine and Rehabilitation at Northwestern University Feinberg School of Medicine in Chicago. "This population is unique in that it is heterogeneous in individual sporting activity (varsity vs club sports vs recreational activity), and students can have relatively high academic demands placed on them.  

"The pivotal consensus statement on concussion in sport from the Fourth International Conference on Concussions advocates for cognitive rest. Yet maintaining a period of cognitive rest in collegiate students is particularly challenging due to the academic rigors of their schooling. Therefore, our research team wanted to determine if recovery time for patients in a college setting is different from those people outside of that setting," said Dr. Jayabalan.

To answer this question, Dr. Jayabalan and colleagues reviewed the medical charts of 128 students who were seen for concussion during the 2014-2015 academic year. They included subjects aged 18 or older at evaluation and enrolled as full-time students. Subjects were diagnosed with a concussion using the consensus statement on Concussion in Sport from the Zurich Guidelines. The investigators excluded subjects not examined within the first seven days after injury, those who did not complain of concussion-related symptoms on initial examination, those who did not complete the Standardized Concussion Assessment Tool, and those who did not provide a specific date of injury or date of symptom resolution.

On average, the students were age 20, and the population was 53.1% female. Forty-four students were varsity athletes, 33 played club sports, 34 played recreational sports, and 17 did not engage in regular physical activity or did not report their activity level.

The average duration of concussion symptoms for all subjects was 17.89 days. Dr. Jayabalan's team found that varsity athletes experienced a shorter duration of concussion symptoms (mean, 11.5 days), compared with club athletes (mean, 18.61 days) and recreational athletes (mean, 22.59 days). This difference could result from the higher amount of medical support student athletes receive, said Dr. Jayabalan. Concussions that were related to sports were shorter in duration (mean, 14.96 days), compared with those that were sustained during nonsporting activity (mean, 21.75 days).  

Female students took longer to recover, compared with men (20.79 days vs 14.60 days). People with seizure disorders or prior concussions were more likely to have symptoms that lasted longer than 28 days. Finally, graduate students took two weeks longer to recover, compared with undergraduates (31 days vs 16 days), although the number of graduate students with concussion was relatively small in this study.

"This is the first cross-sectional study reporting the outcome of concussions at a collegiate institution," said Dr. Jayabalan. University students who sustain a concussion need improved resources, he added. "The findings in our study highlight the difficulty in treating collegiate students with concussions, due to both the academic rigors of institutions and the differing needs of student populations. The study also provides insight into at-risk subsets of the student population. Factors such as level of sport, year in school, athlete versus nonathlete, premorbid conditions, and gender may affect outcome, and this needs to be an important consideration for the physician managing concussed college students."

As a next step, the research team plans to implement resources for students with concussion and assess their effect on recovery.

Day of Hospital Admission May Affect Outcome of Head Trauma

Older adults who are admitted to the hospital with head trauma during the weekend have a 14% increased risk of dying, compared with those admitted on a weekday, according to researchers.

Weekend hospital admission is associated with higher instances of death in cardiovascular emergencies and stroke, but the effect of weekend admissions on patients with head trauma is not well defined. Researchers from the University of Texas Southwestern Medical School, Johns Hopkins University School of Medicine, and the Johns Hopkins Bloomberg School of Public Health used data from the 2006, 2007, and 2008 Nationwide Inpatient Sample—a large, publicly available dataset that contains a sampling of data for seven million hospital stays each year—to determine whether older adults admitted to the hospital for head trauma during the weekend were at a higher mortality risk than those admitted during the week.

"Older adults are some of the most vulnerable members of our society, and multiple studies point to differences in outcomes for older adult patients. After seeing the weekend trend in other areas, we wanted to see if a similar pattern existed for older adult patients suffering traumatic head injuries," said Salman Hirani, MD, a second-year resident in the department of rehabilitation medicine at Icahn School of Medicine at Mount Sinai in New York City.

The team identified 38,675 patients with head injury in the sample who met their criteria, which included serious and severe head injuries, based on the Abbreviated Injury Scale (AIS). Individuals between ages 65 and 89 with head AIS equal to 3 or 4 and no other region score less than 3 were included. The researchers calculated Individual Charlson comorbidity scores and excluded individuals with missing mortality, sex, or insurance data. Dr. Hirani and colleagues used Wilcoxon rank sum and Student t-tests to compare demographics, length of stay, and total charges for weekday versus weekend admissions. The χ² tests compared sex and head injury severity. The investigators used logistic regression to model mortality, adjusting for age, sex, injury severity, comorbidity, and insurance status.

From the initial group, the researchers identified 9,937 patients (25.6%) who were admitted during the weekend. The average age of patients admitted during the weekend and those admitted on weekdays was 78. Weekend patients had fewer additional injuries and coexisting diseases outside of head trauma, compared with those admitted during the week (mean Charlson, 1.07 vs 1.14). Weekend patients also had lower head injury severity (58.3% vs 60.8% of weekday patients had an AIS of 4). Weekend patients were also predominantly female, when compared with weekday patients (52% vs 50%).

The median length of stay in the hospital was one day shorter for weekend patients (four days vs five days), said Dr. Hirani. In addition, the investigators found no significant differences in the charges incurred during each patient's stay. The average charge for weekend patients was $27,128 per patient per stay, compared with $27,703 per patient per stay for weekday patients.  

Where the groups differed was in the percentage of patients who did not survive their injuries. Proportional mortality was higher among weekend patients (9.3% vs 8.4%). After the researchers adjusted the data, weekend patients had a 14% increased risk of death, compared with weekday patients. For patients that survive their hospital stay, long term morbidity and functional capacity is not noted in the literature, said Dr. Hirani. Early rehabilitation intervention has been shown to reduce morbidity in such patients and could be critical for patients' long-term survival, he added.  

"Overall, weekend patients were less severely injured, had fewer coexisting diseases and conditions, and generated the same amount of charges for their care as weekday patients, yet they experienced a greater likelihood of death," says Dr. Hirani. "While we are not sure of the exact reason for this [result], we can continue to investigate and encourage hospitals to take a look at their own outcomes in order to put into place policies that would improve survival for older adults with traumatic brain injuries. Ultimately, we know that Level I trauma centers do not exhibit this weekend effect. It may then be important for an older adult with a traumatic brain injury, especially those occurring over the weekend, to be admitted to or transferred to a Level I trauma center or a facility with full-time staffing around the clock, as these patients may require closer observation."

What Are the Long-Term Effects of Traumatic Brain Injury?

Many parents whose children have had a traumatic brain injury (TBI) want to know what their children will be like 10 years after the injury. Research is beginning to indicate answers to this question.

Investigators from Cincinnati Children's Hospital have conducted research on the long-term effects of TBI. They currently have data for an average of seven years after injury. Patients with mild to moderate brain injuries are two times more likely to have developed attention problems, and those with severe injuries are five times more likely to develop secondary ADHD. These researchers are also finding that the family environment influences the development of these attention problems.

Parenting and the home environment exert a powerful influence on recovery. Children with severe TBI in optimal environments may show few effects of their injuries, while children with milder injuries from disadvantaged or chaotic homes often demonstrate persistent problems, according to the data.

Early family response may be particularly important for long-term outcomes, suggesting that working to promote effective parenting may be an important early intervention. Certain skills that can affect social functioning, such as speed of information processing, inhibition, and reasoning, show greater long-term effects. Many children do well in the long term after brain injury, and most do not have across-the-board deficits.

More than 630,000 children and teenagers in the United States are treated in emergency rooms for TBI each year. But predictors of recovery following TBI are unclear. These environmental factors include family functioning, parenting practices, home environment, and socioeconomic status. Researchers at Cincinnati Children's hospital are working to identify genes that affect recovery after TBI and to understand how these genes may interact with environmental factors to influence recovery.

The investigators will be collecting salivary DNA samples from more than 330 children participating in the Approaches and Decisions in Acute Pediatric TBI Trial. The primary outcome will be global functioning at 3, 6, and 12 months post injury, and secondary outcomes will include a comprehensive assessment of cognitive and behavioral functioning at 12 months post injury. This project will provide information to inform individualized prognosis and treatment plans.

Controlling a Prosthesis With a Brain-Computer Interface

A brain-computer interface (BCI) that uses surface scalp electrodes can help a patient control a lower-extremity prosthesis and thus improve his or her daily life, researchers reported.  

A BCI allows a person to control a computer using his or her thoughts. The person is trained to use a specific thought such as flexing a knee for control. The thought generates electrical activity in the nerve cells and brainwaves. A chip can be implanted in the brain to monitor electrical activity, or electrodes can be placed on the scalp to monitor brainwaves. In people with paralysis or amputation, a BCI can help control the movement of muscles, limbs, and prosthetics.

"In general, using a prosthesis is an unnatural act that requires training [and] extra effort and can have a certain amount of awkwardness to it," said Douglas P. Murphy, MD, Associate Professor of Physical Medicine and Rehabilitation at Virginia Commonwealth University in Richmond. Dr. Murphy and colleagues sought to establish the feasibility of manipulating a prosthetic knee with a BCI. The use of a prosthesis can be difficult when climbing stairs or ramps, for example. The goal of all prosthetic research is to establish the same ease, comfort, and ability that the patient had with his or her natural leg, and controlling a prosthesis with thought is a big step in that direction, said Dr. Murphy.

Dr. Murphy's team worked with a person whose leg had been amputated above the knee (ie, a transfemoral amputee). Using surface scalp electrodes to transmit brainwave data to a computer software program, the participant learned how to activate a knee-unlocking switch through mental imaging. Surface scalp electrodes transmitted brainwave data to a software program that was keyed to activate the switch when the event-related desynchronization (ERD) in the EEG recording reached a certain threshold.  

"In our first attempt at using BCI with a lower extremity prosthesis, we wanted to test a simple system before moving on to more complicated ones to test the feasibility of the concept," said Dr. Murphy. "Thus, we chose control of the simplest prosthetic knee, which is the manual locking knee. When locked, the knee is rigid and straight, and when unlocked, the knee swings freely. Someone with an above-knee amputation would have to physically unlock the knee to sit and could lock or unlock in standing or walking, depending on his or her needs. We were interested to see if our participant could literally think his way to unlocking his prosthetic."

The participant learned to activate the knee-unlocking switch on his prosthesis that turned on a motor and unlocked his prosthetic knee. He walked up and down parallel bars while demonstrating his ability to unlock the knee to swing his leg and to sit down. Throughout the study, the participant was able to successfully unlock his knee between 50% and 100% of the time, and he responded to a questionnaire about his reactions to using the BCI with his prosthesis.

"The ultimate goal of this research is to provide the individual with a prosthesis that more easily and more successfully meets his or her needs for movement and walking," said Dr. Murphy. "The system should be comfortable [and] easy to use and serve useful purposes. The patient's subjective experience should reflect these goals. Our subject gave a good example of how this system could help him. He likes to hike with his children. Sometimes he is carrying his daughter and coming down a hill. With BCI control, he could adjust his prosthesis for descending the hill easily. This is the type of daily life activity we believe can be improved with BCI."

Based on this study, the BCI-controlled prosthesis would give patients a hands-free system of control, as well as a prosthesis that is responsive to more of their needs and takes less energy to use in complex environments. This system is in the early stages of development, and research is continuing.  

College Students Take Longer to Recover From a Concussion

College students take significantly more time to recover from a concussion than the general national average of seven to 14 days, investigators reported.

The Centers for Disease Control and Prevention estimates that between 1.6 million and 3.8 million concussions occur in the United States each year. On average, a person takes seven to 14 days to recover from a concussion. "This duration is in the pediatric and sports-specific populations, however. No prior study has evaluated the outcome of concussions in a collegiate student population," said Prakash Jayabalan, MD, PhD, Assistant Professor of Physical Medicine and Rehabilitation at Northwestern University Feinberg School of Medicine in Chicago. "This population is unique in that it is heterogeneous in individual sporting activity (varsity vs club sports vs recreational activity), and students can have relatively high academic demands placed on them.  

"The pivotal consensus statement on concussion in sport from the Fourth International Conference on Concussions advocates for cognitive rest. Yet maintaining a period of cognitive rest in collegiate students is particularly challenging due to the academic rigors of their schooling. Therefore, our research team wanted to determine if recovery time for patients in a college setting is different from those people outside of that setting," said Dr. Jayabalan.

To answer this question, Dr. Jayabalan and colleagues reviewed the medical charts of 128 students who were seen for concussion during the 2014-2015 academic year. They included subjects aged 18 or older at evaluation and enrolled as full-time students. Subjects were diagnosed with a concussion using the consensus statement on Concussion in Sport from the Zurich Guidelines. The investigators excluded subjects not examined within the first seven days after injury, those who did not complain of concussion-related symptoms on initial examination, those who did not complete the Standardized Concussion Assessment Tool, and those who did not provide a specific date of injury or date of symptom resolution.

On average, the students were age 20, and the population was 53.1% female. Forty-four students were varsity athletes, 33 played club sports, 34 played recreational sports, and 17 did not engage in regular physical activity or did not report their activity level.

The average duration of concussion symptoms for all subjects was 17.89 days. Dr. Jayabalan's team found that varsity athletes experienced a shorter duration of concussion symptoms (mean, 11.5 days), compared with club athletes (mean, 18.61 days) and recreational athletes (mean, 22.59 days). This difference could result from the higher amount of medical support student athletes receive, said Dr. Jayabalan. Concussions that were related to sports were shorter in duration (mean, 14.96 days), compared with those that were sustained during nonsporting activity (mean, 21.75 days).  

Female students took longer to recover, compared with men (20.79 days vs 14.60 days). People with seizure disorders or prior concussions were more likely to have symptoms that lasted longer than 28 days. Finally, graduate students took two weeks longer to recover, compared with undergraduates (31 days vs 16 days), although the number of graduate students with concussion was relatively small in this study.

"This is the first cross-sectional study reporting the outcome of concussions at a collegiate institution," said Dr. Jayabalan. University students who sustain a concussion need improved resources, he added. "The findings in our study highlight the difficulty in treating collegiate students with concussions, due to both the academic rigors of institutions and the differing needs of student populations. The study also provides insight into at-risk subsets of the student population. Factors such as level of sport, year in school, athlete versus nonathlete, premorbid conditions, and gender may affect outcome, and this needs to be an important consideration for the physician managing concussed college students."

As a next step, the research team plans to implement resources for students with concussion and assess their effect on recovery.

Day of Hospital Admission May Affect Outcome of Head Trauma

Older adults who are admitted to the hospital with head trauma during the weekend have a 14% increased risk of dying, compared with those admitted on a weekday, according to researchers.

Weekend hospital admission is associated with higher instances of death in cardiovascular emergencies and stroke, but the effect of weekend admissions on patients with head trauma is not well defined. Researchers from the University of Texas Southwestern Medical School, Johns Hopkins University School of Medicine, and the Johns Hopkins Bloomberg School of Public Health used data from the 2006, 2007, and 2008 Nationwide Inpatient Sample—a large, publicly available dataset that contains a sampling of data for seven million hospital stays each year—to determine whether older adults admitted to the hospital for head trauma during the weekend were at a higher mortality risk than those admitted during the week.

"Older adults are some of the most vulnerable members of our society, and multiple studies point to differences in outcomes for older adult patients. After seeing the weekend trend in other areas, we wanted to see if a similar pattern existed for older adult patients suffering traumatic head injuries," said Salman Hirani, MD, a second-year resident in the department of rehabilitation medicine at Icahn School of Medicine at Mount Sinai in New York City.

The team identified 38,675 patients with head injury in the sample who met their criteria, which included serious and severe head injuries, based on the Abbreviated Injury Scale (AIS). Individuals between ages 65 and 89 with head AIS equal to 3 or 4 and no other region score less than 3 were included. The researchers calculated Individual Charlson comorbidity scores and excluded individuals with missing mortality, sex, or insurance data. Dr. Hirani and colleagues used Wilcoxon rank sum and Student t-tests to compare demographics, length of stay, and total charges for weekday versus weekend admissions. The χ² tests compared sex and head injury severity. The investigators used logistic regression to model mortality, adjusting for age, sex, injury severity, comorbidity, and insurance status.

From the initial group, the researchers identified 9,937 patients (25.6%) who were admitted during the weekend. The average age of patients admitted during the weekend and those admitted on weekdays was 78. Weekend patients had fewer additional injuries and coexisting diseases outside of head trauma, compared with those admitted during the week (mean Charlson, 1.07 vs 1.14). Weekend patients also had lower head injury severity (58.3% vs 60.8% of weekday patients had an AIS of 4). Weekend patients were also predominantly female, when compared with weekday patients (52% vs 50%).

The median length of stay in the hospital was one day shorter for weekend patients (four days vs five days), said Dr. Hirani. In addition, the investigators found no significant differences in the charges incurred during each patient's stay. The average charge for weekend patients was $27,128 per patient per stay, compared with $27,703 per patient per stay for weekday patients.  

Where the groups differed was in the percentage of patients who did not survive their injuries. Proportional mortality was higher among weekend patients (9.3% vs 8.4%). After the researchers adjusted the data, weekend patients had a 14% increased risk of death, compared with weekday patients. For patients that survive their hospital stay, long term morbidity and functional capacity is not noted in the literature, said Dr. Hirani. Early rehabilitation intervention has been shown to reduce morbidity in such patients and could be critical for patients' long-term survival, he added.  

"Overall, weekend patients were less severely injured, had fewer coexisting diseases and conditions, and generated the same amount of charges for their care as weekday patients, yet they experienced a greater likelihood of death," says Dr. Hirani. "While we are not sure of the exact reason for this [result], we can continue to investigate and encourage hospitals to take a look at their own outcomes in order to put into place policies that would improve survival for older adults with traumatic brain injuries. Ultimately, we know that Level I trauma centers do not exhibit this weekend effect. It may then be important for an older adult with a traumatic brain injury, especially those occurring over the weekend, to be admitted to or transferred to a Level I trauma center or a facility with full-time staffing around the clock, as these patients may require closer observation."

What Are the Long-Term Effects of Traumatic Brain Injury?

Many parents whose children have had a traumatic brain injury (TBI) want to know what their children will be like 10 years after the injury. Research is beginning to indicate answers to this question.

Investigators from Cincinnati Children's Hospital have conducted research on the long-term effects of TBI. They currently have data for an average of seven years after injury. Patients with mild to moderate brain injuries are two times more likely to have developed attention problems, and those with severe injuries are five times more likely to develop secondary ADHD. These researchers are also finding that the family environment influences the development of these attention problems.

Parenting and the home environment exert a powerful influence on recovery. Children with severe TBI in optimal environments may show few effects of their injuries, while children with milder injuries from disadvantaged or chaotic homes often demonstrate persistent problems, according to the data.

Early family response may be particularly important for long-term outcomes, suggesting that working to promote effective parenting may be an important early intervention. Certain skills that can affect social functioning, such as speed of information processing, inhibition, and reasoning, show greater long-term effects. Many children do well in the long term after brain injury, and most do not have across-the-board deficits.

More than 630,000 children and teenagers in the United States are treated in emergency rooms for TBI each year. But predictors of recovery following TBI are unclear. These environmental factors include family functioning, parenting practices, home environment, and socioeconomic status. Researchers at Cincinnati Children's hospital are working to identify genes that affect recovery after TBI and to understand how these genes may interact with environmental factors to influence recovery.

The investigators will be collecting salivary DNA samples from more than 330 children participating in the Approaches and Decisions in Acute Pediatric TBI Trial. The primary outcome will be global functioning at 3, 6, and 12 months post injury, and secondary outcomes will include a comprehensive assessment of cognitive and behavioral functioning at 12 months post injury. This project will provide information to inform individualized prognosis and treatment plans.

Controlling a Prosthesis With a Brain-Computer Interface

A brain-computer interface (BCI) that uses surface scalp electrodes can help a patient control a lower-extremity prosthesis and thus improve his or her daily life, researchers reported.  

A BCI allows a person to control a computer using his or her thoughts. The person is trained to use a specific thought such as flexing a knee for control. The thought generates electrical activity in the nerve cells and brainwaves. A chip can be implanted in the brain to monitor electrical activity, or electrodes can be placed on the scalp to monitor brainwaves. In people with paralysis or amputation, a BCI can help control the movement of muscles, limbs, and prosthetics.

"In general, using a prosthesis is an unnatural act that requires training [and] extra effort and can have a certain amount of awkwardness to it," said Douglas P. Murphy, MD, Associate Professor of Physical Medicine and Rehabilitation at Virginia Commonwealth University in Richmond. Dr. Murphy and colleagues sought to establish the feasibility of manipulating a prosthetic knee with a BCI. The use of a prosthesis can be difficult when climbing stairs or ramps, for example. The goal of all prosthetic research is to establish the same ease, comfort, and ability that the patient had with his or her natural leg, and controlling a prosthesis with thought is a big step in that direction, said Dr. Murphy.

Dr. Murphy's team worked with a person whose leg had been amputated above the knee (ie, a transfemoral amputee). Using surface scalp electrodes to transmit brainwave data to a computer software program, the participant learned how to activate a knee-unlocking switch through mental imaging. Surface scalp electrodes transmitted brainwave data to a software program that was keyed to activate the switch when the event-related desynchronization (ERD) in the EEG recording reached a certain threshold.  

"In our first attempt at using BCI with a lower extremity prosthesis, we wanted to test a simple system before moving on to more complicated ones to test the feasibility of the concept," said Dr. Murphy. "Thus, we chose control of the simplest prosthetic knee, which is the manual locking knee. When locked, the knee is rigid and straight, and when unlocked, the knee swings freely. Someone with an above-knee amputation would have to physically unlock the knee to sit and could lock or unlock in standing or walking, depending on his or her needs. We were interested to see if our participant could literally think his way to unlocking his prosthetic."

The participant learned to activate the knee-unlocking switch on his prosthesis that turned on a motor and unlocked his prosthetic knee. He walked up and down parallel bars while demonstrating his ability to unlock the knee to swing his leg and to sit down. Throughout the study, the participant was able to successfully unlock his knee between 50% and 100% of the time, and he responded to a questionnaire about his reactions to using the BCI with his prosthesis.

"The ultimate goal of this research is to provide the individual with a prosthesis that more easily and more successfully meets his or her needs for movement and walking," said Dr. Murphy. "The system should be comfortable [and] easy to use and serve useful purposes. The patient's subjective experience should reflect these goals. Our subject gave a good example of how this system could help him. He likes to hike with his children. Sometimes he is carrying his daughter and coming down a hill. With BCI control, he could adjust his prosthesis for descending the hill easily. This is the type of daily life activity we believe can be improved with BCI."

Based on this study, the BCI-controlled prosthesis would give patients a hands-free system of control, as well as a prosthesis that is responsive to more of their needs and takes less energy to use in complex environments. This system is in the early stages of development, and research is continuing.  

College Students Take Longer to Recover From a Concussion

College students take significantly more time to recover from a concussion than the general national average of seven to 14 days, investigators reported.

The Centers for Disease Control and Prevention estimates that between 1.6 million and 3.8 million concussions occur in the United States each year. On average, a person takes seven to 14 days to recover from a concussion. "This duration is in the pediatric and sports-specific populations, however. No prior study has evaluated the outcome of concussions in a collegiate student population," said Prakash Jayabalan, MD, PhD, Assistant Professor of Physical Medicine and Rehabilitation at Northwestern University Feinberg School of Medicine in Chicago. "This population is unique in that it is heterogeneous in individual sporting activity (varsity vs club sports vs recreational activity), and students can have relatively high academic demands placed on them.  

"The pivotal consensus statement on concussion in sport from the Fourth International Conference on Concussions advocates for cognitive rest. Yet maintaining a period of cognitive rest in collegiate students is particularly challenging due to the academic rigors of their schooling. Therefore, our research team wanted to determine if recovery time for patients in a college setting is different from those people outside of that setting," said Dr. Jayabalan.

To answer this question, Dr. Jayabalan and colleagues reviewed the medical charts of 128 students who were seen for concussion during the 2014-2015 academic year. They included subjects aged 18 or older at evaluation and enrolled as full-time students. Subjects were diagnosed with a concussion using the consensus statement on Concussion in Sport from the Zurich Guidelines. The investigators excluded subjects not examined within the first seven days after injury, those who did not complain of concussion-related symptoms on initial examination, those who did not complete the Standardized Concussion Assessment Tool, and those who did not provide a specific date of injury or date of symptom resolution.

On average, the students were age 20, and the population was 53.1% female. Forty-four students were varsity athletes, 33 played club sports, 34 played recreational sports, and 17 did not engage in regular physical activity or did not report their activity level.

The average duration of concussion symptoms for all subjects was 17.89 days. Dr. Jayabalan's team found that varsity athletes experienced a shorter duration of concussion symptoms (mean, 11.5 days), compared with club athletes (mean, 18.61 days) and recreational athletes (mean, 22.59 days). This difference could result from the higher amount of medical support student athletes receive, said Dr. Jayabalan. Concussions that were related to sports were shorter in duration (mean, 14.96 days), compared with those that were sustained during nonsporting activity (mean, 21.75 days).  

Female students took longer to recover, compared with men (20.79 days vs 14.60 days). People with seizure disorders or prior concussions were more likely to have symptoms that lasted longer than 28 days. Finally, graduate students took two weeks longer to recover, compared with undergraduates (31 days vs 16 days), although the number of graduate students with concussion was relatively small in this study.

"This is the first cross-sectional study reporting the outcome of concussions at a collegiate institution," said Dr. Jayabalan. University students who sustain a concussion need improved resources, he added. "The findings in our study highlight the difficulty in treating collegiate students with concussions, due to both the academic rigors of institutions and the differing needs of student populations. The study also provides insight into at-risk subsets of the student population. Factors such as level of sport, year in school, athlete versus nonathlete, premorbid conditions, and gender may affect outcome, and this needs to be an important consideration for the physician managing concussed college students."

As a next step, the research team plans to implement resources for students with concussion and assess their effect on recovery.

Day of Hospital Admission May Affect Outcome of Head Trauma

Older adults who are admitted to the hospital with head trauma during the weekend have a 14% increased risk of dying, compared with those admitted on a weekday, according to researchers.

Weekend hospital admission is associated with higher instances of death in cardiovascular emergencies and stroke, but the effect of weekend admissions on patients with head trauma is not well defined. Researchers from the University of Texas Southwestern Medical School, Johns Hopkins University School of Medicine, and the Johns Hopkins Bloomberg School of Public Health used data from the 2006, 2007, and 2008 Nationwide Inpatient Sample—a large, publicly available dataset that contains a sampling of data for seven million hospital stays each year—to determine whether older adults admitted to the hospital for head trauma during the weekend were at a higher mortality risk than those admitted during the week.

"Older adults are some of the most vulnerable members of our society, and multiple studies point to differences in outcomes for older adult patients. After seeing the weekend trend in other areas, we wanted to see if a similar pattern existed for older adult patients suffering traumatic head injuries," said Salman Hirani, MD, a second-year resident in the department of rehabilitation medicine at Icahn School of Medicine at Mount Sinai in New York City.

The team identified 38,675 patients with head injury in the sample who met their criteria, which included serious and severe head injuries, based on the Abbreviated Injury Scale (AIS). Individuals between ages 65 and 89 with head AIS equal to 3 or 4 and no other region score less than 3 were included. The researchers calculated Individual Charlson comorbidity scores and excluded individuals with missing mortality, sex, or insurance data. Dr. Hirani and colleagues used Wilcoxon rank sum and Student t-tests to compare demographics, length of stay, and total charges for weekday versus weekend admissions. The χ² tests compared sex and head injury severity. The investigators used logistic regression to model mortality, adjusting for age, sex, injury severity, comorbidity, and insurance status.

From the initial group, the researchers identified 9,937 patients (25.6%) who were admitted during the weekend. The average age of patients admitted during the weekend and those admitted on weekdays was 78. Weekend patients had fewer additional injuries and coexisting diseases outside of head trauma, compared with those admitted during the week (mean Charlson, 1.07 vs 1.14). Weekend patients also had lower head injury severity (58.3% vs 60.8% of weekday patients had an AIS of 4). Weekend patients were also predominantly female, when compared with weekday patients (52% vs 50%).

The median length of stay in the hospital was one day shorter for weekend patients (four days vs five days), said Dr. Hirani. In addition, the investigators found no significant differences in the charges incurred during each patient's stay. The average charge for weekend patients was $27,128 per patient per stay, compared with $27,703 per patient per stay for weekday patients.  

Where the groups differed was in the percentage of patients who did not survive their injuries. Proportional mortality was higher among weekend patients (9.3% vs 8.4%). After the researchers adjusted the data, weekend patients had a 14% increased risk of death, compared with weekday patients. For patients that survive their hospital stay, long term morbidity and functional capacity is not noted in the literature, said Dr. Hirani. Early rehabilitation intervention has been shown to reduce morbidity in such patients and could be critical for patients' long-term survival, he added.  

"Overall, weekend patients were less severely injured, had fewer coexisting diseases and conditions, and generated the same amount of charges for their care as weekday patients, yet they experienced a greater likelihood of death," says Dr. Hirani. "While we are not sure of the exact reason for this [result], we can continue to investigate and encourage hospitals to take a look at their own outcomes in order to put into place policies that would improve survival for older adults with traumatic brain injuries. Ultimately, we know that Level I trauma centers do not exhibit this weekend effect. It may then be important for an older adult with a traumatic brain injury, especially those occurring over the weekend, to be admitted to or transferred to a Level I trauma center or a facility with full-time staffing around the clock, as these patients may require closer observation."

What Are the Long-Term Effects of Traumatic Brain Injury?

Many parents whose children have had a traumatic brain injury (TBI) want to know what their children will be like 10 years after the injury. Research is beginning to indicate answers to this question.

Investigators from Cincinnati Children's Hospital have conducted research on the long-term effects of TBI. They currently have data for an average of seven years after injury. Patients with mild to moderate brain injuries are two times more likely to have developed attention problems, and those with severe injuries are five times more likely to develop secondary ADHD. These researchers are also finding that the family environment influences the development of these attention problems.

Parenting and the home environment exert a powerful influence on recovery. Children with severe TBI in optimal environments may show few effects of their injuries, while children with milder injuries from disadvantaged or chaotic homes often demonstrate persistent problems, according to the data.

Early family response may be particularly important for long-term outcomes, suggesting that working to promote effective parenting may be an important early intervention. Certain skills that can affect social functioning, such as speed of information processing, inhibition, and reasoning, show greater long-term effects. Many children do well in the long term after brain injury, and most do not have across-the-board deficits.

More than 630,000 children and teenagers in the United States are treated in emergency rooms for TBI each year. But predictors of recovery following TBI are unclear. These environmental factors include family functioning, parenting practices, home environment, and socioeconomic status. Researchers at Cincinnati Children's hospital are working to identify genes that affect recovery after TBI and to understand how these genes may interact with environmental factors to influence recovery.

The investigators will be collecting salivary DNA samples from more than 330 children participating in the Approaches and Decisions in Acute Pediatric TBI Trial. The primary outcome will be global functioning at 3, 6, and 12 months post injury, and secondary outcomes will include a comprehensive assessment of cognitive and behavioral functioning at 12 months post injury. This project will provide information to inform individualized prognosis and treatment plans.