Traumatic Brain Injury

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.

Among collegiate athletes, elevated plasma tau concentrations within six hours after a sport-related concussion predict a prolonged recovery, according to research published online ahead of print January 6 in Neurology. This finding suggests that tau levels may help to determine when athletes should return to play. Variability of tau concentrations across athletes and the effect of physical exertion on plasma tau may complicate the use of the biomarker for concussion management, however.

Approximately 3.8 million sport-related concussions occur each year in the United States, but no biomarkers are known to predict recovery and an athlete’s readiness to return to play. Postconcussive symptoms typically resolve within 10 days in about half of collegiate athletes, but symptoms are chronic in a subset of patients. Shahim et al found that plasma tau elevations predicted a return to play of more than 10 days in professional ice hockey players in Sweden.

Diagnosing Sport-Related Concussion

Jessica Gill, RN, PhD, an investigator with the National Institute of Nursing Research at the NIH, and colleagues conducted a study to determine whether changes in plasma tau after sport-related concussion relate to return to play in men and women collegiate athletes. The researchers included students with concussion, as well as athlete and nonathlete controls. The athletes participated in various National Collegiate Athletic Association (NCAA) division I and III contact sports (ie, football, soccer, basketball, hockey, and lacrosse).

Between 2009 and 2014, 632 athletes underwent plasma sampling and cognitive testing prior to the sports seasons and were followed prospectively for a diagnosis of sport-related concussion. Sport-related concussions were witnessed by an on-field certified athletic trainer and met the Sport Concussion Assessment Tool 2 definition of concussion.Investigators collected blood samples from athletes with concussion and athlete controls at six hours, 24 hours, 72 hours, and seven days after a concussion. Nonathlete controls had blood draws at an unrelated time point. Investigators measured total tau using an ultrasensitive immunoassay.

Return to play for each athlete was determined by athletic trainers or team physicians. They followed NCAA guidelines, which recommend that athletes be asymptomatic at rest and as they progressively resume activity before returning to play.

A total of 46 athletes were diagnosed with a sport-related concussion. Concussions occurred between 19 days and 218 days after baseline assessments (mean, 92.3 days). Thirty-seven athletes without concussion served as athlete controls. Athletes with and without concussion did not differ significantly in sport played, history of sport-related concussion, or other demographic features. A control group of 21 healthy nonathletes was demographically similar to the athlete groups.Return to play information was available for 41 of the athletes with concussion. Athletes who took more than 10 days to recover were considered to have a long return to play (23 athletes). Those who recovered in less than 10 days had a short return to play (18 athletes). The mean return to play duration was 21.68 days (range, two days to 263 days). Five athletes had a return to play duration of 30 days or more. Approximately 39% returned to play in less than 10 days. There were no significant differences in sport played or history of concussion among those with long return to play versus short return to play. Women made up 61% of the long return to play group and 28% of the short return to play group.

Tau Measurements

Compared with nonathletes, athletes had significantly higher mean tau concentrations at baseline and all other time points. The longitudinal pattern of tau differed significantly between athletes with and without concussion. Athletes with concussion had significantly lower mean total tau at 24 hours (6.06 pg/mL vs 7.89 pg/mL) and 72 hours (5.19 pg/mL vs 6.94 pg/mL), compared with athlete controls.

Athletes with a long return to play had higher tau concentrations overall, after controlling for sex, than those with a short return to play. The differences were statistically significant at six hours (10.98 pg/mL vs 7.02 pg/mL), 24 hours (7.19 pg/mL vs 4.08 pg/mL), and 72 hours (6.29 pg/mL vs 3.94 pg/mL).

Mean change in tau from baseline also significantly differed between the return to play groups. Athletes with long return to play had a mean increase of 2.26 pg/mL at six hours postconcussion, compared with a mean reduction of 1.19 pg/mL in the short return to play group, after controlling for sex. Area under the curve (AUC) analyses revealed that higher total tau six hours post concussion and change in tau from baseline to six hours post concussion predicted long return to play (AUC of 0.81 and 0.80, respectively). Higher total tau at 72 hours postconcussion also was a significant predictor of long return to play (AUC, 0.82).

“These findings suggest that changes in total tau within six hours of a sport-related concussion may provide vital information about return to play decisions, and may serve to mitigate the negative consequences of returning to play prematurely,” Dr. Gill and colleagues said. Preclinical models link insufficient recovery time from a mild traumatic brain injury (mTBI) to greater neuropathology following a subsequent mTBI, including pathology that overlaps with that of chronic traumatic encephalopathy.

Lower levels of tau in athletes with concussion, compared with athletes without concussion, at 24 hours and 72 hours “may be due to the effects of physical exertion on tau,” the researchers said. Limitations of the study include the relatively small sample size within subanalyses of long and short return to play.

More Research Is Needed

“While normally measured in CSF, tau measured in blood could provide the opportunity to assess neurologic injury shortly after concussion, as well as facilitate monitoring of recovery over time,” said Barbara B. Bendlin, PhD, Associate Professor of Medicine and Public Health at the University of Wisconsin–Madison, and Michael Makdissi, MBBS, PhD, research fellow at the Florey Institute of Neuroscience and Mental Health and Adjunct Associate Professor of Rehabilitation, Nutrition, and Sport at the La Trobe Sport and Exercise Medicine Research Centre in Australia, in an accompanying editorial.

However, differences in plasma tau levels between athletes and nonathletes; lower plasma tau levels at 24 hours and 72 hours post concussion in athletes with concussion, compared with nonconcussed teammates; variability across players; and fluctuations in plasma tau levels over time in general may complicate the use of the biomarker in concussion management. In addition, tau in plasma may reflect CNS and peripheral nervous system origins.

“This study and others conducted in the sports setting open the door for further evaluation and possible future implementation of blood-based biomarkers for evaluation of concussion,” they said. “Nevertheless, more work is needed before blood-based biomarkers can be used for management of sport-related concussion.”

—Jake Remaly

Suggested Reading

Bendlin BB, Makdissi M. Blood-based biomarkers for evaluating sport-related concussion: Back in the game. Neurology. 2017 Jan 6 [Epub ahead of print].

Gill J, Merchant-Borna K, Jeromin A, et al. Acute plasma tau relates to prolonged return to play after concussion. Neurology. 2017 Jan 6 [Epub ahead of print].

Shahim P, Tegner Y, Wilson DH, et al. Blood biomarkers for brain injury in concussed professional ice hockey players. JAMA Neurol. 2014;71(6):684-692.

Among collegiate athletes, elevated plasma tau concentrations within six hours after a sport-related concussion predict a prolonged recovery, according to research published online ahead of print January 6 in Neurology. This finding suggests that tau levels may help to determine when athletes should return to play. Variability of tau concentrations across athletes and the effect of physical exertion on plasma tau may complicate the use of the biomarker for concussion management, however.

Approximately 3.8 million sport-related concussions occur each year in the United States, but no biomarkers are known to predict recovery and an athlete’s readiness to return to play. Postconcussive symptoms typically resolve within 10 days in about half of collegiate athletes, but symptoms are chronic in a subset of patients. Shahim et al found that plasma tau elevations predicted a return to play of more than 10 days in professional ice hockey players in Sweden.

Diagnosing Sport-Related Concussion

Jessica Gill, RN, PhD, an investigator with the National Institute of Nursing Research at the NIH, and colleagues conducted a study to determine whether changes in plasma tau after sport-related concussion relate to return to play in men and women collegiate athletes. The researchers included students with concussion, as well as athlete and nonathlete controls. The athletes participated in various National Collegiate Athletic Association (NCAA) division I and III contact sports (ie, football, soccer, basketball, hockey, and lacrosse).

Between 2009 and 2014, 632 athletes underwent plasma sampling and cognitive testing prior to the sports seasons and were followed prospectively for a diagnosis of sport-related concussion. Sport-related concussions were witnessed by an on-field certified athletic trainer and met the Sport Concussion Assessment Tool 2 definition of concussion.Investigators collected blood samples from athletes with concussion and athlete controls at six hours, 24 hours, 72 hours, and seven days after a concussion. Nonathlete controls had blood draws at an unrelated time point. Investigators measured total tau using an ultrasensitive immunoassay.

Return to play for each athlete was determined by athletic trainers or team physicians. They followed NCAA guidelines, which recommend that athletes be asymptomatic at rest and as they progressively resume activity before returning to play.

A total of 46 athletes were diagnosed with a sport-related concussion. Concussions occurred between 19 days and 218 days after baseline assessments (mean, 92.3 days). Thirty-seven athletes without concussion served as athlete controls. Athletes with and without concussion did not differ significantly in sport played, history of sport-related concussion, or other demographic features. A control group of 21 healthy nonathletes was demographically similar to the athlete groups.Return to play information was available for 41 of the athletes with concussion. Athletes who took more than 10 days to recover were considered to have a long return to play (23 athletes). Those who recovered in less than 10 days had a short return to play (18 athletes). The mean return to play duration was 21.68 days (range, two days to 263 days). Five athletes had a return to play duration of 30 days or more. Approximately 39% returned to play in less than 10 days. There were no significant differences in sport played or history of concussion among those with long return to play versus short return to play. Women made up 61% of the long return to play group and 28% of the short return to play group.

Tau Measurements

Compared with nonathletes, athletes had significantly higher mean tau concentrations at baseline and all other time points. The longitudinal pattern of tau differed significantly between athletes with and without concussion. Athletes with concussion had significantly lower mean total tau at 24 hours (6.06 pg/mL vs 7.89 pg/mL) and 72 hours (5.19 pg/mL vs 6.94 pg/mL), compared with athlete controls.

Athletes with a long return to play had higher tau concentrations overall, after controlling for sex, than those with a short return to play. The differences were statistically significant at six hours (10.98 pg/mL vs 7.02 pg/mL), 24 hours (7.19 pg/mL vs 4.08 pg/mL), and 72 hours (6.29 pg/mL vs 3.94 pg/mL).

Mean change in tau from baseline also significantly differed between the return to play groups. Athletes with long return to play had a mean increase of 2.26 pg/mL at six hours postconcussion, compared with a mean reduction of 1.19 pg/mL in the short return to play group, after controlling for sex. Area under the curve (AUC) analyses revealed that higher total tau six hours post concussion and change in tau from baseline to six hours post concussion predicted long return to play (AUC of 0.81 and 0.80, respectively). Higher total tau at 72 hours postconcussion also was a significant predictor of long return to play (AUC, 0.82).

“These findings suggest that changes in total tau within six hours of a sport-related concussion may provide vital information about return to play decisions, and may serve to mitigate the negative consequences of returning to play prematurely,” Dr. Gill and colleagues said. Preclinical models link insufficient recovery time from a mild traumatic brain injury (mTBI) to greater neuropathology following a subsequent mTBI, including pathology that overlaps with that of chronic traumatic encephalopathy.

Lower levels of tau in athletes with concussion, compared with athletes without concussion, at 24 hours and 72 hours “may be due to the effects of physical exertion on tau,” the researchers said. Limitations of the study include the relatively small sample size within subanalyses of long and short return to play.

More Research Is Needed

“While normally measured in CSF, tau measured in blood could provide the opportunity to assess neurologic injury shortly after concussion, as well as facilitate monitoring of recovery over time,” said Barbara B. Bendlin, PhD, Associate Professor of Medicine and Public Health at the University of Wisconsin–Madison, and Michael Makdissi, MBBS, PhD, research fellow at the Florey Institute of Neuroscience and Mental Health and Adjunct Associate Professor of Rehabilitation, Nutrition, and Sport at the La Trobe Sport and Exercise Medicine Research Centre in Australia, in an accompanying editorial.

However, differences in plasma tau levels between athletes and nonathletes; lower plasma tau levels at 24 hours and 72 hours post concussion in athletes with concussion, compared with nonconcussed teammates; variability across players; and fluctuations in plasma tau levels over time in general may complicate the use of the biomarker in concussion management. In addition, tau in plasma may reflect CNS and peripheral nervous system origins.

“This study and others conducted in the sports setting open the door for further evaluation and possible future implementation of blood-based biomarkers for evaluation of concussion,” they said. “Nevertheless, more work is needed before blood-based biomarkers can be used for management of sport-related concussion.”

—Jake Remaly

Suggested Reading

Bendlin BB, Makdissi M. Blood-based biomarkers for evaluating sport-related concussion: Back in the game. Neurology. 2017 Jan 6 [Epub ahead of print].

Gill J, Merchant-Borna K, Jeromin A, et al. Acute plasma tau relates to prolonged return to play after concussion. Neurology. 2017 Jan 6 [Epub ahead of print].

Shahim P, Tegner Y, Wilson DH, et al. Blood biomarkers for brain injury in concussed professional ice hockey players. JAMA Neurol. 2014;71(6):684-692.

Among collegiate athletes, elevated plasma tau concentrations within six hours after a sport-related concussion predict a prolonged recovery, according to research published online ahead of print January 6 in Neurology. This finding suggests that tau levels may help to determine when athletes should return to play. Variability of tau concentrations across athletes and the effect of physical exertion on plasma tau may complicate the use of the biomarker for concussion management, however.

Approximately 3.8 million sport-related concussions occur each year in the United States, but no biomarkers are known to predict recovery and an athlete’s readiness to return to play. Postconcussive symptoms typically resolve within 10 days in about half of collegiate athletes, but symptoms are chronic in a subset of patients. Shahim et al found that plasma tau elevations predicted a return to play of more than 10 days in professional ice hockey players in Sweden.

Diagnosing Sport-Related Concussion

Jessica Gill, RN, PhD, an investigator with the National Institute of Nursing Research at the NIH, and colleagues conducted a study to determine whether changes in plasma tau after sport-related concussion relate to return to play in men and women collegiate athletes. The researchers included students with concussion, as well as athlete and nonathlete controls. The athletes participated in various National Collegiate Athletic Association (NCAA) division I and III contact sports (ie, football, soccer, basketball, hockey, and lacrosse).

Between 2009 and 2014, 632 athletes underwent plasma sampling and cognitive testing prior to the sports seasons and were followed prospectively for a diagnosis of sport-related concussion. Sport-related concussions were witnessed by an on-field certified athletic trainer and met the Sport Concussion Assessment Tool 2 definition of concussion.Investigators collected blood samples from athletes with concussion and athlete controls at six hours, 24 hours, 72 hours, and seven days after a concussion. Nonathlete controls had blood draws at an unrelated time point. Investigators measured total tau using an ultrasensitive immunoassay.

Return to play for each athlete was determined by athletic trainers or team physicians. They followed NCAA guidelines, which recommend that athletes be asymptomatic at rest and as they progressively resume activity before returning to play.

A total of 46 athletes were diagnosed with a sport-related concussion. Concussions occurred between 19 days and 218 days after baseline assessments (mean, 92.3 days). Thirty-seven athletes without concussion served as athlete controls. Athletes with and without concussion did not differ significantly in sport played, history of sport-related concussion, or other demographic features. A control group of 21 healthy nonathletes was demographically similar to the athlete groups.Return to play information was available for 41 of the athletes with concussion. Athletes who took more than 10 days to recover were considered to have a long return to play (23 athletes). Those who recovered in less than 10 days had a short return to play (18 athletes). The mean return to play duration was 21.68 days (range, two days to 263 days). Five athletes had a return to play duration of 30 days or more. Approximately 39% returned to play in less than 10 days. There were no significant differences in sport played or history of concussion among those with long return to play versus short return to play. Women made up 61% of the long return to play group and 28% of the short return to play group.

Tau Measurements

Compared with nonathletes, athletes had significantly higher mean tau concentrations at baseline and all other time points. The longitudinal pattern of tau differed significantly between athletes with and without concussion. Athletes with concussion had significantly lower mean total tau at 24 hours (6.06 pg/mL vs 7.89 pg/mL) and 72 hours (5.19 pg/mL vs 6.94 pg/mL), compared with athlete controls.

Athletes with a long return to play had higher tau concentrations overall, after controlling for sex, than those with a short return to play. The differences were statistically significant at six hours (10.98 pg/mL vs 7.02 pg/mL), 24 hours (7.19 pg/mL vs 4.08 pg/mL), and 72 hours (6.29 pg/mL vs 3.94 pg/mL).

Mean change in tau from baseline also significantly differed between the return to play groups. Athletes with long return to play had a mean increase of 2.26 pg/mL at six hours postconcussion, compared with a mean reduction of 1.19 pg/mL in the short return to play group, after controlling for sex. Area under the curve (AUC) analyses revealed that higher total tau six hours post concussion and change in tau from baseline to six hours post concussion predicted long return to play (AUC of 0.81 and 0.80, respectively). Higher total tau at 72 hours postconcussion also was a significant predictor of long return to play (AUC, 0.82).

“These findings suggest that changes in total tau within six hours of a sport-related concussion may provide vital information about return to play decisions, and may serve to mitigate the negative consequences of returning to play prematurely,” Dr. Gill and colleagues said. Preclinical models link insufficient recovery time from a mild traumatic brain injury (mTBI) to greater neuropathology following a subsequent mTBI, including pathology that overlaps with that of chronic traumatic encephalopathy.

Lower levels of tau in athletes with concussion, compared with athletes without concussion, at 24 hours and 72 hours “may be due to the effects of physical exertion on tau,” the researchers said. Limitations of the study include the relatively small sample size within subanalyses of long and short return to play.

More Research Is Needed

“While normally measured in CSF, tau measured in blood could provide the opportunity to assess neurologic injury shortly after concussion, as well as facilitate monitoring of recovery over time,” said Barbara B. Bendlin, PhD, Associate Professor of Medicine and Public Health at the University of Wisconsin–Madison, and Michael Makdissi, MBBS, PhD, research fellow at the Florey Institute of Neuroscience and Mental Health and Adjunct Associate Professor of Rehabilitation, Nutrition, and Sport at the La Trobe Sport and Exercise Medicine Research Centre in Australia, in an accompanying editorial.

However, differences in plasma tau levels between athletes and nonathletes; lower plasma tau levels at 24 hours and 72 hours post concussion in athletes with concussion, compared with nonconcussed teammates; variability across players; and fluctuations in plasma tau levels over time in general may complicate the use of the biomarker in concussion management. In addition, tau in plasma may reflect CNS and peripheral nervous system origins.

“This study and others conducted in the sports setting open the door for further evaluation and possible future implementation of blood-based biomarkers for evaluation of concussion,” they said. “Nevertheless, more work is needed before blood-based biomarkers can be used for management of sport-related concussion.”

—Jake Remaly

Suggested Reading

Bendlin BB, Makdissi M. Blood-based biomarkers for evaluating sport-related concussion: Back in the game. Neurology. 2017 Jan 6 [Epub ahead of print].

Gill J, Merchant-Borna K, Jeromin A, et al. Acute plasma tau relates to prolonged return to play after concussion. Neurology. 2017 Jan 6 [Epub ahead of print].

Shahim P, Tegner Y, Wilson DH, et al. Blood biomarkers for brain injury in concussed professional ice hockey players. JAMA Neurol. 2014;71(6):684-692.

VANCOUVER—Initial pediatric concussion evaluations provide an opportunity to recognize premorbid conditions that may be exacerbated by the injury; address problems with prior management, such as excessive rest or NSAID overuse; and identify treatment approaches, according to a seminar delivered at the 45th Annual Meeting of the Child Neurology Society.

Neurologists also may decide whether imaging is warranted and note risk factors for prolonged recovery, said Sharief Taraman, MD, Director of the Children’s Concussion Program at Children’s Hospital of Orange County in Orange, California, and Assistant Clinical Professor of Pediatrics at the University of California, Irvine.

Imaging Likely Not Needed

In most cases, a CT scan is not necessary, Dr. Taraman said. He encouraged neurologists to work with their emergency department colleagues to ensure that patients only undergo CT scans when appropriate. His department uses Pediatric Emergency Care Applied Research Network (PECARN) criteria to determine when a CT scan is warranted. Many patients do not have signs of altered mental status in the emergency department, and “there is really no good reason to scan many of these kids,” he said. Patients also typically do not undergo MRI unless “a significant neurologic finding … suggests that there might have been a stronger mechanism of action.”

History taking is a vital component of initial management, and identifying premorbid conditions is a key factor, Dr. Taraman said. “What we have seen is that concussion symptoms act as a magnifying glass. If I have migraine and I get a concussion, my migraine will likely become exacerbated,” he said. Patients may also present for evaluation of concussion but have an alternate diagnosis that better explains their symptoms. For example, Dr. Taraman described a patient who had persistent symptoms following a concussion. “Listening to the story, it was clearly sleep apnea,” he said. The child underwent polysomnography and received continuous positive airway pressure treatment because he had 40 apneas in an hour.

During the evaluation, neurologists can recognize poor initial management of the injury, such as excessive bed rest or removal from activities. NSAID overuse also is a big problem. Emergency departments may tell patients to take ibuprofen every eight hours for five weeks, which can lead to rebound headaches, Dr. Taraman said.

Facilitate Recovery

Recognition of certain symptoms can inform the patient’s prognosis and suggest ways to speed recovery. For example, neurologists should look for vestibular dysfunction or balance problems and decide whether to address these symptoms. Neurologists also should check for and address cervical strain and ocular dysfunction. Treating severe convergence insufficiency or excess may help patients recover faster.

Anxiety and mood disorders suggest a prolonged recovery. Some patients develop adjustment disorder after concussion. “Interestingly, we see that patients who have more severe traumatic brain injury … are unaware of their deficits,” whereas high-functioning patients who feel slightly off perceive their deficits, which “causes a lot of discomfort for them,” he said.

Symptoms from concussions that involve assaults and litigation tend to take longer to resolve. Some patients’ symptoms persist until litigation ends, although typically not due to malingering but rather due to increased psychological stress.

Poor headache control, sleep disturbances, prior concussions, and a history of prolonged concussion recovery are other risk factors for prolonged recovery.

The Sport Concussion Assessment Tool 3 (SCAT3) is a free, standardized way of assessing symptoms. Developed as a sideline assessment tool, the SCAT3 also works well as a symptoms form, Dr. Taraman said. The tool includes a quick cognitive assessment and balance exam, and online video tutorials explain how to perform the assessment. After assessing a patient’s symptoms, including cognition, concentration, balance, and convergence insufficiency, “then you can decide, how … to triage the patient and start managing them.”

—Jake Remaly

Suggested Reading

Bressan S, Romanato S, Mion T, et al. Implementation of adapted PECARN decision rule for children with minor head injury in the pediatric emergency department. Acad Emerg Med. 2012;19(7):801-807.

Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170.

Yengo-Kahn AM, Hale AT, Zalneraitis BH, et al. The Sport Concussion Assessment Tool: a systematic review. Neurosurg Focus. 2016;40(4):E6.

VANCOUVER—Initial pediatric concussion evaluations provide an opportunity to recognize premorbid conditions that may be exacerbated by the injury; address problems with prior management, such as excessive rest or NSAID overuse; and identify treatment approaches, according to a seminar delivered at the 45th Annual Meeting of the Child Neurology Society.

Neurologists also may decide whether imaging is warranted and note risk factors for prolonged recovery, said Sharief Taraman, MD, Director of the Children’s Concussion Program at Children’s Hospital of Orange County in Orange, California, and Assistant Clinical Professor of Pediatrics at the University of California, Irvine.

Imaging Likely Not Needed

In most cases, a CT scan is not necessary, Dr. Taraman said. He encouraged neurologists to work with their emergency department colleagues to ensure that patients only undergo CT scans when appropriate. His department uses Pediatric Emergency Care Applied Research Network (PECARN) criteria to determine when a CT scan is warranted. Many patients do not have signs of altered mental status in the emergency department, and “there is really no good reason to scan many of these kids,” he said. Patients also typically do not undergo MRI unless “a significant neurologic finding … suggests that there might have been a stronger mechanism of action.”

History taking is a vital component of initial management, and identifying premorbid conditions is a key factor, Dr. Taraman said. “What we have seen is that concussion symptoms act as a magnifying glass. If I have migraine and I get a concussion, my migraine will likely become exacerbated,” he said. Patients may also present for evaluation of concussion but have an alternate diagnosis that better explains their symptoms. For example, Dr. Taraman described a patient who had persistent symptoms following a concussion. “Listening to the story, it was clearly sleep apnea,” he said. The child underwent polysomnography and received continuous positive airway pressure treatment because he had 40 apneas in an hour.

During the evaluation, neurologists can recognize poor initial management of the injury, such as excessive bed rest or removal from activities. NSAID overuse also is a big problem. Emergency departments may tell patients to take ibuprofen every eight hours for five weeks, which can lead to rebound headaches, Dr. Taraman said.

Facilitate Recovery

Recognition of certain symptoms can inform the patient’s prognosis and suggest ways to speed recovery. For example, neurologists should look for vestibular dysfunction or balance problems and decide whether to address these symptoms. Neurologists also should check for and address cervical strain and ocular dysfunction. Treating severe convergence insufficiency or excess may help patients recover faster.

Anxiety and mood disorders suggest a prolonged recovery. Some patients develop adjustment disorder after concussion. “Interestingly, we see that patients who have more severe traumatic brain injury … are unaware of their deficits,” whereas high-functioning patients who feel slightly off perceive their deficits, which “causes a lot of discomfort for them,” he said.

Symptoms from concussions that involve assaults and litigation tend to take longer to resolve. Some patients’ symptoms persist until litigation ends, although typically not due to malingering but rather due to increased psychological stress.

Poor headache control, sleep disturbances, prior concussions, and a history of prolonged concussion recovery are other risk factors for prolonged recovery.

The Sport Concussion Assessment Tool 3 (SCAT3) is a free, standardized way of assessing symptoms. Developed as a sideline assessment tool, the SCAT3 also works well as a symptoms form, Dr. Taraman said. The tool includes a quick cognitive assessment and balance exam, and online video tutorials explain how to perform the assessment. After assessing a patient’s symptoms, including cognition, concentration, balance, and convergence insufficiency, “then you can decide, how … to triage the patient and start managing them.”

—Jake Remaly

Suggested Reading

Bressan S, Romanato S, Mion T, et al. Implementation of adapted PECARN decision rule for children with minor head injury in the pediatric emergency department. Acad Emerg Med. 2012;19(7):801-807.

Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170.

Yengo-Kahn AM, Hale AT, Zalneraitis BH, et al. The Sport Concussion Assessment Tool: a systematic review. Neurosurg Focus. 2016;40(4):E6.

VANCOUVER—Initial pediatric concussion evaluations provide an opportunity to recognize premorbid conditions that may be exacerbated by the injury; address problems with prior management, such as excessive rest or NSAID overuse; and identify treatment approaches, according to a seminar delivered at the 45th Annual Meeting of the Child Neurology Society.

Neurologists also may decide whether imaging is warranted and note risk factors for prolonged recovery, said Sharief Taraman, MD, Director of the Children’s Concussion Program at Children’s Hospital of Orange County in Orange, California, and Assistant Clinical Professor of Pediatrics at the University of California, Irvine.

Imaging Likely Not Needed

In most cases, a CT scan is not necessary, Dr. Taraman said. He encouraged neurologists to work with their emergency department colleagues to ensure that patients only undergo CT scans when appropriate. His department uses Pediatric Emergency Care Applied Research Network (PECARN) criteria to determine when a CT scan is warranted. Many patients do not have signs of altered mental status in the emergency department, and “there is really no good reason to scan many of these kids,” he said. Patients also typically do not undergo MRI unless “a significant neurologic finding … suggests that there might have been a stronger mechanism of action.”

History taking is a vital component of initial management, and identifying premorbid conditions is a key factor, Dr. Taraman said. “What we have seen is that concussion symptoms act as a magnifying glass. If I have migraine and I get a concussion, my migraine will likely become exacerbated,” he said. Patients may also present for evaluation of concussion but have an alternate diagnosis that better explains their symptoms. For example, Dr. Taraman described a patient who had persistent symptoms following a concussion. “Listening to the story, it was clearly sleep apnea,” he said. The child underwent polysomnography and received continuous positive airway pressure treatment because he had 40 apneas in an hour.

During the evaluation, neurologists can recognize poor initial management of the injury, such as excessive bed rest or removal from activities. NSAID overuse also is a big problem. Emergency departments may tell patients to take ibuprofen every eight hours for five weeks, which can lead to rebound headaches, Dr. Taraman said.

Facilitate Recovery

Recognition of certain symptoms can inform the patient’s prognosis and suggest ways to speed recovery. For example, neurologists should look for vestibular dysfunction or balance problems and decide whether to address these symptoms. Neurologists also should check for and address cervical strain and ocular dysfunction. Treating severe convergence insufficiency or excess may help patients recover faster.

Anxiety and mood disorders suggest a prolonged recovery. Some patients develop adjustment disorder after concussion. “Interestingly, we see that patients who have more severe traumatic brain injury … are unaware of their deficits,” whereas high-functioning patients who feel slightly off perceive their deficits, which “causes a lot of discomfort for them,” he said.

Symptoms from concussions that involve assaults and litigation tend to take longer to resolve. Some patients’ symptoms persist until litigation ends, although typically not due to malingering but rather due to increased psychological stress.

Poor headache control, sleep disturbances, prior concussions, and a history of prolonged concussion recovery are other risk factors for prolonged recovery.

The Sport Concussion Assessment Tool 3 (SCAT3) is a free, standardized way of assessing symptoms. Developed as a sideline assessment tool, the SCAT3 also works well as a symptoms form, Dr. Taraman said. The tool includes a quick cognitive assessment and balance exam, and online video tutorials explain how to perform the assessment. After assessing a patient’s symptoms, including cognition, concentration, balance, and convergence insufficiency, “then you can decide, how … to triage the patient and start managing them.”

—Jake Remaly

Suggested Reading

Bressan S, Romanato S, Mion T, et al. Implementation of adapted PECARN decision rule for children with minor head injury in the pediatric emergency department. Acad Emerg Med. 2012;19(7):801-807.

Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170.

Yengo-Kahn AM, Hale AT, Zalneraitis BH, et al. The Sport Concussion Assessment Tool: a systematic review. Neurosurg Focus. 2016;40(4):E6.

Studies Provide More Insight Into Zika Effects

Three studies reported on the effects of the Zika virus outbreak in Brazil. The first study examined CT findings of the CNS in 16 newborn babies with congenital Zika virus infection confirmed by tests in CSF. The researchers identified a pattern of CT brain findings in the babies, including decreased brain volume, simplified gyral pattern, calcifications, ventricular dilatation, and prominent occipital bone.

"We live in Pernambuco, a state in northeastern Brazil, which had the highest number of patients with microcephaly during the Zika outbreak in our country," said Natacha Calheiros de Lima Petribu, MD, of the Department of Radiology at Barão de Lucena Hospital. "Our study proves that Zika virus infection can cause congenital brain damage in babies with and without microcephaly."  

Another study analyzed the imaging results of three target groups affected by Zika: adults who developed acute neurologic syndrome, newborns with vertical infection with neurologic disorders, and pregnant women with rash outbreaks suggestive of Zika. Many of the adults had symptoms of Guillain-Barré syndrome. A few showed inflammation of the brain and spinal cord (ie, Bickerstaff's encephalitis) or brainstem and spinal cord lesions. Common MRI findings included enhancement of certain spinal and facial nerves. In the newborns, MRI showed orbital injuries and anatomical changes in brain tissue.  

"It was alarming to find so many cases of neurologic syndromes in adults, some very serious, related to Zika virus infection," said study author Emerson de Melo Casagrande, MD, of the Department of Radiology at Antonio Pedro University Hospital--Federal Fluminense University. "We have also noticed a difference between these syndromes, even though the trigger was the same."

In a third study, ultrasound and fetal MRI were performed on pregnant patients with Zika virus infection at different gestational ages. Once the babies were born, they underwent ultrasound, CT, and MRI. The researchers then created 3-D virtual and physical models of the skulls. More than half of the babies had microcephaly, brain calcifications, and loss of brain tissue volume, along with other structural changes.

"The emergence of Zika virus in the Americas has coincided with increased reports of babies born with microcephaly," said study author Heron Werner Jr, MD, PhD, of the Department of Radiology at Clínica de Diagnóstico por Imagem. "An early diagnosis may help in treating these babies after birth. Moreover, the knowledge of abnormalities present in the CNS may give hints about the pathophysiology of the disease."

Head Impacts Lead to Brain Changes in High School Football Players

Brain imaging exams performed on high school football players after a single season reveal changes in the gray and white matter that correlated with exposure to head impacts, according to researchers.

"It is important to understand the potential changes occurring in the brain related to youth contact sports," said Elizabeth Moody Davenport, PhD, a postdoctoral researcher at UT Southwestern Medical Center in Dallas. "We know that some professional football players suffer from a serious condition called chronic traumatic encephalopathy or CTE. We are attempting to find out when and how that process starts, so that we can keep sports a healthy activity for millions of children and adolescents."

The study included 24 players from a high school football team in North Carolina, each of whom wore a helmet outfitted with the Head Impact Telemetry System (HITS) during all practices and games. The helmets are lined with six accelerometers that measure the magnitude, location, and direction of a hit. Data from the helmets can be uploaded to a computer for analysis.  

"We saw changes in these young players' brains on both structural and functional imaging after a single season of football," said Dr. Davenport.  

In the study, each player underwent pre- and post-season imaging, including a specialized MRI scan, from which diffusion tensor imaging and diffusion kurtosis imaging data were extracted to measure the brain's white matter integrity, and a magnetoencephalography (MEG) scan, which records and analyzes the magnetic fields produced by brain waves. Diffusion imaging can measure the structural white matter changes in the brain, and MEG assesses changes in function.

"MEG can be used to measure delta waves in the brain, which are a type of distress signal," said Dr. Davenport. "Delta waves represent slow wave activity that increases after brain injuries. The delta waves we saw came from the surface of the brain, while diffusion imaging is a measure of the white matter deeper in the brain."  

The research team calculated the change in imaging metrics between the pre- and post-season imaging exams. They measured abnormalities observed on diffusion imaging and abnormally increased delta-wave activity on MEG. The imaging results were then combined with player-specific impact data from the HITS. None of the 24 players were diagnosed with a concussion during the study.

Players with greater head impact exposure had the greatest change in diffusion imaging and MEG metrics. "Change in diffusion imaging metrics correlated most to linear acceleration, similar to the impact of a car crash," said Dr. Davenport. "MEG changes correlated most to rotational impact, similar to a boxer's punch. These results demonstrate that you need both imaging metrics to assess impact exposure, because they correlate with different biomechanical processes."

Similar studies are being conducted this fall, and a consortium has been formed to continue the brain imaging research in youth contact sports across the country, said Dr. Davenport. "Without a larger population that is closely followed in a longitudinal study, it is difficult to know the long-term effects of these changes," she said. "We do not know if the brain's developmental trajectory is altered, or if the off-season time allows for the brain to return to normal."

Depression in Soldiers Linked to Brain Disruption From Injury

Using multiple brain imaging techniques, researchers have found that a disruption of the circuitry in the brain's cognitive-emotional pathways may provide a physical foundation for depression symptoms in some service members who have had mild traumatic brain injury (mTBI) in combat. "We can link these connectivity changes in the brain to poor top-down emotional processing and greater maladaptive rumination, or worrying, in symptomatic depressed soldiers after mTBI," said Ping-Hong Yeh, PhD, scientist and physicist at the National Intrepid Center of Excellence, Walter Reed National Military Medical Center in Bethesda, Maryland.

According to the Defense and Veterans Brain Injury Center, 352,619 service members worldwide have been diagnosed with TBI since 2000, the majority of these cases being mTBI. In addition, psychiatric disorders, such as anxiety and major depressive disorders, are becoming common in military personnel with brain injuries.

"With the increased survival of soldiers due to improvements in body armor and advanced medical care, there has been an increase in the number of soldiers surviving major trauma. Consequently, a large number of soldiers are returning from war with mTBI," said Dr. Yeh. "Mood disorders are common in military-related mTBI patients. This is an ongoing problem facing a large number of warriors in current areas of conflict, and it is likely to be a persistent problem for the foreseeable future."

For the study, researchers used diffusion-weighted imaging (DWI) and resting-state functional MRI (fMRI) to examine 130 active male service members diagnosed with mTBI and a control group of 52 men without mTBI. Depression symptoms were rated based on the Beck Depression Inventory (BDI), a 21-item, self-reporting assessment that measures characteristic attitudes and symptoms of depression. Patients with a BDI score greater than 20 are considered to have moderate to severe depression symptoms.

BDI scores showed that 75 of the patients with mTBI had moderate to severe depression symptoms. Imaging results showed that white matter tracts—the circuits that connect brain regions critical for cognitive and emotional control—were disrupted in the patients with moderate to severe depression symptoms. Researchers also saw changes in the gray matter cognitive-emotional networks in these patients.

"We found consistencies in the locations of disrupted neurocircuitry, as revealed by DWI and resting-state fMRI, that are unique to the clinical symptoms of mTBI patients," said Dr. Yeh. "We have related the brain structural and functional changes in cognitive-emotional networks to depressive symptoms in mTBI patients."  

This research can possibly lead to treatment strategies in the future, he added. "Though the results of this study were not applied directly to patient care, the neuroimaging changes we found might be incorporated into treatment plans for personalized medicine in the future."  

Short-Term Sleep Deprivation Affects Heart Function

Getting too little sleep takes a toll on your heart, researchers reported. People who work in fire and emergency medical services, medical residencies, and other high-stress jobs are often called upon to work 24-hour shifts with little opportunity for sleep. While it is known that extreme fatigue can affect many physical, cognitive, and emotional processes, this is the first study to examine how working a 24-hour shift specifically affects cardiac function.

"For the first time, we have shown that short-term sleep deprivation in the context of 24-hour shifts can lead to a significant increase in cardiac contractility, blood pressure, and heart rate," said study author Daniel Kuetting, MD, of the Department of Diagnostic and Interventional Radiology at the University of Bonn in Germany.  

For the study, Dr. Kuetting and colleagues recruited 20 healthy radiologists (19 men) with a mean age of 31.6. Each of the study participants underwent cardiovascular magnetic resonance (CMR) imaging with strain analysis before and after a 24-hour shift with an average of three hours of sleep.

"Cardiac function in the context of sleep deprivation has not previously been investigated with CMR strain analysis, the most sensitive parameter of cardiac contractility," said Dr. Kuetting. The researchers also collected blood and urine samples from the participants and measured blood pressure and heart rate.  

Following short-term sleep deprivation, the participants showed significant increases in mean peak systolic strain (-23.4 vs -21.9), systolic (118.5 mmHg vs 112.8 mmHg) and diastolic (69.2 mmHg vs 62.9 mmHg) blood pressure and heart rate (68.9 bpm vs 63.0 bpm). In addition, the participants had significant increases in levels of thyroid stimulating hormone (TSH), thyroid hormones FT3 and FT4, and cortisol.  

Although the researchers were able to perform follow-up examinations of half of the participants after regular sleep, further study in a larger cohort is needed to determine possible long-term effects of sleep loss, said Dr. Kuetting.

"The study was designed to investigate real-life work-related sleep deprivation," said Dr. Kuetting. "While the participants were not permitted to consume caffeine or food and beverages containing theobromine, such as chocolate, nuts, or tea, we did not take into account factors like individual stress level or environmental stimuli."

As people continue to work longer hours or work at more than one job to make ends meet, it is critical to investigate the detrimental effects of too much work and not enough sleep. The results of this pilot study are transferable to other professions in which long periods of uninterrupted labor are common, said Dr. Kuetting. "These findings may help us better understand how workload and shift duration affect public health."  

Aerobic Exercise Preserves Brain Volume and Improves Cognitive Function

Using a new MRI technique, researchers have found that adults with mild cognitive impairment (MCI) who exercised four times per week during a six-month period experienced an increase in brain volume in specific areas of the brain, but adults who participated in aerobic exercise experienced greater gains than those who just stretched.  

"Even over a short period of time, we saw aerobic exercise lead to a remarkable change in the brain," said Laura D. Baker, PhD, Associate Professor of Gerontology and Geriatric Medicine at Wake Forest School of Medicine (WFSM) in Winston-Salem, North Carolina.

The study included 35 adults with MCI participating in a randomized, controlled trial of exercise intervention. The participants were separated into two groups. Sixteen adults (average age, 63) engaged in aerobic activity, including treadmill, stationary bike, or elliptical training, four times per week for six months. A control group of 19 adults (average age, 67) participated in stretching exercises with the same frequency. High-resolution brain MR images were acquired from all participants before and after the six-month activity period. The MRI results were compared using conventional and biomechanical metrics to measure the change in brain volume and shape.  

"We used high-resolution MR images to measure anatomical changes within areas of the brain to obtain volumetric data and directional information," said Jeongchul Kim, PhD, a coinvestigator at WFSM.  

The analysis revealed that for both the aerobic and stretching groups, brain volume increased in most gray matter regions, including the temporal lobe, which supports short-term memory.  

"Compared to the stretching group, the aerobic activity group had greater preservation of total brain volume, increased local gray matter volume, and increased directional stretch of brain tissue," said Dr. Kim.  

Among participants of the stretching group, the analysis revealed a local contraction, or atrophy, within the white matter connecting fibers. Such directional deformation, or shape change, is partially related to volume loss, but not always, according to Dr. Kim.

"Directional changes in the brain without local volume changes could be a novel biomarker for neurologic disease," he said. "It may be a more sensitive marker for the tiny changes that occur in a specific brain region before volumetric changes are detectable on MRI."  

Both MRI measures are important to the treatment of MCI and Alzheimer's disease, which require the careful tracking of changes in the brain while patients engage in interventions, including diet and exercise, to slow the progression of the disease.  

Study participants were tested to determine the effect of exercise intervention on cognitive performance. Participants in the aerobic exercise group showed statistically significant improvement in executive function after six months, whereas the stretching group did not improve.  

"Any type of exercise can be beneficial," said Dr. Kim. "If possible, aerobic activity may create potential benefits for higher cognitive functioning."    

Studies Provide More Insight Into Zika Effects

Three studies reported on the effects of the Zika virus outbreak in Brazil. The first study examined CT findings of the CNS in 16 newborn babies with congenital Zika virus infection confirmed by tests in CSF. The researchers identified a pattern of CT brain findings in the babies, including decreased brain volume, simplified gyral pattern, calcifications, ventricular dilatation, and prominent occipital bone.

"We live in Pernambuco, a state in northeastern Brazil, which had the highest number of patients with microcephaly during the Zika outbreak in our country," said Natacha Calheiros de Lima Petribu, MD, of the Department of Radiology at Barão de Lucena Hospital. "Our study proves that Zika virus infection can cause congenital brain damage in babies with and without microcephaly."  

Another study analyzed the imaging results of three target groups affected by Zika: adults who developed acute neurologic syndrome, newborns with vertical infection with neurologic disorders, and pregnant women with rash outbreaks suggestive of Zika. Many of the adults had symptoms of Guillain-Barré syndrome. A few showed inflammation of the brain and spinal cord (ie, Bickerstaff's encephalitis) or brainstem and spinal cord lesions. Common MRI findings included enhancement of certain spinal and facial nerves. In the newborns, MRI showed orbital injuries and anatomical changes in brain tissue.  

"It was alarming to find so many cases of neurologic syndromes in adults, some very serious, related to Zika virus infection," said study author Emerson de Melo Casagrande, MD, of the Department of Radiology at Antonio Pedro University Hospital--Federal Fluminense University. "We have also noticed a difference between these syndromes, even though the trigger was the same."

In a third study, ultrasound and fetal MRI were performed on pregnant patients with Zika virus infection at different gestational ages. Once the babies were born, they underwent ultrasound, CT, and MRI. The researchers then created 3-D virtual and physical models of the skulls. More than half of the babies had microcephaly, brain calcifications, and loss of brain tissue volume, along with other structural changes.

"The emergence of Zika virus in the Americas has coincided with increased reports of babies born with microcephaly," said study author Heron Werner Jr, MD, PhD, of the Department of Radiology at Clínica de Diagnóstico por Imagem. "An early diagnosis may help in treating these babies after birth. Moreover, the knowledge of abnormalities present in the CNS may give hints about the pathophysiology of the disease."

Head Impacts Lead to Brain Changes in High School Football Players

Brain imaging exams performed on high school football players after a single season reveal changes in the gray and white matter that correlated with exposure to head impacts, according to researchers.

"It is important to understand the potential changes occurring in the brain related to youth contact sports," said Elizabeth Moody Davenport, PhD, a postdoctoral researcher at UT Southwestern Medical Center in Dallas. "We know that some professional football players suffer from a serious condition called chronic traumatic encephalopathy or CTE. We are attempting to find out when and how that process starts, so that we can keep sports a healthy activity for millions of children and adolescents."

The study included 24 players from a high school football team in North Carolina, each of whom wore a helmet outfitted with the Head Impact Telemetry System (HITS) during all practices and games. The helmets are lined with six accelerometers that measure the magnitude, location, and direction of a hit. Data from the helmets can be uploaded to a computer for analysis.  

"We saw changes in these young players' brains on both structural and functional imaging after a single season of football," said Dr. Davenport.  

In the study, each player underwent pre- and post-season imaging, including a specialized MRI scan, from which diffusion tensor imaging and diffusion kurtosis imaging data were extracted to measure the brain's white matter integrity, and a magnetoencephalography (MEG) scan, which records and analyzes the magnetic fields produced by brain waves. Diffusion imaging can measure the structural white matter changes in the brain, and MEG assesses changes in function.

"MEG can be used to measure delta waves in the brain, which are a type of distress signal," said Dr. Davenport. "Delta waves represent slow wave activity that increases after brain injuries. The delta waves we saw came from the surface of the brain, while diffusion imaging is a measure of the white matter deeper in the brain."  

The research team calculated the change in imaging metrics between the pre- and post-season imaging exams. They measured abnormalities observed on diffusion imaging and abnormally increased delta-wave activity on MEG. The imaging results were then combined with player-specific impact data from the HITS. None of the 24 players were diagnosed with a concussion during the study.

Players with greater head impact exposure had the greatest change in diffusion imaging and MEG metrics. "Change in diffusion imaging metrics correlated most to linear acceleration, similar to the impact of a car crash," said Dr. Davenport. "MEG changes correlated most to rotational impact, similar to a boxer's punch. These results demonstrate that you need both imaging metrics to assess impact exposure, because they correlate with different biomechanical processes."

Similar studies are being conducted this fall, and a consortium has been formed to continue the brain imaging research in youth contact sports across the country, said Dr. Davenport. "Without a larger population that is closely followed in a longitudinal study, it is difficult to know the long-term effects of these changes," she said. "We do not know if the brain's developmental trajectory is altered, or if the off-season time allows for the brain to return to normal."

Depression in Soldiers Linked to Brain Disruption From Injury

Using multiple brain imaging techniques, researchers have found that a disruption of the circuitry in the brain's cognitive-emotional pathways may provide a physical foundation for depression symptoms in some service members who have had mild traumatic brain injury (mTBI) in combat. "We can link these connectivity changes in the brain to poor top-down emotional processing and greater maladaptive rumination, or worrying, in symptomatic depressed soldiers after mTBI," said Ping-Hong Yeh, PhD, scientist and physicist at the National Intrepid Center of Excellence, Walter Reed National Military Medical Center in Bethesda, Maryland.

According to the Defense and Veterans Brain Injury Center, 352,619 service members worldwide have been diagnosed with TBI since 2000, the majority of these cases being mTBI. In addition, psychiatric disorders, such as anxiety and major depressive disorders, are becoming common in military personnel with brain injuries.

"With the increased survival of soldiers due to improvements in body armor and advanced medical care, there has been an increase in the number of soldiers surviving major trauma. Consequently, a large number of soldiers are returning from war with mTBI," said Dr. Yeh. "Mood disorders are common in military-related mTBI patients. This is an ongoing problem facing a large number of warriors in current areas of conflict, and it is likely to be a persistent problem for the foreseeable future."

For the study, researchers used diffusion-weighted imaging (DWI) and resting-state functional MRI (fMRI) to examine 130 active male service members diagnosed with mTBI and a control group of 52 men without mTBI. Depression symptoms were rated based on the Beck Depression Inventory (BDI), a 21-item, self-reporting assessment that measures characteristic attitudes and symptoms of depression. Patients with a BDI score greater than 20 are considered to have moderate to severe depression symptoms.

BDI scores showed that 75 of the patients with mTBI had moderate to severe depression symptoms. Imaging results showed that white matter tracts—the circuits that connect brain regions critical for cognitive and emotional control—were disrupted in the patients with moderate to severe depression symptoms. Researchers also saw changes in the gray matter cognitive-emotional networks in these patients.

"We found consistencies in the locations of disrupted neurocircuitry, as revealed by DWI and resting-state fMRI, that are unique to the clinical symptoms of mTBI patients," said Dr. Yeh. "We have related the brain structural and functional changes in cognitive-emotional networks to depressive symptoms in mTBI patients."  

This research can possibly lead to treatment strategies in the future, he added. "Though the results of this study were not applied directly to patient care, the neuroimaging changes we found might be incorporated into treatment plans for personalized medicine in the future."  

Short-Term Sleep Deprivation Affects Heart Function

Getting too little sleep takes a toll on your heart, researchers reported. People who work in fire and emergency medical services, medical residencies, and other high-stress jobs are often called upon to work 24-hour shifts with little opportunity for sleep. While it is known that extreme fatigue can affect many physical, cognitive, and emotional processes, this is the first study to examine how working a 24-hour shift specifically affects cardiac function.

"For the first time, we have shown that short-term sleep deprivation in the context of 24-hour shifts can lead to a significant increase in cardiac contractility, blood pressure, and heart rate," said study author Daniel Kuetting, MD, of the Department of Diagnostic and Interventional Radiology at the University of Bonn in Germany.  

For the study, Dr. Kuetting and colleagues recruited 20 healthy radiologists (19 men) with a mean age of 31.6. Each of the study participants underwent cardiovascular magnetic resonance (CMR) imaging with strain analysis before and after a 24-hour shift with an average of three hours of sleep.

"Cardiac function in the context of sleep deprivation has not previously been investigated with CMR strain analysis, the most sensitive parameter of cardiac contractility," said Dr. Kuetting. The researchers also collected blood and urine samples from the participants and measured blood pressure and heart rate.  

Following short-term sleep deprivation, the participants showed significant increases in mean peak systolic strain (-23.4 vs -21.9), systolic (118.5 mmHg vs 112.8 mmHg) and diastolic (69.2 mmHg vs 62.9 mmHg) blood pressure and heart rate (68.9 bpm vs 63.0 bpm). In addition, the participants had significant increases in levels of thyroid stimulating hormone (TSH), thyroid hormones FT3 and FT4, and cortisol.  

Although the researchers were able to perform follow-up examinations of half of the participants after regular sleep, further study in a larger cohort is needed to determine possible long-term effects of sleep loss, said Dr. Kuetting.

"The study was designed to investigate real-life work-related sleep deprivation," said Dr. Kuetting. "While the participants were not permitted to consume caffeine or food and beverages containing theobromine, such as chocolate, nuts, or tea, we did not take into account factors like individual stress level or environmental stimuli."

As people continue to work longer hours or work at more than one job to make ends meet, it is critical to investigate the detrimental effects of too much work and not enough sleep. The results of this pilot study are transferable to other professions in which long periods of uninterrupted labor are common, said Dr. Kuetting. "These findings may help us better understand how workload and shift duration affect public health."  

Aerobic Exercise Preserves Brain Volume and Improves Cognitive Function

Using a new MRI technique, researchers have found that adults with mild cognitive impairment (MCI) who exercised four times per week during a six-month period experienced an increase in brain volume in specific areas of the brain, but adults who participated in aerobic exercise experienced greater gains than those who just stretched.  

"Even over a short period of time, we saw aerobic exercise lead to a remarkable change in the brain," said Laura D. Baker, PhD, Associate Professor of Gerontology and Geriatric Medicine at Wake Forest School of Medicine (WFSM) in Winston-Salem, North Carolina.

The study included 35 adults with MCI participating in a randomized, controlled trial of exercise intervention. The participants were separated into two groups. Sixteen adults (average age, 63) engaged in aerobic activity, including treadmill, stationary bike, or elliptical training, four times per week for six months. A control group of 19 adults (average age, 67) participated in stretching exercises with the same frequency. High-resolution brain MR images were acquired from all participants before and after the six-month activity period. The MRI results were compared using conventional and biomechanical metrics to measure the change in brain volume and shape.  

"We used high-resolution MR images to measure anatomical changes within areas of the brain to obtain volumetric data and directional information," said Jeongchul Kim, PhD, a coinvestigator at WFSM.  

The analysis revealed that for both the aerobic and stretching groups, brain volume increased in most gray matter regions, including the temporal lobe, which supports short-term memory.  

"Compared to the stretching group, the aerobic activity group had greater preservation of total brain volume, increased local gray matter volume, and increased directional stretch of brain tissue," said Dr. Kim.  

Among participants of the stretching group, the analysis revealed a local contraction, or atrophy, within the white matter connecting fibers. Such directional deformation, or shape change, is partially related to volume loss, but not always, according to Dr. Kim.

"Directional changes in the brain without local volume changes could be a novel biomarker for neurologic disease," he said. "It may be a more sensitive marker for the tiny changes that occur in a specific brain region before volumetric changes are detectable on MRI."  

Both MRI measures are important to the treatment of MCI and Alzheimer's disease, which require the careful tracking of changes in the brain while patients engage in interventions, including diet and exercise, to slow the progression of the disease.  

Study participants were tested to determine the effect of exercise intervention on cognitive performance. Participants in the aerobic exercise group showed statistically significant improvement in executive function after six months, whereas the stretching group did not improve.  

"Any type of exercise can be beneficial," said Dr. Kim. "If possible, aerobic activity may create potential benefits for higher cognitive functioning."    

Studies Provide More Insight Into Zika Effects

Three studies reported on the effects of the Zika virus outbreak in Brazil. The first study examined CT findings of the CNS in 16 newborn babies with congenital Zika virus infection confirmed by tests in CSF. The researchers identified a pattern of CT brain findings in the babies, including decreased brain volume, simplified gyral pattern, calcifications, ventricular dilatation, and prominent occipital bone.

"We live in Pernambuco, a state in northeastern Brazil, which had the highest number of patients with microcephaly during the Zika outbreak in our country," said Natacha Calheiros de Lima Petribu, MD, of the Department of Radiology at Barão de Lucena Hospital. "Our study proves that Zika virus infection can cause congenital brain damage in babies with and without microcephaly."  

Another study analyzed the imaging results of three target groups affected by Zika: adults who developed acute neurologic syndrome, newborns with vertical infection with neurologic disorders, and pregnant women with rash outbreaks suggestive of Zika. Many of the adults had symptoms of Guillain-Barré syndrome. A few showed inflammation of the brain and spinal cord (ie, Bickerstaff's encephalitis) or brainstem and spinal cord lesions. Common MRI findings included enhancement of certain spinal and facial nerves. In the newborns, MRI showed orbital injuries and anatomical changes in brain tissue.  

"It was alarming to find so many cases of neurologic syndromes in adults, some very serious, related to Zika virus infection," said study author Emerson de Melo Casagrande, MD, of the Department of Radiology at Antonio Pedro University Hospital--Federal Fluminense University. "We have also noticed a difference between these syndromes, even though the trigger was the same."

In a third study, ultrasound and fetal MRI were performed on pregnant patients with Zika virus infection at different gestational ages. Once the babies were born, they underwent ultrasound, CT, and MRI. The researchers then created 3-D virtual and physical models of the skulls. More than half of the babies had microcephaly, brain calcifications, and loss of brain tissue volume, along with other structural changes.

"The emergence of Zika virus in the Americas has coincided with increased reports of babies born with microcephaly," said study author Heron Werner Jr, MD, PhD, of the Department of Radiology at Clínica de Diagnóstico por Imagem. "An early diagnosis may help in treating these babies after birth. Moreover, the knowledge of abnormalities present in the CNS may give hints about the pathophysiology of the disease."

Head Impacts Lead to Brain Changes in High School Football Players

Brain imaging exams performed on high school football players after a single season reveal changes in the gray and white matter that correlated with exposure to head impacts, according to researchers.

"It is important to understand the potential changes occurring in the brain related to youth contact sports," said Elizabeth Moody Davenport, PhD, a postdoctoral researcher at UT Southwestern Medical Center in Dallas. "We know that some professional football players suffer from a serious condition called chronic traumatic encephalopathy or CTE. We are attempting to find out when and how that process starts, so that we can keep sports a healthy activity for millions of children and adolescents."

The study included 24 players from a high school football team in North Carolina, each of whom wore a helmet outfitted with the Head Impact Telemetry System (HITS) during all practices and games. The helmets are lined with six accelerometers that measure the magnitude, location, and direction of a hit. Data from the helmets can be uploaded to a computer for analysis.  

"We saw changes in these young players' brains on both structural and functional imaging after a single season of football," said Dr. Davenport.  

In the study, each player underwent pre- and post-season imaging, including a specialized MRI scan, from which diffusion tensor imaging and diffusion kurtosis imaging data were extracted to measure the brain's white matter integrity, and a magnetoencephalography (MEG) scan, which records and analyzes the magnetic fields produced by brain waves. Diffusion imaging can measure the structural white matter changes in the brain, and MEG assesses changes in function.

"MEG can be used to measure delta waves in the brain, which are a type of distress signal," said Dr. Davenport. "Delta waves represent slow wave activity that increases after brain injuries. The delta waves we saw came from the surface of the brain, while diffusion imaging is a measure of the white matter deeper in the brain."  

The research team calculated the change in imaging metrics between the pre- and post-season imaging exams. They measured abnormalities observed on diffusion imaging and abnormally increased delta-wave activity on MEG. The imaging results were then combined with player-specific impact data from the HITS. None of the 24 players were diagnosed with a concussion during the study.

Players with greater head impact exposure had the greatest change in diffusion imaging and MEG metrics. "Change in diffusion imaging metrics correlated most to linear acceleration, similar to the impact of a car crash," said Dr. Davenport. "MEG changes correlated most to rotational impact, similar to a boxer's punch. These results demonstrate that you need both imaging metrics to assess impact exposure, because they correlate with different biomechanical processes."

Similar studies are being conducted this fall, and a consortium has been formed to continue the brain imaging research in youth contact sports across the country, said Dr. Davenport. "Without a larger population that is closely followed in a longitudinal study, it is difficult to know the long-term effects of these changes," she said. "We do not know if the brain's developmental trajectory is altered, or if the off-season time allows for the brain to return to normal."

Depression in Soldiers Linked to Brain Disruption From Injury

Using multiple brain imaging techniques, researchers have found that a disruption of the circuitry in the brain's cognitive-emotional pathways may provide a physical foundation for depression symptoms in some service members who have had mild traumatic brain injury (mTBI) in combat. "We can link these connectivity changes in the brain to poor top-down emotional processing and greater maladaptive rumination, or worrying, in symptomatic depressed soldiers after mTBI," said Ping-Hong Yeh, PhD, scientist and physicist at the National Intrepid Center of Excellence, Walter Reed National Military Medical Center in Bethesda, Maryland.

According to the Defense and Veterans Brain Injury Center, 352,619 service members worldwide have been diagnosed with TBI since 2000, the majority of these cases being mTBI. In addition, psychiatric disorders, such as anxiety and major depressive disorders, are becoming common in military personnel with brain injuries.

"With the increased survival of soldiers due to improvements in body armor and advanced medical care, there has been an increase in the number of soldiers surviving major trauma. Consequently, a large number of soldiers are returning from war with mTBI," said Dr. Yeh. "Mood disorders are common in military-related mTBI patients. This is an ongoing problem facing a large number of warriors in current areas of conflict, and it is likely to be a persistent problem for the foreseeable future."

For the study, researchers used diffusion-weighted imaging (DWI) and resting-state functional MRI (fMRI) to examine 130 active male service members diagnosed with mTBI and a control group of 52 men without mTBI. Depression symptoms were rated based on the Beck Depression Inventory (BDI), a 21-item, self-reporting assessment that measures characteristic attitudes and symptoms of depression. Patients with a BDI score greater than 20 are considered to have moderate to severe depression symptoms.

BDI scores showed that 75 of the patients with mTBI had moderate to severe depression symptoms. Imaging results showed that white matter tracts—the circuits that connect brain regions critical for cognitive and emotional control—were disrupted in the patients with moderate to severe depression symptoms. Researchers also saw changes in the gray matter cognitive-emotional networks in these patients.

"We found consistencies in the locations of disrupted neurocircuitry, as revealed by DWI and resting-state fMRI, that are unique to the clinical symptoms of mTBI patients," said Dr. Yeh. "We have related the brain structural and functional changes in cognitive-emotional networks to depressive symptoms in mTBI patients."  

This research can possibly lead to treatment strategies in the future, he added. "Though the results of this study were not applied directly to patient care, the neuroimaging changes we found might be incorporated into treatment plans for personalized medicine in the future."  

Short-Term Sleep Deprivation Affects Heart Function

Getting too little sleep takes a toll on your heart, researchers reported. People who work in fire and emergency medical services, medical residencies, and other high-stress jobs are often called upon to work 24-hour shifts with little opportunity for sleep. While it is known that extreme fatigue can affect many physical, cognitive, and emotional processes, this is the first study to examine how working a 24-hour shift specifically affects cardiac function.

"For the first time, we have shown that short-term sleep deprivation in the context of 24-hour shifts can lead to a significant increase in cardiac contractility, blood pressure, and heart rate," said study author Daniel Kuetting, MD, of the Department of Diagnostic and Interventional Radiology at the University of Bonn in Germany.  

For the study, Dr. Kuetting and colleagues recruited 20 healthy radiologists (19 men) with a mean age of 31.6. Each of the study participants underwent cardiovascular magnetic resonance (CMR) imaging with strain analysis before and after a 24-hour shift with an average of three hours of sleep.

"Cardiac function in the context of sleep deprivation has not previously been investigated with CMR strain analysis, the most sensitive parameter of cardiac contractility," said Dr. Kuetting. The researchers also collected blood and urine samples from the participants and measured blood pressure and heart rate.  

Following short-term sleep deprivation, the participants showed significant increases in mean peak systolic strain (-23.4 vs -21.9), systolic (118.5 mmHg vs 112.8 mmHg) and diastolic (69.2 mmHg vs 62.9 mmHg) blood pressure and heart rate (68.9 bpm vs 63.0 bpm). In addition, the participants had significant increases in levels of thyroid stimulating hormone (TSH), thyroid hormones FT3 and FT4, and cortisol.  

Although the researchers were able to perform follow-up examinations of half of the participants after regular sleep, further study in a larger cohort is needed to determine possible long-term effects of sleep loss, said Dr. Kuetting.

"The study was designed to investigate real-life work-related sleep deprivation," said Dr. Kuetting. "While the participants were not permitted to consume caffeine or food and beverages containing theobromine, such as chocolate, nuts, or tea, we did not take into account factors like individual stress level or environmental stimuli."

As people continue to work longer hours or work at more than one job to make ends meet, it is critical to investigate the detrimental effects of too much work and not enough sleep. The results of this pilot study are transferable to other professions in which long periods of uninterrupted labor are common, said Dr. Kuetting. "These findings may help us better understand how workload and shift duration affect public health."  

Aerobic Exercise Preserves Brain Volume and Improves Cognitive Function

Using a new MRI technique, researchers have found that adults with mild cognitive impairment (MCI) who exercised four times per week during a six-month period experienced an increase in brain volume in specific areas of the brain, but adults who participated in aerobic exercise experienced greater gains than those who just stretched.  

"Even over a short period of time, we saw aerobic exercise lead to a remarkable change in the brain," said Laura D. Baker, PhD, Associate Professor of Gerontology and Geriatric Medicine at Wake Forest School of Medicine (WFSM) in Winston-Salem, North Carolina.

The study included 35 adults with MCI participating in a randomized, controlled trial of exercise intervention. The participants were separated into two groups. Sixteen adults (average age, 63) engaged in aerobic activity, including treadmill, stationary bike, or elliptical training, four times per week for six months. A control group of 19 adults (average age, 67) participated in stretching exercises with the same frequency. High-resolution brain MR images were acquired from all participants before and after the six-month activity period. The MRI results were compared using conventional and biomechanical metrics to measure the change in brain volume and shape.  

"We used high-resolution MR images to measure anatomical changes within areas of the brain to obtain volumetric data and directional information," said Jeongchul Kim, PhD, a coinvestigator at WFSM.  

The analysis revealed that for both the aerobic and stretching groups, brain volume increased in most gray matter regions, including the temporal lobe, which supports short-term memory.  

"Compared to the stretching group, the aerobic activity group had greater preservation of total brain volume, increased local gray matter volume, and increased directional stretch of brain tissue," said Dr. Kim.  

Among participants of the stretching group, the analysis revealed a local contraction, or atrophy, within the white matter connecting fibers. Such directional deformation, or shape change, is partially related to volume loss, but not always, according to Dr. Kim.

"Directional changes in the brain without local volume changes could be a novel biomarker for neurologic disease," he said. "It may be a more sensitive marker for the tiny changes that occur in a specific brain region before volumetric changes are detectable on MRI."  

Both MRI measures are important to the treatment of MCI and Alzheimer's disease, which require the careful tracking of changes in the brain while patients engage in interventions, including diet and exercise, to slow the progression of the disease.  

Study participants were tested to determine the effect of exercise intervention on cognitive performance. Participants in the aerobic exercise group showed statistically significant improvement in executive function after six months, whereas the stretching group did not improve.  

"Any type of exercise can be beneficial," said Dr. Kim. "If possible, aerobic activity may create potential benefits for higher cognitive functioning."    

After a traumatic brain injury (TBI), people also experience major sleep problems, including changes in their sleep–wake cycle. A new study published online ahead of print December 21, 2016, in Neurology showed that recovering from these two conditions occurs in parallel.

“These results suggest that monitoring a person’s sleep–wake cycle may be a useful tool for assessing their recovery after TBI,” said study author Nadia Gosselin, PhD, an Assistant Professor in the Department of Psychology at the University of Montréal in Québec. “We found that when someone sustained a brain injury and had not recovered a certain level of consciousness to keep them awake and aware of their surroundings, they were not able to generate a good sleep–wake cycle. But as they recovered, their quality of sleep improved.”

The study involved 30 people, ages 17 to 58, who had been hospitalized for moderate to severe TBI. Most of the patients were in a coma when they were admitted to the hospital, and all initially received care in an ICU. The injuries were caused by motor vehicle accidents for 20 people, falls for seven people, recreational or sports activities for two people and a blow to the head for one person. They were hospitalized for an average of 45 days, with monitoring for the study beginning an average of 21 days into the patient’s stay.

Each person was monitored daily for an average of 11 days for level of consciousness and thinking abilities using the Rancho Los Amigos scale, which ranges from 1 to 8. Each person also wore an activity monitor on the wrist so researchers could measure their sleep.

Researchers found that consciousness and thinking abilities improved hand in hand with measures of quality of sleep, showing a linear relationship.

One measure, the daytime activity ratio, reflects the percentage of activity that occurs during the day. Immediately after the injury, activity occurs throughout the day and night. The study showed that participants reached an acceptable sleep–wake cycle, with a daytime activity ratio of at least 80%, at the same point when they emerged from a minimally conscious state.

The participants still had inadequate sleep–wake cycles, at a score of 5 on the Rancho Los Amigos scale, where people are confused and give inappropriate responses to stimuli, but are able to follow simple commands. Sleep–wake cycles reached adequate levels at the same time that people reached a score of 6 on the Rancho Los Amigos scale, which is when people can give appropriate responses while still depending on outside input for direction. At that level, they can remember relearned tasks, but cannot remember new tasks.

The results were the same when researchers adjusted for the amount of time that had passed since the injury and the amount of medications they had received while they were in the ICU.

“It is possible that there are common underlying brain mechanisms involved in both recovery from TBI and improvement in sleep,” said Dr. Gosselin. “Still, more study needs to be done, and future research may want to examine how hospital lighting and noise also affect quality of sleep for those with TBI.”

Suggested Reading

Duclos C, Dumont M, Arbour C, et al. Parallel recovery of consciousness and sleep in acute traumatic brain injury. Neurology. 2016 Dec 21 [Epub ahead of print].

Soddu A, Bassetti CL. A good sleep for a fresh mind in patients with acute tramatic brain injury. Neurology. 2016 Dec 21 [Epub ahead of print].

After a traumatic brain injury (TBI), people also experience major sleep problems, including changes in their sleep–wake cycle. A new study published online ahead of print December 21, 2016, in Neurology showed that recovering from these two conditions occurs in parallel.

“These results suggest that monitoring a person’s sleep–wake cycle may be a useful tool for assessing their recovery after TBI,” said study author Nadia Gosselin, PhD, an Assistant Professor in the Department of Psychology at the University of Montréal in Québec. “We found that when someone sustained a brain injury and had not recovered a certain level of consciousness to keep them awake and aware of their surroundings, they were not able to generate a good sleep–wake cycle. But as they recovered, their quality of sleep improved.”

The study involved 30 people, ages 17 to 58, who had been hospitalized for moderate to severe TBI. Most of the patients were in a coma when they were admitted to the hospital, and all initially received care in an ICU. The injuries were caused by motor vehicle accidents for 20 people, falls for seven people, recreational or sports activities for two people and a blow to the head for one person. They were hospitalized for an average of 45 days, with monitoring for the study beginning an average of 21 days into the patient’s stay.

Each person was monitored daily for an average of 11 days for level of consciousness and thinking abilities using the Rancho Los Amigos scale, which ranges from 1 to 8. Each person also wore an activity monitor on the wrist so researchers could measure their sleep.

Researchers found that consciousness and thinking abilities improved hand in hand with measures of quality of sleep, showing a linear relationship.

One measure, the daytime activity ratio, reflects the percentage of activity that occurs during the day. Immediately after the injury, activity occurs throughout the day and night. The study showed that participants reached an acceptable sleep–wake cycle, with a daytime activity ratio of at least 80%, at the same point when they emerged from a minimally conscious state.

The participants still had inadequate sleep–wake cycles, at a score of 5 on the Rancho Los Amigos scale, where people are confused and give inappropriate responses to stimuli, but are able to follow simple commands. Sleep–wake cycles reached adequate levels at the same time that people reached a score of 6 on the Rancho Los Amigos scale, which is when people can give appropriate responses while still depending on outside input for direction. At that level, they can remember relearned tasks, but cannot remember new tasks.

The results were the same when researchers adjusted for the amount of time that had passed since the injury and the amount of medications they had received while they were in the ICU.

“It is possible that there are common underlying brain mechanisms involved in both recovery from TBI and improvement in sleep,” said Dr. Gosselin. “Still, more study needs to be done, and future research may want to examine how hospital lighting and noise also affect quality of sleep for those with TBI.”

Suggested Reading

Duclos C, Dumont M, Arbour C, et al. Parallel recovery of consciousness and sleep in acute traumatic brain injury. Neurology. 2016 Dec 21 [Epub ahead of print].

Soddu A, Bassetti CL. A good sleep for a fresh mind in patients with acute tramatic brain injury. Neurology. 2016 Dec 21 [Epub ahead of print].

After a traumatic brain injury (TBI), people also experience major sleep problems, including changes in their sleep–wake cycle. A new study published online ahead of print December 21, 2016, in Neurology showed that recovering from these two conditions occurs in parallel.

“These results suggest that monitoring a person’s sleep–wake cycle may be a useful tool for assessing their recovery after TBI,” said study author Nadia Gosselin, PhD, an Assistant Professor in the Department of Psychology at the University of Montréal in Québec. “We found that when someone sustained a brain injury and had not recovered a certain level of consciousness to keep them awake and aware of their surroundings, they were not able to generate a good sleep–wake cycle. But as they recovered, their quality of sleep improved.”

The study involved 30 people, ages 17 to 58, who had been hospitalized for moderate to severe TBI. Most of the patients were in a coma when they were admitted to the hospital, and all initially received care in an ICU. The injuries were caused by motor vehicle accidents for 20 people, falls for seven people, recreational or sports activities for two people and a blow to the head for one person. They were hospitalized for an average of 45 days, with monitoring for the study beginning an average of 21 days into the patient’s stay.

Each person was monitored daily for an average of 11 days for level of consciousness and thinking abilities using the Rancho Los Amigos scale, which ranges from 1 to 8. Each person also wore an activity monitor on the wrist so researchers could measure their sleep.

Researchers found that consciousness and thinking abilities improved hand in hand with measures of quality of sleep, showing a linear relationship.

One measure, the daytime activity ratio, reflects the percentage of activity that occurs during the day. Immediately after the injury, activity occurs throughout the day and night. The study showed that participants reached an acceptable sleep–wake cycle, with a daytime activity ratio of at least 80%, at the same point when they emerged from a minimally conscious state.

The participants still had inadequate sleep–wake cycles, at a score of 5 on the Rancho Los Amigos scale, where people are confused and give inappropriate responses to stimuli, but are able to follow simple commands. Sleep–wake cycles reached adequate levels at the same time that people reached a score of 6 on the Rancho Los Amigos scale, which is when people can give appropriate responses while still depending on outside input for direction. At that level, they can remember relearned tasks, but cannot remember new tasks.

The results were the same when researchers adjusted for the amount of time that had passed since the injury and the amount of medications they had received while they were in the ICU.

“It is possible that there are common underlying brain mechanisms involved in both recovery from TBI and improvement in sleep,” said Dr. Gosselin. “Still, more study needs to be done, and future research may want to examine how hospital lighting and noise also affect quality of sleep for those with TBI.”

Suggested Reading

Duclos C, Dumont M, Arbour C, et al. Parallel recovery of consciousness and sleep in acute traumatic brain injury. Neurology. 2016 Dec 21 [Epub ahead of print].

Soddu A, Bassetti CL. A good sleep for a fresh mind in patients with acute tramatic brain injury. Neurology. 2016 Dec 21 [Epub ahead of print].

VANCOUVER—Early reductions in N-acetylaspartate (NAA) after pediatric traumatic brain injury (TBI) predict neuropsychologic outcomes one year later, according to a study presented at the 45th Annual Meeting of the Child Neurology Society.

Researchers at Loma Linda University in California conducted a prospective study that looked at NAA levels. In a separate but related study, they found that hemorrhagic MRI brain lesions after pediatric TBI are associated with neurologic and neuropsychologic outcomes at one year.

NAA Levels

Barbara Holshouser, PhD, Professor of Radiology at Loma Linda University, and colleagues used MR spectroscopic imaging (MRSI) to assess NAA levels in 69 children with TBI. Patients were ages 4 to 18, had a Glasgow Coma Scale (GCS) score of 13 to 15, and had hemorrhage or contusion on imaging. Initial scans to assess NAA levels were conducted an average of 11.5 days after injury. Follow-up scans were conducted at one year. The researchers obtained mean NAA/creatine, NAA/choline, and choline/creatine ratios for each brain region. They also scanned 75 controls with no history of head injury.

Patients in the TBI group (n = 69) had an average age of 11.8, and 19 patients were female. Seventeen patients were injured in motor vehicle accidents, 22 patients were hit by a motor vehicle, and one patient was injured in a fight. The other patients were injured in accidents that involved all-terrain vehicles (six patients), falls (16 patients), sports (six patients), and boating (one patient). Patients in the control group (n = 75) had an average age of 12.5, and 39 were female.

Patients with TBI had significant decreases of NAA/creatine and NAA/choline in all brain regions, compared with controls. Patients with TBI were dichotomized by those with a 12-month Pediatric Cerebral Performance Category Scale (PCPCS) score of 1 (ie, normal) and those with a PCPCS score 2 to 5 (ie, with disability).

A logistic regression analysis using total and regional NAA/creatine ratios predicted dichotomized PCPCS, full-scale IQ, general memory, and general attention scores at one year.

“A reduction of NAA in the subcortical region, consisting of the basal ganglia, corpus callosum, and thalamus, showed the strongest, most significant correlations” with tests of visual spatial processing, attention, general memory, and immediate and delayed visual memory. “At the subacute stage, a reduction of NAA caused by neuronal loss or dysfunction is a sensitive marker of injury that can be used to predict long-term (12-month) neurologic and neuropsychologic outcomes,” the researchers concluded.

Hemorrhagic Lesions

Stephen Ashwal, MD, Professor of Pediatric Neurology at Loma Linda University, and colleagues presented the results of a related study that found that, among children with moderate or severe TBI or complicated mild TBI, hemorrhagic MRI brain lesions are associated with neurologic and neuropsychologic outcomes at one year.

Susceptibility weighted imaging (SWI) has improved the ability of MRI to detect and quantify micro- and macro-hemorrhagic lesions after TBI. Studies in children, however, had not included repeated long-term MRI combined with neurologic and neuropsychologic measures. Dr. Ashwal and colleagues conducted a study to assess the relationship of acute lesions with one-year neurologic and neuropsychologic outcomes.

The researchers included 74 patients with moderate or severe TBI (ie, GCS score of less than 13) or complicated mild TBI (ie, with hemorrhagic intracranial injury on CT). Patients underwent MRI at six to 18 days after injury and at one year to determine the number and volume of hemorrhagic brain lesions.

Patients had an average age of 11.4, and 53 were male. Injury mechanisms were assault (one patient), sports (six patients), falls (20 patients), and vehicular (47 patients). Initial median GCS score was 9. Mean initial SWI lesion number was 84.3, and mean initial SWI lesion volume was 10,810.6 cm3.

Thirty-six patients had severe TBI (ie, GCS score of 3 to 8). Patients with severe TBI had higher mean SWI lesion numbers and volumes and lower scores on neuropsychologic tests at 12 months. SWI lesions correlated with general 12-month outcome scores on the PCPCS, King’s Outcome Scale for Childhood Head Injury, and Barthel Activities of Daily Living Index.

Initial SWI lesions correlated with measures of general memory (Children’s Memory Scale) and attention (Test of Everyday Attention for Children), but not IQ. In addition, SWI lesion volume in the occipital lobe correlated with visual immediate memory and visual delayed memory scores. Lesions in the temporal lobe also correlated with visual delayed memory scores.

Total lesion number and volume decreased by approximately 50% over 12 months regardless of initial GCS score, and improvement in lesions was associated with improved neurologic outcomes, Dr. Ashwal and colleagues said.

—Jake Remaly

VANCOUVER—Early reductions in N-acetylaspartate (NAA) after pediatric traumatic brain injury (TBI) predict neuropsychologic outcomes one year later, according to a study presented at the 45th Annual Meeting of the Child Neurology Society.

Researchers at Loma Linda University in California conducted a prospective study that looked at NAA levels. In a separate but related study, they found that hemorrhagic MRI brain lesions after pediatric TBI are associated with neurologic and neuropsychologic outcomes at one year.

NAA Levels

Barbara Holshouser, PhD, Professor of Radiology at Loma Linda University, and colleagues used MR spectroscopic imaging (MRSI) to assess NAA levels in 69 children with TBI. Patients were ages 4 to 18, had a Glasgow Coma Scale (GCS) score of 13 to 15, and had hemorrhage or contusion on imaging. Initial scans to assess NAA levels were conducted an average of 11.5 days after injury. Follow-up scans were conducted at one year. The researchers obtained mean NAA/creatine, NAA/choline, and choline/creatine ratios for each brain region. They also scanned 75 controls with no history of head injury.

Patients in the TBI group (n = 69) had an average age of 11.8, and 19 patients were female. Seventeen patients were injured in motor vehicle accidents, 22 patients were hit by a motor vehicle, and one patient was injured in a fight. The other patients were injured in accidents that involved all-terrain vehicles (six patients), falls (16 patients), sports (six patients), and boating (one patient). Patients in the control group (n = 75) had an average age of 12.5, and 39 were female.

Patients with TBI had significant decreases of NAA/creatine and NAA/choline in all brain regions, compared with controls. Patients with TBI were dichotomized by those with a 12-month Pediatric Cerebral Performance Category Scale (PCPCS) score of 1 (ie, normal) and those with a PCPCS score 2 to 5 (ie, with disability).

A logistic regression analysis using total and regional NAA/creatine ratios predicted dichotomized PCPCS, full-scale IQ, general memory, and general attention scores at one year.

“A reduction of NAA in the subcortical region, consisting of the basal ganglia, corpus callosum, and thalamus, showed the strongest, most significant correlations” with tests of visual spatial processing, attention, general memory, and immediate and delayed visual memory. “At the subacute stage, a reduction of NAA caused by neuronal loss or dysfunction is a sensitive marker of injury that can be used to predict long-term (12-month) neurologic and neuropsychologic outcomes,” the researchers concluded.

Hemorrhagic Lesions

Stephen Ashwal, MD, Professor of Pediatric Neurology at Loma Linda University, and colleagues presented the results of a related study that found that, among children with moderate or severe TBI or complicated mild TBI, hemorrhagic MRI brain lesions are associated with neurologic and neuropsychologic outcomes at one year.

Susceptibility weighted imaging (SWI) has improved the ability of MRI to detect and quantify micro- and macro-hemorrhagic lesions after TBI. Studies in children, however, had not included repeated long-term MRI combined with neurologic and neuropsychologic measures. Dr. Ashwal and colleagues conducted a study to assess the relationship of acute lesions with one-year neurologic and neuropsychologic outcomes.

The researchers included 74 patients with moderate or severe TBI (ie, GCS score of less than 13) or complicated mild TBI (ie, with hemorrhagic intracranial injury on CT). Patients underwent MRI at six to 18 days after injury and at one year to determine the number and volume of hemorrhagic brain lesions.

Patients had an average age of 11.4, and 53 were male. Injury mechanisms were assault (one patient), sports (six patients), falls (20 patients), and vehicular (47 patients). Initial median GCS score was 9. Mean initial SWI lesion number was 84.3, and mean initial SWI lesion volume was 10,810.6 cm3.

Thirty-six patients had severe TBI (ie, GCS score of 3 to 8). Patients with severe TBI had higher mean SWI lesion numbers and volumes and lower scores on neuropsychologic tests at 12 months. SWI lesions correlated with general 12-month outcome scores on the PCPCS, King’s Outcome Scale for Childhood Head Injury, and Barthel Activities of Daily Living Index.

Initial SWI lesions correlated with measures of general memory (Children’s Memory Scale) and attention (Test of Everyday Attention for Children), but not IQ. In addition, SWI lesion volume in the occipital lobe correlated with visual immediate memory and visual delayed memory scores. Lesions in the temporal lobe also correlated with visual delayed memory scores.

Total lesion number and volume decreased by approximately 50% over 12 months regardless of initial GCS score, and improvement in lesions was associated with improved neurologic outcomes, Dr. Ashwal and colleagues said.

—Jake Remaly

VANCOUVER—Early reductions in N-acetylaspartate (NAA) after pediatric traumatic brain injury (TBI) predict neuropsychologic outcomes one year later, according to a study presented at the 45th Annual Meeting of the Child Neurology Society.

Researchers at Loma Linda University in California conducted a prospective study that looked at NAA levels. In a separate but related study, they found that hemorrhagic MRI brain lesions after pediatric TBI are associated with neurologic and neuropsychologic outcomes at one year.

NAA Levels

Barbara Holshouser, PhD, Professor of Radiology at Loma Linda University, and colleagues used MR spectroscopic imaging (MRSI) to assess NAA levels in 69 children with TBI. Patients were ages 4 to 18, had a Glasgow Coma Scale (GCS) score of 13 to 15, and had hemorrhage or contusion on imaging. Initial scans to assess NAA levels were conducted an average of 11.5 days after injury. Follow-up scans were conducted at one year. The researchers obtained mean NAA/creatine, NAA/choline, and choline/creatine ratios for each brain region. They also scanned 75 controls with no history of head injury.

Patients in the TBI group (n = 69) had an average age of 11.8, and 19 patients were female. Seventeen patients were injured in motor vehicle accidents, 22 patients were hit by a motor vehicle, and one patient was injured in a fight. The other patients were injured in accidents that involved all-terrain vehicles (six patients), falls (16 patients), sports (six patients), and boating (one patient). Patients in the control group (n = 75) had an average age of 12.5, and 39 were female.

Patients with TBI had significant decreases of NAA/creatine and NAA/choline in all brain regions, compared with controls. Patients with TBI were dichotomized by those with a 12-month Pediatric Cerebral Performance Category Scale (PCPCS) score of 1 (ie, normal) and those with a PCPCS score 2 to 5 (ie, with disability).

A logistic regression analysis using total and regional NAA/creatine ratios predicted dichotomized PCPCS, full-scale IQ, general memory, and general attention scores at one year.

“A reduction of NAA in the subcortical region, consisting of the basal ganglia, corpus callosum, and thalamus, showed the strongest, most significant correlations” with tests of visual spatial processing, attention, general memory, and immediate and delayed visual memory. “At the subacute stage, a reduction of NAA caused by neuronal loss or dysfunction is a sensitive marker of injury that can be used to predict long-term (12-month) neurologic and neuropsychologic outcomes,” the researchers concluded.

Hemorrhagic Lesions

Stephen Ashwal, MD, Professor of Pediatric Neurology at Loma Linda University, and colleagues presented the results of a related study that found that, among children with moderate or severe TBI or complicated mild TBI, hemorrhagic MRI brain lesions are associated with neurologic and neuropsychologic outcomes at one year.

Susceptibility weighted imaging (SWI) has improved the ability of MRI to detect and quantify micro- and macro-hemorrhagic lesions after TBI. Studies in children, however, had not included repeated long-term MRI combined with neurologic and neuropsychologic measures. Dr. Ashwal and colleagues conducted a study to assess the relationship of acute lesions with one-year neurologic and neuropsychologic outcomes.

The researchers included 74 patients with moderate or severe TBI (ie, GCS score of less than 13) or complicated mild TBI (ie, with hemorrhagic intracranial injury on CT). Patients underwent MRI at six to 18 days after injury and at one year to determine the number and volume of hemorrhagic brain lesions.

Patients had an average age of 11.4, and 53 were male. Injury mechanisms were assault (one patient), sports (six patients), falls (20 patients), and vehicular (47 patients). Initial median GCS score was 9. Mean initial SWI lesion number was 84.3, and mean initial SWI lesion volume was 10,810.6 cm3.

Thirty-six patients had severe TBI (ie, GCS score of 3 to 8). Patients with severe TBI had higher mean SWI lesion numbers and volumes and lower scores on neuropsychologic tests at 12 months. SWI lesions correlated with general 12-month outcome scores on the PCPCS, King’s Outcome Scale for Childhood Head Injury, and Barthel Activities of Daily Living Index.

Initial SWI lesions correlated with measures of general memory (Children’s Memory Scale) and attention (Test of Everyday Attention for Children), but not IQ. In addition, SWI lesion volume in the occipital lobe correlated with visual immediate memory and visual delayed memory scores. Lesions in the temporal lobe also correlated with visual delayed memory scores.

Total lesion number and volume decreased by approximately 50% over 12 months regardless of initial GCS score, and improvement in lesions was associated with improved neurologic outcomes, Dr. Ashwal and colleagues said.

—Jake Remaly

NEW ORLEANS – The severity and duration of hypotension in traumatic brain injury patients during EMS transport to an emergency department has a tight and essentially linear relationship to their mortality rate during subsequent weeks of recovery, according to an analysis of more than 7,500 brain-injured patients.

For each doubling of the combined severity and duration of hypotension during the prehospital period, when systolic blood pressure was less than 90 mm Hg, patient mortality rose by 19%, Daniel W. Spaite, MD, reported at the American Heart Association scientific sessions.

However, the results do not address whether aggressive treatment of hypotension by EMS technicians in a patient with traumatic brain injury (TBI) leads to reduced mortality. That question is being assessed as part of the primary endpoint of the Excellence in Prehospital Injury Care-Traumatic Brain Injury (EPIC-TBI) study, which should have an answer by the end of 2017, said Dr. Spaite, professor of emergency medicine at the University of Arizona in Tuscon.

Mitchel L. Zoler/Frontline Medical News

[email protected] On Twitter @mitchelzoler

NEW ORLEANS – The severity and duration of hypotension in traumatic brain injury patients during EMS transport to an emergency department has a tight and essentially linear relationship to their mortality rate during subsequent weeks of recovery, according to an analysis of more than 7,500 brain-injured patients.

For each doubling of the combined severity and duration of hypotension during the prehospital period, when systolic blood pressure was less than 90 mm Hg, patient mortality rose by 19%, Daniel W. Spaite, MD, reported at the American Heart Association scientific sessions.

However, the results do not address whether aggressive treatment of hypotension by EMS technicians in a patient with traumatic brain injury (TBI) leads to reduced mortality. That question is being assessed as part of the primary endpoint of the Excellence in Prehospital Injury Care-Traumatic Brain Injury (EPIC-TBI) study, which should have an answer by the end of 2017, said Dr. Spaite, professor of emergency medicine at the University of Arizona in Tuscon.

Mitchel L. Zoler/Frontline Medical News

[email protected] On Twitter @mitchelzoler

NEW ORLEANS – The severity and duration of hypotension in traumatic brain injury patients during EMS transport to an emergency department has a tight and essentially linear relationship to their mortality rate during subsequent weeks of recovery, according to an analysis of more than 7,500 brain-injured patients.

For each doubling of the combined severity and duration of hypotension during the prehospital period, when systolic blood pressure was less than 90 mm Hg, patient mortality rose by 19%, Daniel W. Spaite, MD, reported at the American Heart Association scientific sessions.

However, the results do not address whether aggressive treatment of hypotension by EMS technicians in a patient with traumatic brain injury (TBI) leads to reduced mortality. That question is being assessed as part of the primary endpoint of the Excellence in Prehospital Injury Care-Traumatic Brain Injury (EPIC-TBI) study, which should have an answer by the end of 2017, said Dr. Spaite, professor of emergency medicine at the University of Arizona in Tuscon.

Mitchel L. Zoler/Frontline Medical News

[email protected] On Twitter @mitchelzoler