Traumatic Brain Injury

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

Sertraline may help to prevent the onset of depressive disorders after a traumatic brain injury (TBI), according to data published online ahead of print September 14 in JAMA Psychiatry.

“Our findings suggest that sertraline given at a low dosage early after TBI is an efficacious strategy to prevent depression after TBI,” said Ricardo E. Jorge, MD, Professor of Psychiatry and Behavioral Sciences at Baylor College of Medicine in Houston.

Every year, there are approximately 1.7 million cases of TBI in the United States. TBI contributes to 30% of all injury deaths and is a major cause of death and disability in the US, according to the Centers for Disease Control and Prevention.

Depressive disorders are common after TBI. In two studies, 58 of 157 patients developed a depressive disorder during the first year following TBI. Dr. Jorge and his colleagues conducted a double-blind, placebo-controlled study to assess the efficacy of sertraline in preventing depressive disorders following TBI. Their main outcome was time to onset of depressive disorder, as defined by the DSM-IV, associated with TBI.

“We hypothesized that the time from baseline to onset of depressive disorders would be greater in a group of patients randomized to receive sertraline treatment versus a group of patients randomized to receive placebo,” said Dr. Jorge. “We also hypothesized that, when compared with patients receiving placebo, patients receiving sertraline would show better performance in a set of neuropsychologic tests after six months of treatment.”

For the study, 94 patients were randomized to receive 100 mg/day of sertraline or placebo once daily for 24 weeks or until the development of a mood disorder. The age of participants ranged between 18 and 85, and patients had mild, moderate, or severe TBI. In addition, participants were required to have complete recovery of posttraumatic amnesia within four weeks of the traumatic episode. Patients with ongoing depression were excluded from the study. Furthermore, patients with mood disorders were required to have been in full remission for at least a year following discontinuation of treatment.

Researchers used the Mini-International Neuropsychiatric Interview and DSM-IV criteria to diagnose depressive disorders. In addition, participants were evaluated at baseline and at two, four, eight, 12, 16, 20, and 24 weeks. A Mini-International Neuropsychiatric Interview was administered via telephone on weeks six, 10, 14, 18, and 22.

The number of patients needed to treat to prevent development of depression after TBI at 24 weeks was 5.9. There were no incident cases of anxiety disorders, and one patient had suicidal ideation. Nearly all patients reported mild or moderate adverse events in the sertraline and placebo groups. Sexual adverse events were mild and did not significantly impact the quality of life of participants. Frequencies of dry mouth and diarrhea were higher among participants who received sertraline.

“The fact that small doses of sertraline are efficacious to prevent depression after TBI stands in sharp contrast to the lack of efficacy of antidepressants to treat depression in the chronic stage of TBI,” said Dr. Jorge.

Limitations of this study include its scarce representation of ethnic and racial minorities, small sample size, and limited follow-up following incident TBI.

—Erica Tricarico

Suggested Reading

Jorge RE, Acion L, Burin DI, Robinson RG. Sertraline for preventing mood disorders following traumatic brain injury. JAMA Psychiatry. 2016 Sep 14 [Epub ahead of print].

Sertraline may help to prevent the onset of depressive disorders after a traumatic brain injury (TBI), according to data published online ahead of print September 14 in JAMA Psychiatry.

“Our findings suggest that sertraline given at a low dosage early after TBI is an efficacious strategy to prevent depression after TBI,” said Ricardo E. Jorge, MD, Professor of Psychiatry and Behavioral Sciences at Baylor College of Medicine in Houston.

Every year, there are approximately 1.7 million cases of TBI in the United States. TBI contributes to 30% of all injury deaths and is a major cause of death and disability in the US, according to the Centers for Disease Control and Prevention.

Depressive disorders are common after TBI. In two studies, 58 of 157 patients developed a depressive disorder during the first year following TBI. Dr. Jorge and his colleagues conducted a double-blind, placebo-controlled study to assess the efficacy of sertraline in preventing depressive disorders following TBI. Their main outcome was time to onset of depressive disorder, as defined by the DSM-IV, associated with TBI.

“We hypothesized that the time from baseline to onset of depressive disorders would be greater in a group of patients randomized to receive sertraline treatment versus a group of patients randomized to receive placebo,” said Dr. Jorge. “We also hypothesized that, when compared with patients receiving placebo, patients receiving sertraline would show better performance in a set of neuropsychologic tests after six months of treatment.”

For the study, 94 patients were randomized to receive 100 mg/day of sertraline or placebo once daily for 24 weeks or until the development of a mood disorder. The age of participants ranged between 18 and 85, and patients had mild, moderate, or severe TBI. In addition, participants were required to have complete recovery of posttraumatic amnesia within four weeks of the traumatic episode. Patients with ongoing depression were excluded from the study. Furthermore, patients with mood disorders were required to have been in full remission for at least a year following discontinuation of treatment.

Researchers used the Mini-International Neuropsychiatric Interview and DSM-IV criteria to diagnose depressive disorders. In addition, participants were evaluated at baseline and at two, four, eight, 12, 16, 20, and 24 weeks. A Mini-International Neuropsychiatric Interview was administered via telephone on weeks six, 10, 14, 18, and 22.

The number of patients needed to treat to prevent development of depression after TBI at 24 weeks was 5.9. There were no incident cases of anxiety disorders, and one patient had suicidal ideation. Nearly all patients reported mild or moderate adverse events in the sertraline and placebo groups. Sexual adverse events were mild and did not significantly impact the quality of life of participants. Frequencies of dry mouth and diarrhea were higher among participants who received sertraline.

“The fact that small doses of sertraline are efficacious to prevent depression after TBI stands in sharp contrast to the lack of efficacy of antidepressants to treat depression in the chronic stage of TBI,” said Dr. Jorge.

Limitations of this study include its scarce representation of ethnic and racial minorities, small sample size, and limited follow-up following incident TBI.

—Erica Tricarico

Suggested Reading

Jorge RE, Acion L, Burin DI, Robinson RG. Sertraline for preventing mood disorders following traumatic brain injury. JAMA Psychiatry. 2016 Sep 14 [Epub ahead of print].

Sertraline may help to prevent the onset of depressive disorders after a traumatic brain injury (TBI), according to data published online ahead of print September 14 in JAMA Psychiatry.

“Our findings suggest that sertraline given at a low dosage early after TBI is an efficacious strategy to prevent depression after TBI,” said Ricardo E. Jorge, MD, Professor of Psychiatry and Behavioral Sciences at Baylor College of Medicine in Houston.

Every year, there are approximately 1.7 million cases of TBI in the United States. TBI contributes to 30% of all injury deaths and is a major cause of death and disability in the US, according to the Centers for Disease Control and Prevention.

Depressive disorders are common after TBI. In two studies, 58 of 157 patients developed a depressive disorder during the first year following TBI. Dr. Jorge and his colleagues conducted a double-blind, placebo-controlled study to assess the efficacy of sertraline in preventing depressive disorders following TBI. Their main outcome was time to onset of depressive disorder, as defined by the DSM-IV, associated with TBI.

“We hypothesized that the time from baseline to onset of depressive disorders would be greater in a group of patients randomized to receive sertraline treatment versus a group of patients randomized to receive placebo,” said Dr. Jorge. “We also hypothesized that, when compared with patients receiving placebo, patients receiving sertraline would show better performance in a set of neuropsychologic tests after six months of treatment.”

For the study, 94 patients were randomized to receive 100 mg/day of sertraline or placebo once daily for 24 weeks or until the development of a mood disorder. The age of participants ranged between 18 and 85, and patients had mild, moderate, or severe TBI. In addition, participants were required to have complete recovery of posttraumatic amnesia within four weeks of the traumatic episode. Patients with ongoing depression were excluded from the study. Furthermore, patients with mood disorders were required to have been in full remission for at least a year following discontinuation of treatment.

Researchers used the Mini-International Neuropsychiatric Interview and DSM-IV criteria to diagnose depressive disorders. In addition, participants were evaluated at baseline and at two, four, eight, 12, 16, 20, and 24 weeks. A Mini-International Neuropsychiatric Interview was administered via telephone on weeks six, 10, 14, 18, and 22.

The number of patients needed to treat to prevent development of depression after TBI at 24 weeks was 5.9. There were no incident cases of anxiety disorders, and one patient had suicidal ideation. Nearly all patients reported mild or moderate adverse events in the sertraline and placebo groups. Sexual adverse events were mild and did not significantly impact the quality of life of participants. Frequencies of dry mouth and diarrhea were higher among participants who received sertraline.

“The fact that small doses of sertraline are efficacious to prevent depression after TBI stands in sharp contrast to the lack of efficacy of antidepressants to treat depression in the chronic stage of TBI,” said Dr. Jorge.

Limitations of this study include its scarce representation of ethnic and racial minorities, small sample size, and limited follow-up following incident TBI.

—Erica Tricarico

Suggested Reading

Jorge RE, Acion L, Burin DI, Robinson RG. Sertraline for preventing mood disorders following traumatic brain injury. JAMA Psychiatry. 2016 Sep 14 [Epub ahead of print].

HILTON HEAD, SC—Physicians sometimes order unnecessary medical tests and procedures for their patients, which results in wasteful spending and inappropriate care. Following medical associations’ practice recommendations, which have been collected by the Choosing Wisely initiative, can help physicians reduce waste in the health care system and provide appropriate treatment for patients, according to an overview presented at the 39th Annual Contemporary Clinical Neurology Symposium.

Avoiding Unnecessary Treatments and Tests

The American Board of Internal Medicine Foundation created the Choosing Wisely website to encourage dialogue between physicians and patients about the overuse of treatments and tests. An additional goal was to empower patients to make informed treatment decisions. More than 70 societies, including the American Academy of Neurology (AAN) and the American Headache Society, submitted recommendations to advise patients and clinicians about proper healthcare. “You can find a list of all the organizations that contributed on the Choosing Wisely website, and each one was asked to contribute five different topics for Choosing Wisely,” said Peter Donofrio, MD, Professor of Neurology at Vanderbilt University in Nashville.

The AAN recommends that clinicians not perform an EEG for headaches. In addition, the organization recommends that physicians not perform imaging of the carotid arteries for simple syncope without other neurologic symptoms. For patients with migraine, opioids or butalbital treatment should be a last resort. The AAN also recommends that doctors not prescribe interferon-beta or glatiramer acetate for patients with disability resulting from progressive, nonrelapsing forms of multiple sclerosis, because the drugs are ineffective. Finally, it advises doctors not to recommend carotid endarterectomy for asymptomatic carotid stenosis unless the complication rate from surgery is less than 3%.

The American Association of Neuromuscular and Electrodiagnostic Medicine recommends that physicians not perform MRI scans of the brain or spine for patients with peripheral neuropathy without signs of cerebral or spinal cord disease. In addition, the association discourages physicians from performing nerve conduction studies (NCSs) without a needle EMG for radiculopathy assessment. It also recommends that physicians not order or perform four-limb EMG/NCS testing for neck or back pain after trauma.

Treating Acute Low Back Pain and Headache

Other medical associations have made recommendations regarding the assessment and treatment of acute low back pain and headache. The North American Spine Society does not recommend advanced imaging of the spine within the first six weeks in patients with nonspecific acute low back pain in the absence of red flags.

The American Headache Society (AHS) recommends that physicians avoid advising prolonged or frequent use of over-the-counter pain medications for headache. The organization also discourages physicians from prescribing opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders. Furthermore, it does not recommend surgical deactivation of migraine trigger points outside of a clinical trial. In addition, the society advises physicians not to perform CT imaging for headache when an MRI is available, except in emergency settings. The society also recommends that physicians should not perform neuroimaging studies for patients with stable headaches that meet migraine criteria.

When CT Scans Are Unnecessary in Children

The American Academy of Pediatrics (AAP) advises that CT scans and MRI scans are not necessary in a child with simple febrile seizure. The AAP also does not recommend CT scans for the immediate evaluation of minor head injuries; clinical observation and Pediatric Emergency Care Applied Research Network (PECARN) criteria should be used to determine whether imaging is indicated.

Treating Insomnia and Sleep Disorders

The American Academy of Sleep Medicine advises doctors not to prescribe medication for childhood insomnia, which usually arises from parent–child interactions and responds to behavioral intervention. In addition, the academy does not recommend the use of hypnotics as a primary therapy for chronic insomnia in adults; instead, it advises physicians to offer cognitive behavioral therapy and reserve medication for adjunctive treatment when necessary. It recommends that a polysomnography be avoided in chronic insomnia unless symptoms suggest a comorbid sleep disorder. Additional Choosing Wisely recommendations are available at www.choosingwisely.org.

—Erica Tricarico

Suggested Reading

Callaghan BC, De Lott LB, Kerber KA, et al. Neurology Choosing Wisely recommendations: 74 and growing. Neurol Clin Pract. 2015;5(5):439-447.

Langer-Gould AM, Anderson WE, Armstrong MJ, et al. The American Academy of Neurology’s top five choosing wisely recommendations. Neurology. 2013;81(11):1004-1011.

Loder E, Weisenbaum E, Fishberg B, et al. Choosing wisely in headache medicine: the American Headache Society’s list of five things physicians and patients should question. Headache. 2013;53(10):1651-1659.

HILTON HEAD, SC—Physicians sometimes order unnecessary medical tests and procedures for their patients, which results in wasteful spending and inappropriate care. Following medical associations’ practice recommendations, which have been collected by the Choosing Wisely initiative, can help physicians reduce waste in the health care system and provide appropriate treatment for patients, according to an overview presented at the 39th Annual Contemporary Clinical Neurology Symposium.

Avoiding Unnecessary Treatments and Tests

The American Board of Internal Medicine Foundation created the Choosing Wisely website to encourage dialogue between physicians and patients about the overuse of treatments and tests. An additional goal was to empower patients to make informed treatment decisions. More than 70 societies, including the American Academy of Neurology (AAN) and the American Headache Society, submitted recommendations to advise patients and clinicians about proper healthcare. “You can find a list of all the organizations that contributed on the Choosing Wisely website, and each one was asked to contribute five different topics for Choosing Wisely,” said Peter Donofrio, MD, Professor of Neurology at Vanderbilt University in Nashville.

The AAN recommends that clinicians not perform an EEG for headaches. In addition, the organization recommends that physicians not perform imaging of the carotid arteries for simple syncope without other neurologic symptoms. For patients with migraine, opioids or butalbital treatment should be a last resort. The AAN also recommends that doctors not prescribe interferon-beta or glatiramer acetate for patients with disability resulting from progressive, nonrelapsing forms of multiple sclerosis, because the drugs are ineffective. Finally, it advises doctors not to recommend carotid endarterectomy for asymptomatic carotid stenosis unless the complication rate from surgery is less than 3%.

The American Association of Neuromuscular and Electrodiagnostic Medicine recommends that physicians not perform MRI scans of the brain or spine for patients with peripheral neuropathy without signs of cerebral or spinal cord disease. In addition, the association discourages physicians from performing nerve conduction studies (NCSs) without a needle EMG for radiculopathy assessment. It also recommends that physicians not order or perform four-limb EMG/NCS testing for neck or back pain after trauma.

Treating Acute Low Back Pain and Headache

Other medical associations have made recommendations regarding the assessment and treatment of acute low back pain and headache. The North American Spine Society does not recommend advanced imaging of the spine within the first six weeks in patients with nonspecific acute low back pain in the absence of red flags.

The American Headache Society (AHS) recommends that physicians avoid advising prolonged or frequent use of over-the-counter pain medications for headache. The organization also discourages physicians from prescribing opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders. Furthermore, it does not recommend surgical deactivation of migraine trigger points outside of a clinical trial. In addition, the society advises physicians not to perform CT imaging for headache when an MRI is available, except in emergency settings. The society also recommends that physicians should not perform neuroimaging studies for patients with stable headaches that meet migraine criteria.

When CT Scans Are Unnecessary in Children

The American Academy of Pediatrics (AAP) advises that CT scans and MRI scans are not necessary in a child with simple febrile seizure. The AAP also does not recommend CT scans for the immediate evaluation of minor head injuries; clinical observation and Pediatric Emergency Care Applied Research Network (PECARN) criteria should be used to determine whether imaging is indicated.

Treating Insomnia and Sleep Disorders

The American Academy of Sleep Medicine advises doctors not to prescribe medication for childhood insomnia, which usually arises from parent–child interactions and responds to behavioral intervention. In addition, the academy does not recommend the use of hypnotics as a primary therapy for chronic insomnia in adults; instead, it advises physicians to offer cognitive behavioral therapy and reserve medication for adjunctive treatment when necessary. It recommends that a polysomnography be avoided in chronic insomnia unless symptoms suggest a comorbid sleep disorder. Additional Choosing Wisely recommendations are available at www.choosingwisely.org.

—Erica Tricarico

Suggested Reading

Callaghan BC, De Lott LB, Kerber KA, et al. Neurology Choosing Wisely recommendations: 74 and growing. Neurol Clin Pract. 2015;5(5):439-447.

Langer-Gould AM, Anderson WE, Armstrong MJ, et al. The American Academy of Neurology’s top five choosing wisely recommendations. Neurology. 2013;81(11):1004-1011.

Loder E, Weisenbaum E, Fishberg B, et al. Choosing wisely in headache medicine: the American Headache Society’s list of five things physicians and patients should question. Headache. 2013;53(10):1651-1659.

HILTON HEAD, SC—Physicians sometimes order unnecessary medical tests and procedures for their patients, which results in wasteful spending and inappropriate care. Following medical associations’ practice recommendations, which have been collected by the Choosing Wisely initiative, can help physicians reduce waste in the health care system and provide appropriate treatment for patients, according to an overview presented at the 39th Annual Contemporary Clinical Neurology Symposium.

Avoiding Unnecessary Treatments and Tests

The American Board of Internal Medicine Foundation created the Choosing Wisely website to encourage dialogue between physicians and patients about the overuse of treatments and tests. An additional goal was to empower patients to make informed treatment decisions. More than 70 societies, including the American Academy of Neurology (AAN) and the American Headache Society, submitted recommendations to advise patients and clinicians about proper healthcare. “You can find a list of all the organizations that contributed on the Choosing Wisely website, and each one was asked to contribute five different topics for Choosing Wisely,” said Peter Donofrio, MD, Professor of Neurology at Vanderbilt University in Nashville.

The AAN recommends that clinicians not perform an EEG for headaches. In addition, the organization recommends that physicians not perform imaging of the carotid arteries for simple syncope without other neurologic symptoms. For patients with migraine, opioids or butalbital treatment should be a last resort. The AAN also recommends that doctors not prescribe interferon-beta or glatiramer acetate for patients with disability resulting from progressive, nonrelapsing forms of multiple sclerosis, because the drugs are ineffective. Finally, it advises doctors not to recommend carotid endarterectomy for asymptomatic carotid stenosis unless the complication rate from surgery is less than 3%.

The American Association of Neuromuscular and Electrodiagnostic Medicine recommends that physicians not perform MRI scans of the brain or spine for patients with peripheral neuropathy without signs of cerebral or spinal cord disease. In addition, the association discourages physicians from performing nerve conduction studies (NCSs) without a needle EMG for radiculopathy assessment. It also recommends that physicians not order or perform four-limb EMG/NCS testing for neck or back pain after trauma.

Treating Acute Low Back Pain and Headache

Other medical associations have made recommendations regarding the assessment and treatment of acute low back pain and headache. The North American Spine Society does not recommend advanced imaging of the spine within the first six weeks in patients with nonspecific acute low back pain in the absence of red flags.

The American Headache Society (AHS) recommends that physicians avoid advising prolonged or frequent use of over-the-counter pain medications for headache. The organization also discourages physicians from prescribing opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders. Furthermore, it does not recommend surgical deactivation of migraine trigger points outside of a clinical trial. In addition, the society advises physicians not to perform CT imaging for headache when an MRI is available, except in emergency settings. The society also recommends that physicians should not perform neuroimaging studies for patients with stable headaches that meet migraine criteria.

When CT Scans Are Unnecessary in Children

The American Academy of Pediatrics (AAP) advises that CT scans and MRI scans are not necessary in a child with simple febrile seizure. The AAP also does not recommend CT scans for the immediate evaluation of minor head injuries; clinical observation and Pediatric Emergency Care Applied Research Network (PECARN) criteria should be used to determine whether imaging is indicated.

Treating Insomnia and Sleep Disorders

The American Academy of Sleep Medicine advises doctors not to prescribe medication for childhood insomnia, which usually arises from parent–child interactions and responds to behavioral intervention. In addition, the academy does not recommend the use of hypnotics as a primary therapy for chronic insomnia in adults; instead, it advises physicians to offer cognitive behavioral therapy and reserve medication for adjunctive treatment when necessary. It recommends that a polysomnography be avoided in chronic insomnia unless symptoms suggest a comorbid sleep disorder. Additional Choosing Wisely recommendations are available at www.choosingwisely.org.

—Erica Tricarico

Suggested Reading

Callaghan BC, De Lott LB, Kerber KA, et al. Neurology Choosing Wisely recommendations: 74 and growing. Neurol Clin Pract. 2015;5(5):439-447.

Langer-Gould AM, Anderson WE, Armstrong MJ, et al. The American Academy of Neurology’s top five choosing wisely recommendations. Neurology. 2013;81(11):1004-1011.

Loder E, Weisenbaum E, Fishberg B, et al. Choosing wisely in headache medicine: the American Headache Society’s list of five things physicians and patients should question. Headache. 2013;53(10):1651-1659.

Increasing numbers of adolescents are presenting to physicians for management of concussions. This is mainly because of much greater awareness of the signs, symptoms, and potential adverse effects. While the majority of concussed teens recover in less than two weeks, 10% to 15% will have prolonged symptoms (greater than one month), which has significant negative impact on their health, mood, social functioning, and academic performance. This is the first study to provide evidence-based guidance for treating these slow-to-recover teens.

I definitely believe there is value in adding CBT to postconcussive therapy for teens. I have seen CBT help a large number of my own patients who are suffering from prolonged postconcussion symptoms, so it is good to see the results of this well-done study support this approach. One caveat with CBT is that its success hinges on the patient's being receptive to the idea of CBT and consistent with applying it in daily life, so it may not work for teens who are not motivated to learn and apply its techniques.

I am not surprised by the results of the study. A large proportion of the adolescents I treat for concussions are referred by their pediatricians because they are suffering from prolonged symptoms. We have anecdotally noted that when a collaborative care model is applied, similar to what was provided for the intervention group in this study, including CBT, patients experience more rapid decrease in symptoms, improved mood, and smoother transition back to baseline functioning, especially in school. I suspect this is because CBT teaches them effective coping skills, and the bonus is that these skills are incredibly useful across one's lifetime, not just for concussion recovery.

Adolescents who are slow to recover from a concussion commonly experience depressive symptoms. This study suggests CBT is a promising treatment for improving mood and facilitating recovery for these teens. However, a larger study is needed with more diverse subject population. This study included only 49 subjects, and the majority of them were white females. A larger study is needed to determine whether CBT is as feasible and effective for other populations of teens with prolonged concussion symptoms. Also, longer-term longitudinal studies are needed to better understand the etiology of persistent postconcussive symptoms and long-term effects 10 to 20 years down the road.

—Cynthia LaBella, MD
Director of the Concussion Program
Ann & Robert H. Lurie Children's Hospital of Chicago

Increasing numbers of adolescents are presenting to physicians for management of concussions. This is mainly because of much greater awareness of the signs, symptoms, and potential adverse effects. While the majority of concussed teens recover in less than two weeks, 10% to 15% will have prolonged symptoms (greater than one month), which has significant negative impact on their health, mood, social functioning, and academic performance. This is the first study to provide evidence-based guidance for treating these slow-to-recover teens.

I definitely believe there is value in adding CBT to postconcussive therapy for teens. I have seen CBT help a large number of my own patients who are suffering from prolonged postconcussion symptoms, so it is good to see the results of this well-done study support this approach. One caveat with CBT is that its success hinges on the patient's being receptive to the idea of CBT and consistent with applying it in daily life, so it may not work for teens who are not motivated to learn and apply its techniques.

I am not surprised by the results of the study. A large proportion of the adolescents I treat for concussions are referred by their pediatricians because they are suffering from prolonged symptoms. We have anecdotally noted that when a collaborative care model is applied, similar to what was provided for the intervention group in this study, including CBT, patients experience more rapid decrease in symptoms, improved mood, and smoother transition back to baseline functioning, especially in school. I suspect this is because CBT teaches them effective coping skills, and the bonus is that these skills are incredibly useful across one's lifetime, not just for concussion recovery.

Adolescents who are slow to recover from a concussion commonly experience depressive symptoms. This study suggests CBT is a promising treatment for improving mood and facilitating recovery for these teens. However, a larger study is needed with more diverse subject population. This study included only 49 subjects, and the majority of them were white females. A larger study is needed to determine whether CBT is as feasible and effective for other populations of teens with prolonged concussion symptoms. Also, longer-term longitudinal studies are needed to better understand the etiology of persistent postconcussive symptoms and long-term effects 10 to 20 years down the road.

—Cynthia LaBella, MD
Director of the Concussion Program
Ann & Robert H. Lurie Children's Hospital of Chicago

Increasing numbers of adolescents are presenting to physicians for management of concussions. This is mainly because of much greater awareness of the signs, symptoms, and potential adverse effects. While the majority of concussed teens recover in less than two weeks, 10% to 15% will have prolonged symptoms (greater than one month), which has significant negative impact on their health, mood, social functioning, and academic performance. This is the first study to provide evidence-based guidance for treating these slow-to-recover teens.

I definitely believe there is value in adding CBT to postconcussive therapy for teens. I have seen CBT help a large number of my own patients who are suffering from prolonged postconcussion symptoms, so it is good to see the results of this well-done study support this approach. One caveat with CBT is that its success hinges on the patient's being receptive to the idea of CBT and consistent with applying it in daily life, so it may not work for teens who are not motivated to learn and apply its techniques.

I am not surprised by the results of the study. A large proportion of the adolescents I treat for concussions are referred by their pediatricians because they are suffering from prolonged symptoms. We have anecdotally noted that when a collaborative care model is applied, similar to what was provided for the intervention group in this study, including CBT, patients experience more rapid decrease in symptoms, improved mood, and smoother transition back to baseline functioning, especially in school. I suspect this is because CBT teaches them effective coping skills, and the bonus is that these skills are incredibly useful across one's lifetime, not just for concussion recovery.

Adolescents who are slow to recover from a concussion commonly experience depressive symptoms. This study suggests CBT is a promising treatment for improving mood and facilitating recovery for these teens. However, a larger study is needed with more diverse subject population. This study included only 49 subjects, and the majority of them were white females. A larger study is needed to determine whether CBT is as feasible and effective for other populations of teens with prolonged concussion symptoms. Also, longer-term longitudinal studies are needed to better understand the etiology of persistent postconcussive symptoms and long-term effects 10 to 20 years down the road.

—Cynthia LaBella, MD
Director of the Concussion Program
Ann & Robert H. Lurie Children's Hospital of Chicago