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Expanded Disability Pay for Patients With TBI
The VA has developed new regulations that could make getting additional disability pay easier now for some veterans who have traumatic brain injury (TBI) in addition to Parkinson disease, certain types of dementia, depression, unprovoked seizures, or certain diseases of the hypothalamus and pituitary glands.
The new regulations, which took effect in January, were born of a 2008 Institute of Medicine report, Gulf War and Health, Volume 7: Long-Term Consequences of Traumatic Brain Injury. That report was based on a consensus by a National Academy of Sciences committee of experts, which found “sufficient evidence” to link moderate or severe levels of TBI with the other illnesses. The committee noted that even mild TBI is associated with adverse consequences, including memory loss, Alzheimer-like dementia, and seizures.
According to the new regulations if veterans with service-connected TBI also have 1 of the 5 associated illnesses, the second illness will be considered service-connected in the calculations of disability compensation. Eligibility for expanded benefits will depend on the severity of the TBI and the time between the injury causing the TBI and the onset of the second illness. However, veterans can still file a claim to establish direct service connection for those conditions even if they don’t meet the time and severity standards in the new regulation.
Service members who are within 180 days of discharge can file a predischarge claim for TBI online at http://www.eBenefits.va.gov. Veterans who have questions or want to file new disability claims can also use the eBenefits website. The published final rule is available at http://www.regulations.gov.
The VA has developed new regulations that could make getting additional disability pay easier now for some veterans who have traumatic brain injury (TBI) in addition to Parkinson disease, certain types of dementia, depression, unprovoked seizures, or certain diseases of the hypothalamus and pituitary glands.
The new regulations, which took effect in January, were born of a 2008 Institute of Medicine report, Gulf War and Health, Volume 7: Long-Term Consequences of Traumatic Brain Injury. That report was based on a consensus by a National Academy of Sciences committee of experts, which found “sufficient evidence” to link moderate or severe levels of TBI with the other illnesses. The committee noted that even mild TBI is associated with adverse consequences, including memory loss, Alzheimer-like dementia, and seizures.
According to the new regulations if veterans with service-connected TBI also have 1 of the 5 associated illnesses, the second illness will be considered service-connected in the calculations of disability compensation. Eligibility for expanded benefits will depend on the severity of the TBI and the time between the injury causing the TBI and the onset of the second illness. However, veterans can still file a claim to establish direct service connection for those conditions even if they don’t meet the time and severity standards in the new regulation.
Service members who are within 180 days of discharge can file a predischarge claim for TBI online at http://www.eBenefits.va.gov. Veterans who have questions or want to file new disability claims can also use the eBenefits website. The published final rule is available at http://www.regulations.gov.
The VA has developed new regulations that could make getting additional disability pay easier now for some veterans who have traumatic brain injury (TBI) in addition to Parkinson disease, certain types of dementia, depression, unprovoked seizures, or certain diseases of the hypothalamus and pituitary glands.
The new regulations, which took effect in January, were born of a 2008 Institute of Medicine report, Gulf War and Health, Volume 7: Long-Term Consequences of Traumatic Brain Injury. That report was based on a consensus by a National Academy of Sciences committee of experts, which found “sufficient evidence” to link moderate or severe levels of TBI with the other illnesses. The committee noted that even mild TBI is associated with adverse consequences, including memory loss, Alzheimer-like dementia, and seizures.
According to the new regulations if veterans with service-connected TBI also have 1 of the 5 associated illnesses, the second illness will be considered service-connected in the calculations of disability compensation. Eligibility for expanded benefits will depend on the severity of the TBI and the time between the injury causing the TBI and the onset of the second illness. However, veterans can still file a claim to establish direct service connection for those conditions even if they don’t meet the time and severity standards in the new regulation.
Service members who are within 180 days of discharge can file a predischarge claim for TBI online at http://www.eBenefits.va.gov. Veterans who have questions or want to file new disability claims can also use the eBenefits website. The published final rule is available at http://www.regulations.gov.
New and Noteworthy Information—January 2014
The Bacille Calmette-Guérin (BCG) vaccine may benefit patients with clinically isolated syndrome (CIS), according to research published online ahead of print December 4, 2013, in Neurology. A total of 82 participants with CIS were randomized to BCG or placebo and monitored monthly with brain MRI for six months. All patients subsequently received IM interferon β-1a for 12 months. In an open-label extension phase, patients received disease-modifying therapies (DMTs) recommended by their neurologists. During the initial six months, the number of cumulative lesions was significantly lower among vaccinated subjects. The number of total T1-hypointense lesions was lower in the BCG group at months 6, 12, and 18. After 60 months, the probability of clinically definite multiple sclerosis was lower in the BCG plus DMT arm, and more vaccinated people remained DMT-free.
Exercise programs may significantly improve the ability of people with dementia to perform activities of daily living, according to a study published online ahead of print December 4, 2013, in the Cochrane Library. Exercise also may improve cognition in these patients, but may not affect depression. Investigators reviewed randomized controlled trials in which older people diagnosed with dementia were allocated to exercise programs or to control groups, which received standard care or social contact. Sixteen trials with 937 participants met the inclusion criteria. The trials were highly heterogeneous in terms of subtype and severity of participants’ dementia, and type, duration, and frequency of exercise. The researchers found that informal caregivers’ burden may be reduced when the family member with dementia participates in an exercise program.
Thrombin activity may enable neurologists to detect multiple sclerosis (MS) before clinical signs of the disease are present, according to research published online ahead of print November 29, 2013, in Annals of Neurology. Using a novel molecular probe, investigators characterized the activity pattern of thrombin, the central protease of the coagulation cascade, in experimental autoimmune encephalomyelitis. Thrombin activity preceded the onset of neurologic signs; increased at disease peak; and correlated with fibrin deposition, microglial activation, demyelination, axonal damage, and clinical severity. Mice with a genetic deficit in prothrombin confirmed the specificity of the thrombin probe. Scientists may be able to use thrombin activity to develop sensitive probes for the preclinical detection and monitoring of neuroinflammation and MS progression, according to the investigators.
An athlete with concussion symptoms should not be allowed to return to play on the same day, according to the latest consensus statement on sports-related concussion, which was summarized in the December 2013 issue of Neurosurgery. The Concussion in Sport Group (CISG 4) based its recommendations on the advice of an expert panel that was sponsored by five international sports governing bodies. Between 80% and 90% of concussions resolve within seven to 10 days, but recovery may take longer in children and adolescents, according to the consensus statement. The updated statement emphasizes the distinction between concussion and mild traumatic brain injury. The CISG 4 suggests that patients with concussion have normal findings on brain neuroimaging studies (eg, CT scan), but those with traumatic brain injury have abnormal imaging findings.
Vitamin D may prevent multiple sclerosis (MS) by blocking T helper (TH) cells from migrating into the CNS, according to research published online ahead of print December 9, 2013, in Proceedings of the National Academy of Sciences. Investigators administered 1,25-dihydroxyvitamin D3 [1,25(OH)2D3], the bioactive form of vitamin D, to animals with experimental autoimmune encephalomyelitis, a mouse model of MS. Myelin-reactive TH cells were generated in the presence of 1,25(OH)2D3, secreted proinflammatory cytokines, and did not preferentially differentiate into suppressor T cells. The cells left the lymph node, entered the peripheral circulation, and migrated to the immunization sites. TH cells from 1,25(OH)2D3-treated mice were unable to enter the CNS parenchyma, however. Instead, the cells were maintained in the periphery. The mice developed experimental autoimmune encephalomyelitis when treatment ceased.
Among people with type 2 diabetes, dementia incidence may be highest among Native Americans and African Americans and lowest among Asians, according to a study published online ahead of print November 22, 2013, in Diabetes Care. Scientists identified 22,171 patients age 60 or older with diabetes and without preexisting dementia in the Kaiser Permanente Northern California Diabetes Registry. The investigators abstracted prevalent medical history and dementia incidence from medical records and calculated age-adjusted incidence densities. Dementia was diagnosed in 17.1% of patients. Age-adjusted dementia incidence densities were 34/1,000 person-years among Native Americans, 27/1,000 person-years among African Americans, and 19/1,000 person-years among Asians. Hazard ratios (relative to Asians) were 1.64 for Native Americans, 1.44 for African Americans, 1.30 for non-Hispanic whites, and 1.19 for Latinos.
Veterans with blast injuries have changes in brain tissue that may be apparent on imaging years later, according to data presented at the 99th Annual Meeting of the Radiological Society of North America. Researchers compared diffusion tensor imaging (DTI)-derived fractional anisotropy (FA) values in 10 veterans of Operations Iraqi Freedom and Enduring Freedom who had been diagnosed with mild traumatic brain injury with those of 10 healthy controls. The average time elapsed between the blast-induced injury and DTI scan among the patients was 51.3 months. FA values were significantly different between the two groups, and the researchers found significant correlations between FA values and attention, delayed memory, and psychomotor test scores. The results suggest that blast injury may have a long-term impact on the brain.
Among college athletes, head impact exposure may be related to white matter diffusion measures and cognition during the course of one playing season, even in the absence of diagnosed concussion, according to data published online ahead of print December 11, 2013, in Neurology. Researchers prospectively studied 79 noncontact sport athletes and 80 nonconcussed varsity football and ice hockey players who wore helmets that recorded the acceleration-time history of the head following impact. Mean diffusivity (MD) in the corpus callosum was significantly different between groups. Measures of head impact exposure correlated with white matter diffusivity measures in the corpus callosum, amygdala, cerebellar white matter, hippocampus, and thalamus. The magnitude of change in corpus callosum MD postseason was associated with poorer performance on a measure of verbal learning and memory.
Among veterans, traumatic brain injury (TBI) during the most recent deployment is the strongest predictor of postdeployment symptoms of post-traumatic stress disorder (PTSD), even when accounting for predeployment symptoms, prior TBI, and combat intensity, according to research published online ahead of print December 11, 2013, in JAMA Psychiatry. A total of 1,648 active-duty Marine and Navy servicemen underwent clinical interviews and completed self-assessments approximately one month before a seven-month deployment and three to six months after deployment. At the predeployment assessment, 56.8% of participants reported prior TBI. At postdeployment assessment, 19.8% reported sustaining TBI between predeployment and postdeployment assessments. Probability of PTSD was highest for participants with severe predeployment symptoms, high combat intensity, and deployment-related TBI. TBI doubled the PTSD rates for participants with less severe predeployment PTSD symptoms.
Fidgetin inhibition could promote tissue regeneration and repair the broken cell connections that occur in spinal cord injury and other conditions, according to research presented at the 2013 Annual Meeting of the American Society for Cell Biology. Fidgetin prunes unstable microtubule scaffolding in cells, as well as unneeded connections in the neuronal network as the latter grows. Researchers used a novel nanoparticle technology to block fidgetin in the injured nerves of adult rats. The nanoparticles were infused with small interfering RNA that bound the messenger RNA (mRNA) transcribed from the fidgetin gene. The mRNA for fidgetin was not translated, and the cell did not produce fidgetin. Blocking fidgetin restarted tissue growth in the animals. The technique could benefit patients with myocardial infarction or chronic cutaneous wounds.
Deep brain stimulation may improve driving ability for people with Parkinson’s disease, according to a study published online ahead of print December 18, 2013, in Neurology. Investigators studied 23 people who had deep brain stimulators, 21 people with Parkinson’s disease without stimulators, and 21 healthy individuals. Participants were tested with a driving simulator. Individuals with stimulators completed the test once with the stimulator on, once with it off, and once with the stimulator off after receiving levodopa. People with Parkinson’s disease without stimulators performed worse than controls in almost every category. People with stimulators did not perform significantly worse than the controls. Participants with stimulators had an average of 3.8 slight driving errors on the test, compared with 7.5 for the controls and 11.4 for people with Parkinson’s disease without stimulators.
Gadolinium-based contrast medium (Gd-CM) may be associated with abnormalities on brain MRI, according to research published online ahead of print December 17, 2013, in Radiology. Researchers compared unenhanced T1-weighted MR images of 19 patients who had undergone six or more contrast-enhanced brain scans with images of 16 people who had received six or fewer unenhanced scans. The hyperintensity of the dentate nucleus and globus pallidus correlated with the number of Gd-CM administrations. Hyperintensity in the dentate nucleus and globus pallidus on unenhanced MRI may be a consequence of the number of previous Gd-CM administrations, according to the researchers. Because gadolinium has a high signal intensity in the body, the data suggest that the toxic gadolinium component remains in the body in patients with normal renal function.
—Erik Greb
The Bacille Calmette-Guérin (BCG) vaccine may benefit patients with clinically isolated syndrome (CIS), according to research published online ahead of print December 4, 2013, in Neurology. A total of 82 participants with CIS were randomized to BCG or placebo and monitored monthly with brain MRI for six months. All patients subsequently received IM interferon β-1a for 12 months. In an open-label extension phase, patients received disease-modifying therapies (DMTs) recommended by their neurologists. During the initial six months, the number of cumulative lesions was significantly lower among vaccinated subjects. The number of total T1-hypointense lesions was lower in the BCG group at months 6, 12, and 18. After 60 months, the probability of clinically definite multiple sclerosis was lower in the BCG plus DMT arm, and more vaccinated people remained DMT-free.
Exercise programs may significantly improve the ability of people with dementia to perform activities of daily living, according to a study published online ahead of print December 4, 2013, in the Cochrane Library. Exercise also may improve cognition in these patients, but may not affect depression. Investigators reviewed randomized controlled trials in which older people diagnosed with dementia were allocated to exercise programs or to control groups, which received standard care or social contact. Sixteen trials with 937 participants met the inclusion criteria. The trials were highly heterogeneous in terms of subtype and severity of participants’ dementia, and type, duration, and frequency of exercise. The researchers found that informal caregivers’ burden may be reduced when the family member with dementia participates in an exercise program.
Thrombin activity may enable neurologists to detect multiple sclerosis (MS) before clinical signs of the disease are present, according to research published online ahead of print November 29, 2013, in Annals of Neurology. Using a novel molecular probe, investigators characterized the activity pattern of thrombin, the central protease of the coagulation cascade, in experimental autoimmune encephalomyelitis. Thrombin activity preceded the onset of neurologic signs; increased at disease peak; and correlated with fibrin deposition, microglial activation, demyelination, axonal damage, and clinical severity. Mice with a genetic deficit in prothrombin confirmed the specificity of the thrombin probe. Scientists may be able to use thrombin activity to develop sensitive probes for the preclinical detection and monitoring of neuroinflammation and MS progression, according to the investigators.
An athlete with concussion symptoms should not be allowed to return to play on the same day, according to the latest consensus statement on sports-related concussion, which was summarized in the December 2013 issue of Neurosurgery. The Concussion in Sport Group (CISG 4) based its recommendations on the advice of an expert panel that was sponsored by five international sports governing bodies. Between 80% and 90% of concussions resolve within seven to 10 days, but recovery may take longer in children and adolescents, according to the consensus statement. The updated statement emphasizes the distinction between concussion and mild traumatic brain injury. The CISG 4 suggests that patients with concussion have normal findings on brain neuroimaging studies (eg, CT scan), but those with traumatic brain injury have abnormal imaging findings.
Vitamin D may prevent multiple sclerosis (MS) by blocking T helper (TH) cells from migrating into the CNS, according to research published online ahead of print December 9, 2013, in Proceedings of the National Academy of Sciences. Investigators administered 1,25-dihydroxyvitamin D3 [1,25(OH)2D3], the bioactive form of vitamin D, to animals with experimental autoimmune encephalomyelitis, a mouse model of MS. Myelin-reactive TH cells were generated in the presence of 1,25(OH)2D3, secreted proinflammatory cytokines, and did not preferentially differentiate into suppressor T cells. The cells left the lymph node, entered the peripheral circulation, and migrated to the immunization sites. TH cells from 1,25(OH)2D3-treated mice were unable to enter the CNS parenchyma, however. Instead, the cells were maintained in the periphery. The mice developed experimental autoimmune encephalomyelitis when treatment ceased.
Among people with type 2 diabetes, dementia incidence may be highest among Native Americans and African Americans and lowest among Asians, according to a study published online ahead of print November 22, 2013, in Diabetes Care. Scientists identified 22,171 patients age 60 or older with diabetes and without preexisting dementia in the Kaiser Permanente Northern California Diabetes Registry. The investigators abstracted prevalent medical history and dementia incidence from medical records and calculated age-adjusted incidence densities. Dementia was diagnosed in 17.1% of patients. Age-adjusted dementia incidence densities were 34/1,000 person-years among Native Americans, 27/1,000 person-years among African Americans, and 19/1,000 person-years among Asians. Hazard ratios (relative to Asians) were 1.64 for Native Americans, 1.44 for African Americans, 1.30 for non-Hispanic whites, and 1.19 for Latinos.
Veterans with blast injuries have changes in brain tissue that may be apparent on imaging years later, according to data presented at the 99th Annual Meeting of the Radiological Society of North America. Researchers compared diffusion tensor imaging (DTI)-derived fractional anisotropy (FA) values in 10 veterans of Operations Iraqi Freedom and Enduring Freedom who had been diagnosed with mild traumatic brain injury with those of 10 healthy controls. The average time elapsed between the blast-induced injury and DTI scan among the patients was 51.3 months. FA values were significantly different between the two groups, and the researchers found significant correlations between FA values and attention, delayed memory, and psychomotor test scores. The results suggest that blast injury may have a long-term impact on the brain.
Among college athletes, head impact exposure may be related to white matter diffusion measures and cognition during the course of one playing season, even in the absence of diagnosed concussion, according to data published online ahead of print December 11, 2013, in Neurology. Researchers prospectively studied 79 noncontact sport athletes and 80 nonconcussed varsity football and ice hockey players who wore helmets that recorded the acceleration-time history of the head following impact. Mean diffusivity (MD) in the corpus callosum was significantly different between groups. Measures of head impact exposure correlated with white matter diffusivity measures in the corpus callosum, amygdala, cerebellar white matter, hippocampus, and thalamus. The magnitude of change in corpus callosum MD postseason was associated with poorer performance on a measure of verbal learning and memory.
Among veterans, traumatic brain injury (TBI) during the most recent deployment is the strongest predictor of postdeployment symptoms of post-traumatic stress disorder (PTSD), even when accounting for predeployment symptoms, prior TBI, and combat intensity, according to research published online ahead of print December 11, 2013, in JAMA Psychiatry. A total of 1,648 active-duty Marine and Navy servicemen underwent clinical interviews and completed self-assessments approximately one month before a seven-month deployment and three to six months after deployment. At the predeployment assessment, 56.8% of participants reported prior TBI. At postdeployment assessment, 19.8% reported sustaining TBI between predeployment and postdeployment assessments. Probability of PTSD was highest for participants with severe predeployment symptoms, high combat intensity, and deployment-related TBI. TBI doubled the PTSD rates for participants with less severe predeployment PTSD symptoms.
Fidgetin inhibition could promote tissue regeneration and repair the broken cell connections that occur in spinal cord injury and other conditions, according to research presented at the 2013 Annual Meeting of the American Society for Cell Biology. Fidgetin prunes unstable microtubule scaffolding in cells, as well as unneeded connections in the neuronal network as the latter grows. Researchers used a novel nanoparticle technology to block fidgetin in the injured nerves of adult rats. The nanoparticles were infused with small interfering RNA that bound the messenger RNA (mRNA) transcribed from the fidgetin gene. The mRNA for fidgetin was not translated, and the cell did not produce fidgetin. Blocking fidgetin restarted tissue growth in the animals. The technique could benefit patients with myocardial infarction or chronic cutaneous wounds.
Deep brain stimulation may improve driving ability for people with Parkinson’s disease, according to a study published online ahead of print December 18, 2013, in Neurology. Investigators studied 23 people who had deep brain stimulators, 21 people with Parkinson’s disease without stimulators, and 21 healthy individuals. Participants were tested with a driving simulator. Individuals with stimulators completed the test once with the stimulator on, once with it off, and once with the stimulator off after receiving levodopa. People with Parkinson’s disease without stimulators performed worse than controls in almost every category. People with stimulators did not perform significantly worse than the controls. Participants with stimulators had an average of 3.8 slight driving errors on the test, compared with 7.5 for the controls and 11.4 for people with Parkinson’s disease without stimulators.
Gadolinium-based contrast medium (Gd-CM) may be associated with abnormalities on brain MRI, according to research published online ahead of print December 17, 2013, in Radiology. Researchers compared unenhanced T1-weighted MR images of 19 patients who had undergone six or more contrast-enhanced brain scans with images of 16 people who had received six or fewer unenhanced scans. The hyperintensity of the dentate nucleus and globus pallidus correlated with the number of Gd-CM administrations. Hyperintensity in the dentate nucleus and globus pallidus on unenhanced MRI may be a consequence of the number of previous Gd-CM administrations, according to the researchers. Because gadolinium has a high signal intensity in the body, the data suggest that the toxic gadolinium component remains in the body in patients with normal renal function.
—Erik Greb
The Bacille Calmette-Guérin (BCG) vaccine may benefit patients with clinically isolated syndrome (CIS), according to research published online ahead of print December 4, 2013, in Neurology. A total of 82 participants with CIS were randomized to BCG or placebo and monitored monthly with brain MRI for six months. All patients subsequently received IM interferon β-1a for 12 months. In an open-label extension phase, patients received disease-modifying therapies (DMTs) recommended by their neurologists. During the initial six months, the number of cumulative lesions was significantly lower among vaccinated subjects. The number of total T1-hypointense lesions was lower in the BCG group at months 6, 12, and 18. After 60 months, the probability of clinically definite multiple sclerosis was lower in the BCG plus DMT arm, and more vaccinated people remained DMT-free.
Exercise programs may significantly improve the ability of people with dementia to perform activities of daily living, according to a study published online ahead of print December 4, 2013, in the Cochrane Library. Exercise also may improve cognition in these patients, but may not affect depression. Investigators reviewed randomized controlled trials in which older people diagnosed with dementia were allocated to exercise programs or to control groups, which received standard care or social contact. Sixteen trials with 937 participants met the inclusion criteria. The trials were highly heterogeneous in terms of subtype and severity of participants’ dementia, and type, duration, and frequency of exercise. The researchers found that informal caregivers’ burden may be reduced when the family member with dementia participates in an exercise program.
Thrombin activity may enable neurologists to detect multiple sclerosis (MS) before clinical signs of the disease are present, according to research published online ahead of print November 29, 2013, in Annals of Neurology. Using a novel molecular probe, investigators characterized the activity pattern of thrombin, the central protease of the coagulation cascade, in experimental autoimmune encephalomyelitis. Thrombin activity preceded the onset of neurologic signs; increased at disease peak; and correlated with fibrin deposition, microglial activation, demyelination, axonal damage, and clinical severity. Mice with a genetic deficit in prothrombin confirmed the specificity of the thrombin probe. Scientists may be able to use thrombin activity to develop sensitive probes for the preclinical detection and monitoring of neuroinflammation and MS progression, according to the investigators.
An athlete with concussion symptoms should not be allowed to return to play on the same day, according to the latest consensus statement on sports-related concussion, which was summarized in the December 2013 issue of Neurosurgery. The Concussion in Sport Group (CISG 4) based its recommendations on the advice of an expert panel that was sponsored by five international sports governing bodies. Between 80% and 90% of concussions resolve within seven to 10 days, but recovery may take longer in children and adolescents, according to the consensus statement. The updated statement emphasizes the distinction between concussion and mild traumatic brain injury. The CISG 4 suggests that patients with concussion have normal findings on brain neuroimaging studies (eg, CT scan), but those with traumatic brain injury have abnormal imaging findings.
Vitamin D may prevent multiple sclerosis (MS) by blocking T helper (TH) cells from migrating into the CNS, according to research published online ahead of print December 9, 2013, in Proceedings of the National Academy of Sciences. Investigators administered 1,25-dihydroxyvitamin D3 [1,25(OH)2D3], the bioactive form of vitamin D, to animals with experimental autoimmune encephalomyelitis, a mouse model of MS. Myelin-reactive TH cells were generated in the presence of 1,25(OH)2D3, secreted proinflammatory cytokines, and did not preferentially differentiate into suppressor T cells. The cells left the lymph node, entered the peripheral circulation, and migrated to the immunization sites. TH cells from 1,25(OH)2D3-treated mice were unable to enter the CNS parenchyma, however. Instead, the cells were maintained in the periphery. The mice developed experimental autoimmune encephalomyelitis when treatment ceased.
Among people with type 2 diabetes, dementia incidence may be highest among Native Americans and African Americans and lowest among Asians, according to a study published online ahead of print November 22, 2013, in Diabetes Care. Scientists identified 22,171 patients age 60 or older with diabetes and without preexisting dementia in the Kaiser Permanente Northern California Diabetes Registry. The investigators abstracted prevalent medical history and dementia incidence from medical records and calculated age-adjusted incidence densities. Dementia was diagnosed in 17.1% of patients. Age-adjusted dementia incidence densities were 34/1,000 person-years among Native Americans, 27/1,000 person-years among African Americans, and 19/1,000 person-years among Asians. Hazard ratios (relative to Asians) were 1.64 for Native Americans, 1.44 for African Americans, 1.30 for non-Hispanic whites, and 1.19 for Latinos.
Veterans with blast injuries have changes in brain tissue that may be apparent on imaging years later, according to data presented at the 99th Annual Meeting of the Radiological Society of North America. Researchers compared diffusion tensor imaging (DTI)-derived fractional anisotropy (FA) values in 10 veterans of Operations Iraqi Freedom and Enduring Freedom who had been diagnosed with mild traumatic brain injury with those of 10 healthy controls. The average time elapsed between the blast-induced injury and DTI scan among the patients was 51.3 months. FA values were significantly different between the two groups, and the researchers found significant correlations between FA values and attention, delayed memory, and psychomotor test scores. The results suggest that blast injury may have a long-term impact on the brain.
Among college athletes, head impact exposure may be related to white matter diffusion measures and cognition during the course of one playing season, even in the absence of diagnosed concussion, according to data published online ahead of print December 11, 2013, in Neurology. Researchers prospectively studied 79 noncontact sport athletes and 80 nonconcussed varsity football and ice hockey players who wore helmets that recorded the acceleration-time history of the head following impact. Mean diffusivity (MD) in the corpus callosum was significantly different between groups. Measures of head impact exposure correlated with white matter diffusivity measures in the corpus callosum, amygdala, cerebellar white matter, hippocampus, and thalamus. The magnitude of change in corpus callosum MD postseason was associated with poorer performance on a measure of verbal learning and memory.
Among veterans, traumatic brain injury (TBI) during the most recent deployment is the strongest predictor of postdeployment symptoms of post-traumatic stress disorder (PTSD), even when accounting for predeployment symptoms, prior TBI, and combat intensity, according to research published online ahead of print December 11, 2013, in JAMA Psychiatry. A total of 1,648 active-duty Marine and Navy servicemen underwent clinical interviews and completed self-assessments approximately one month before a seven-month deployment and three to six months after deployment. At the predeployment assessment, 56.8% of participants reported prior TBI. At postdeployment assessment, 19.8% reported sustaining TBI between predeployment and postdeployment assessments. Probability of PTSD was highest for participants with severe predeployment symptoms, high combat intensity, and deployment-related TBI. TBI doubled the PTSD rates for participants with less severe predeployment PTSD symptoms.
Fidgetin inhibition could promote tissue regeneration and repair the broken cell connections that occur in spinal cord injury and other conditions, according to research presented at the 2013 Annual Meeting of the American Society for Cell Biology. Fidgetin prunes unstable microtubule scaffolding in cells, as well as unneeded connections in the neuronal network as the latter grows. Researchers used a novel nanoparticle technology to block fidgetin in the injured nerves of adult rats. The nanoparticles were infused with small interfering RNA that bound the messenger RNA (mRNA) transcribed from the fidgetin gene. The mRNA for fidgetin was not translated, and the cell did not produce fidgetin. Blocking fidgetin restarted tissue growth in the animals. The technique could benefit patients with myocardial infarction or chronic cutaneous wounds.
Deep brain stimulation may improve driving ability for people with Parkinson’s disease, according to a study published online ahead of print December 18, 2013, in Neurology. Investigators studied 23 people who had deep brain stimulators, 21 people with Parkinson’s disease without stimulators, and 21 healthy individuals. Participants were tested with a driving simulator. Individuals with stimulators completed the test once with the stimulator on, once with it off, and once with the stimulator off after receiving levodopa. People with Parkinson’s disease without stimulators performed worse than controls in almost every category. People with stimulators did not perform significantly worse than the controls. Participants with stimulators had an average of 3.8 slight driving errors on the test, compared with 7.5 for the controls and 11.4 for people with Parkinson’s disease without stimulators.
Gadolinium-based contrast medium (Gd-CM) may be associated with abnormalities on brain MRI, according to research published online ahead of print December 17, 2013, in Radiology. Researchers compared unenhanced T1-weighted MR images of 19 patients who had undergone six or more contrast-enhanced brain scans with images of 16 people who had received six or fewer unenhanced scans. The hyperintensity of the dentate nucleus and globus pallidus correlated with the number of Gd-CM administrations. Hyperintensity in the dentate nucleus and globus pallidus on unenhanced MRI may be a consequence of the number of previous Gd-CM administrations, according to the researchers. Because gadolinium has a high signal intensity in the body, the data suggest that the toxic gadolinium component remains in the body in patients with normal renal function.
—Erik Greb
New and Noteworthy Information—December 2013
Mild traumatic brain injury (TBI) may be associated with increased cortical fractional anisotropy, but not with cortical or subcortical atrophy, according to research published online ahead of print November 20 in Neurology. Investigators evaluated 50 patients and 50 sex-, age-, and education-matched controls with a clinical and neuroimaging battery approximately 14 days after TBI. A total of 26 patients returned for follow-up four months after injury. Patients had increased fractional anisotropy in the bilateral superior frontal cortex during the semiacute phase of injury. Fractional anisotropy in the left superior frontal cortex remained elevated at four months after injury. The researchers found no significant differences between patients and matched controls on neuropsychologic testing or measures of gray matter atrophy or mean diffusivity at either time point.
Researchers detailed the early clinical course, morbidity, and mortality of the 2012 outbreak of fungal infections associated with methylprednisolone injections in two articles published October 24, 2013, in the New England Journal of Medicine. As of July 1, 2013, a total of 749 cases of infection had been reported in 20 states, including 61 deaths. Of 728 patients for whom data were available, 31% had meningitis and no other documented infection. Of 328 patients without peripheral joint infection who were included in one investigation, 81% had CNS infection, and 19% had non-CNS infections only. The investigators found evidence of Exserohilum rostratum in 36% of patients for whom samples were available. Patients’ median age was 64, and the median incubation period was 47 days. Forty patients had a stroke.
An algorithm may accurately predict time to death, institutionalization, and need for full-time care in patients with Alzheimer’s disease, according to an article published online ahead of print September 24 in the Journal of Alzheimer’s Disease. Investigators followed two study cohorts with mild Alzheimer’s disease for 10 years. The first cohort included 252 patients, and the second included 254 patients. Participants underwent semiannual assessments that included cognition, functional capacity, and medical, psychiatric, and neurologic information. For each of the three outcome measures, the predicted survival curves were well within the 95% confidence intervals of the observed survival curves. The actual and predicted survival curves were statistically equivalent. The algorithm can be adapted to predict other important disease end points, according to the researchers.
High pulse pressure may be associated with increased CSF phosphorylated tau and decreased β-amyloid 1–42 (Aβ1–42) in cognitively normal older adults, according to research published online ahead of print November 13 in Neurology. A total of 177 cognitively normal, stroke-free older adults underwent blood pressure assessment for determination of pulse pressure, as well as lumbar puncture for measurement of CSF Aβ1–42 and phosphorylated tau. High pulse pressure was associated with increased phosphorylated tau, reduced Aβ1–42, and increased phosphorylated tau to Aβ1–42 ratio. After controlling for covariates, the investigators found that pulse pressure remained associated with phosphorylated tau and phosphorylated tau to Aβ1–42 ratio, but was no longer associated with Aβ1–42. The relationship between pulse pressure and CSF biomarkers is age-dependent, said the researchers.
Acute stroke care in hospitals with neurology residency programs may be associated with an increased use of thrombolytics, investigators reported online ahead of print November 1 in Neurology. The disparities between the thrombolysis rates in hospitals with neurology residency programs and those in other teaching hospitals and nonteaching hospitals may be greater among elderly patients. Researchers retrospectively studied a nationally representative sample of patients with ischemic stroke. A total of 712,433 individuals from 6,839 hospital samples were included. Of these patients, 10.1%, 29.1%, and 60.8% were treated in hospitals with neurology residency programs, other teaching hospitals, and nonteaching hospitals, respectively. Patients in hospitals with neurology residency programs received thrombolysis more frequently (3.74%) than those in other teaching hospitals (2.28%) and those in nonteaching hospitals (1.44%).
The FDA has approved Aptiom (eslicarbazepine acetate) as an add-on medication to treat partial-onset seizures associated with epilepsy. In three large, phase III safety and efficacy trials that included more than 1,400 patients with inadequately controlled partial-onset seizures, eslicarbazepine acetate was associated with statistically significant reductions in standardized seizure frequency, compared with placebo. Significantly more patients who received eslicarbazepine acetate had a reduction in seizure frequency of 50% or more, compared with controls. The most common side effects include dizziness, somnolence, nausea, headache, diplopia, vomiting, fatigue, vertigo, ataxia, and blurred vision. Eslicarbazepine acetate will not be classified as a controlled substance. Sunovion (Marlborough, Massachusetts) markets the drug and expects it to be available in the US during the second quarter of 2014.
The FDA has approved the NeuroPace RNS System, a device intended to reduce the frequency of seizures in patients with epilepsy who have not responded well to medications. The device consists of a small neurostimulator implanted within the skull. The neurostimulator is connected to one or two electrodes that are placed where the seizures are suspected to originate within the brain or on the surface of the brain. When it detects abnormal electrical activity, the neurostimulator delivers electrical stimulation to normalize brain activity and prevent seizures. In a randomized study of 191 patients, the average number of seizures per month was reduced by approximately 38% at three months in patients in whom the device was turned on. The RNS System is manufactured by NeuroPace (Mountainview, California).
Reducing blood pressure with antihypertensive medications may not decrease the likelihood of death and major disability among patients with acute ischemic stroke, according to a study published online ahead of print November 17 in JAMA. Researchers studied 4,071 patients with nonthrombolyzed ischemic stroke within 48 hours of onset and elevated systolic blood pressure. Patients were randomized to receive antihypertensive treatment or to discontinue all antihypertensive medications during hospitalization. Mean systolic blood pressure was reduced from 166.7 mm Hg to 144.7 mm Hg within 24 hours in the antihypertensive treatment group and from 165.6 mm Hg to 152.9 mm Hg in the control group within 24 hours after randomization. The researchers found no difference in the rates of death and major disability between the treatment groups.
Persons with high urinary concentrations of tungsten may have an increased risk of stroke, according to a study published November 11 in PLOS One. Investigators analyzed associations between tungsten, commonly used in mobile phones and computers, and cardiovascular disease or stroke using crude and adjusted logistic regression models in a cohort of 8,614 adults (ages 18 to 74) with 193 reported stroke diagnoses and 428 reported diagnoses of cardiovascular disease. The researchers also stratified the data to characterize associations in a subset of individuals between ages 18 and 50. Elevated tungsten concentrations were strongly associated with an increase in the prevalence of stroke, independent of typical risk factors (odds ratio: 1.66). The association between tungsten and stroke in the young age category was still evident (odds ratio: 2.17).
Traumatic brain injury (TBI) may be associated with increased amyloid deposition, according to research published online ahead of print November 11 in JAMA Neurology. Investigators used carbon 11-labeled Pittsburgh Compound B ([11C]PiB) PET to image amyloid deposition in 11 controls and 15 patients between one and 361 days after TBI. Compared with the controls, the patients with TBI had significantly increased [11C]PiB distribution volume ratios in cortical gray matter and the striatum, but not in the thalamus or white matter. The investigators observed increases in [11C]PiB distribution volume ratios in patients with TBI across most cortical subregions. The increases were replicated using comparisons of standardized uptake value ratios and could not be accounted for by methodologic confounders.
Compared with persons who speak only one language, bilingual individuals may have a delayed onset of dementia, according to a study published online ahead of print November 6 in Neurology. Investigators reviewed case records of 648 patients with dementia (391 bilinguals) diagnosed in a specialist clinic. They compared age at onset of first symptoms between monolingual and bilingual groups and examined the influence of the number of languages spoken, education, occupation, and other potentially interacting variables. Bilingual patients developed dementia 4.5 years later than the monolingual patients. The researchers found a significant difference in age at onset of Alzheimer’s disease dementia, frontotemporal dementia, and vascular dementia. The age difference was also observed in illiterate patients. The investigators found no additional benefit to speaking more than two languages.
Temporal lobe epilepsy (TLE) may entail altered structural connectivity in the brain, according to a study published online ahead of print November 8 in Radiology. Investigators analyzed 60-direction diffusion-tensor imaging and magnetization-prepared rapid acquisition gradient-echo (MP-RAGE) MRI volumes for 24 patients with left TLE and 24 healthy control subjects. MP-RAGE volumes were segmented into 1,015 regions of interest that spanned the entire brain. Patients with TLE had 22% to 45% reduced distant connectivity in the medial orbitofrontal cortex, temporal cortex, posterior cingulate cortex, and precuneus, compared with healthy subjects. Local connectivity, as measured by means of network efficiency, was increased by 85% to 270% in the medial and lateral frontal cortices, insular cortex, posterior cingulate cortex, precuneus, and occipital cortex in patients with TLE, compared with healthy subjects.
Gray matter damage may be a key factor associated with long-term accumulation of disability and cognitive impairment in multiple sclerosis (MS), according to research published November 12 in Neurology. Investigators obtained conventional and magnetization transfer (MT) MRI brain scans at baseline and at 12 months for 73 patients with MS, who were followed prospectively with clinical visits and rating of the Expanded Disability Status Scale (EDSS) score and the MS severity score for a median of 13.3 years. At 13-year follow-up, 66% of patients had significant worsening of disability, and 37% had worse cognition. The multivariable model identified baseline gray matter fraction as the only predictor of disability worsening. Baseline disease duration and average gray matter lesion MT ratio were independent variables associated with cognitive deterioration.
—Erik Greb
Senior Associate Editor
Mild traumatic brain injury (TBI) may be associated with increased cortical fractional anisotropy, but not with cortical or subcortical atrophy, according to research published online ahead of print November 20 in Neurology. Investigators evaluated 50 patients and 50 sex-, age-, and education-matched controls with a clinical and neuroimaging battery approximately 14 days after TBI. A total of 26 patients returned for follow-up four months after injury. Patients had increased fractional anisotropy in the bilateral superior frontal cortex during the semiacute phase of injury. Fractional anisotropy in the left superior frontal cortex remained elevated at four months after injury. The researchers found no significant differences between patients and matched controls on neuropsychologic testing or measures of gray matter atrophy or mean diffusivity at either time point.
Researchers detailed the early clinical course, morbidity, and mortality of the 2012 outbreak of fungal infections associated with methylprednisolone injections in two articles published October 24, 2013, in the New England Journal of Medicine. As of July 1, 2013, a total of 749 cases of infection had been reported in 20 states, including 61 deaths. Of 728 patients for whom data were available, 31% had meningitis and no other documented infection. Of 328 patients without peripheral joint infection who were included in one investigation, 81% had CNS infection, and 19% had non-CNS infections only. The investigators found evidence of Exserohilum rostratum in 36% of patients for whom samples were available. Patients’ median age was 64, and the median incubation period was 47 days. Forty patients had a stroke.
An algorithm may accurately predict time to death, institutionalization, and need for full-time care in patients with Alzheimer’s disease, according to an article published online ahead of print September 24 in the Journal of Alzheimer’s Disease. Investigators followed two study cohorts with mild Alzheimer’s disease for 10 years. The first cohort included 252 patients, and the second included 254 patients. Participants underwent semiannual assessments that included cognition, functional capacity, and medical, psychiatric, and neurologic information. For each of the three outcome measures, the predicted survival curves were well within the 95% confidence intervals of the observed survival curves. The actual and predicted survival curves were statistically equivalent. The algorithm can be adapted to predict other important disease end points, according to the researchers.
High pulse pressure may be associated with increased CSF phosphorylated tau and decreased β-amyloid 1–42 (Aβ1–42) in cognitively normal older adults, according to research published online ahead of print November 13 in Neurology. A total of 177 cognitively normal, stroke-free older adults underwent blood pressure assessment for determination of pulse pressure, as well as lumbar puncture for measurement of CSF Aβ1–42 and phosphorylated tau. High pulse pressure was associated with increased phosphorylated tau, reduced Aβ1–42, and increased phosphorylated tau to Aβ1–42 ratio. After controlling for covariates, the investigators found that pulse pressure remained associated with phosphorylated tau and phosphorylated tau to Aβ1–42 ratio, but was no longer associated with Aβ1–42. The relationship between pulse pressure and CSF biomarkers is age-dependent, said the researchers.
Acute stroke care in hospitals with neurology residency programs may be associated with an increased use of thrombolytics, investigators reported online ahead of print November 1 in Neurology. The disparities between the thrombolysis rates in hospitals with neurology residency programs and those in other teaching hospitals and nonteaching hospitals may be greater among elderly patients. Researchers retrospectively studied a nationally representative sample of patients with ischemic stroke. A total of 712,433 individuals from 6,839 hospital samples were included. Of these patients, 10.1%, 29.1%, and 60.8% were treated in hospitals with neurology residency programs, other teaching hospitals, and nonteaching hospitals, respectively. Patients in hospitals with neurology residency programs received thrombolysis more frequently (3.74%) than those in other teaching hospitals (2.28%) and those in nonteaching hospitals (1.44%).
The FDA has approved Aptiom (eslicarbazepine acetate) as an add-on medication to treat partial-onset seizures associated with epilepsy. In three large, phase III safety and efficacy trials that included more than 1,400 patients with inadequately controlled partial-onset seizures, eslicarbazepine acetate was associated with statistically significant reductions in standardized seizure frequency, compared with placebo. Significantly more patients who received eslicarbazepine acetate had a reduction in seizure frequency of 50% or more, compared with controls. The most common side effects include dizziness, somnolence, nausea, headache, diplopia, vomiting, fatigue, vertigo, ataxia, and blurred vision. Eslicarbazepine acetate will not be classified as a controlled substance. Sunovion (Marlborough, Massachusetts) markets the drug and expects it to be available in the US during the second quarter of 2014.
The FDA has approved the NeuroPace RNS System, a device intended to reduce the frequency of seizures in patients with epilepsy who have not responded well to medications. The device consists of a small neurostimulator implanted within the skull. The neurostimulator is connected to one or two electrodes that are placed where the seizures are suspected to originate within the brain or on the surface of the brain. When it detects abnormal electrical activity, the neurostimulator delivers electrical stimulation to normalize brain activity and prevent seizures. In a randomized study of 191 patients, the average number of seizures per month was reduced by approximately 38% at three months in patients in whom the device was turned on. The RNS System is manufactured by NeuroPace (Mountainview, California).
Reducing blood pressure with antihypertensive medications may not decrease the likelihood of death and major disability among patients with acute ischemic stroke, according to a study published online ahead of print November 17 in JAMA. Researchers studied 4,071 patients with nonthrombolyzed ischemic stroke within 48 hours of onset and elevated systolic blood pressure. Patients were randomized to receive antihypertensive treatment or to discontinue all antihypertensive medications during hospitalization. Mean systolic blood pressure was reduced from 166.7 mm Hg to 144.7 mm Hg within 24 hours in the antihypertensive treatment group and from 165.6 mm Hg to 152.9 mm Hg in the control group within 24 hours after randomization. The researchers found no difference in the rates of death and major disability between the treatment groups.
Persons with high urinary concentrations of tungsten may have an increased risk of stroke, according to a study published November 11 in PLOS One. Investigators analyzed associations between tungsten, commonly used in mobile phones and computers, and cardiovascular disease or stroke using crude and adjusted logistic regression models in a cohort of 8,614 adults (ages 18 to 74) with 193 reported stroke diagnoses and 428 reported diagnoses of cardiovascular disease. The researchers also stratified the data to characterize associations in a subset of individuals between ages 18 and 50. Elevated tungsten concentrations were strongly associated with an increase in the prevalence of stroke, independent of typical risk factors (odds ratio: 1.66). The association between tungsten and stroke in the young age category was still evident (odds ratio: 2.17).
Traumatic brain injury (TBI) may be associated with increased amyloid deposition, according to research published online ahead of print November 11 in JAMA Neurology. Investigators used carbon 11-labeled Pittsburgh Compound B ([11C]PiB) PET to image amyloid deposition in 11 controls and 15 patients between one and 361 days after TBI. Compared with the controls, the patients with TBI had significantly increased [11C]PiB distribution volume ratios in cortical gray matter and the striatum, but not in the thalamus or white matter. The investigators observed increases in [11C]PiB distribution volume ratios in patients with TBI across most cortical subregions. The increases were replicated using comparisons of standardized uptake value ratios and could not be accounted for by methodologic confounders.
Compared with persons who speak only one language, bilingual individuals may have a delayed onset of dementia, according to a study published online ahead of print November 6 in Neurology. Investigators reviewed case records of 648 patients with dementia (391 bilinguals) diagnosed in a specialist clinic. They compared age at onset of first symptoms between monolingual and bilingual groups and examined the influence of the number of languages spoken, education, occupation, and other potentially interacting variables. Bilingual patients developed dementia 4.5 years later than the monolingual patients. The researchers found a significant difference in age at onset of Alzheimer’s disease dementia, frontotemporal dementia, and vascular dementia. The age difference was also observed in illiterate patients. The investigators found no additional benefit to speaking more than two languages.
Temporal lobe epilepsy (TLE) may entail altered structural connectivity in the brain, according to a study published online ahead of print November 8 in Radiology. Investigators analyzed 60-direction diffusion-tensor imaging and magnetization-prepared rapid acquisition gradient-echo (MP-RAGE) MRI volumes for 24 patients with left TLE and 24 healthy control subjects. MP-RAGE volumes were segmented into 1,015 regions of interest that spanned the entire brain. Patients with TLE had 22% to 45% reduced distant connectivity in the medial orbitofrontal cortex, temporal cortex, posterior cingulate cortex, and precuneus, compared with healthy subjects. Local connectivity, as measured by means of network efficiency, was increased by 85% to 270% in the medial and lateral frontal cortices, insular cortex, posterior cingulate cortex, precuneus, and occipital cortex in patients with TLE, compared with healthy subjects.
Gray matter damage may be a key factor associated with long-term accumulation of disability and cognitive impairment in multiple sclerosis (MS), according to research published November 12 in Neurology. Investigators obtained conventional and magnetization transfer (MT) MRI brain scans at baseline and at 12 months for 73 patients with MS, who were followed prospectively with clinical visits and rating of the Expanded Disability Status Scale (EDSS) score and the MS severity score for a median of 13.3 years. At 13-year follow-up, 66% of patients had significant worsening of disability, and 37% had worse cognition. The multivariable model identified baseline gray matter fraction as the only predictor of disability worsening. Baseline disease duration and average gray matter lesion MT ratio were independent variables associated with cognitive deterioration.
—Erik Greb
Senior Associate Editor
Mild traumatic brain injury (TBI) may be associated with increased cortical fractional anisotropy, but not with cortical or subcortical atrophy, according to research published online ahead of print November 20 in Neurology. Investigators evaluated 50 patients and 50 sex-, age-, and education-matched controls with a clinical and neuroimaging battery approximately 14 days after TBI. A total of 26 patients returned for follow-up four months after injury. Patients had increased fractional anisotropy in the bilateral superior frontal cortex during the semiacute phase of injury. Fractional anisotropy in the left superior frontal cortex remained elevated at four months after injury. The researchers found no significant differences between patients and matched controls on neuropsychologic testing or measures of gray matter atrophy or mean diffusivity at either time point.
Researchers detailed the early clinical course, morbidity, and mortality of the 2012 outbreak of fungal infections associated with methylprednisolone injections in two articles published October 24, 2013, in the New England Journal of Medicine. As of July 1, 2013, a total of 749 cases of infection had been reported in 20 states, including 61 deaths. Of 728 patients for whom data were available, 31% had meningitis and no other documented infection. Of 328 patients without peripheral joint infection who were included in one investigation, 81% had CNS infection, and 19% had non-CNS infections only. The investigators found evidence of Exserohilum rostratum in 36% of patients for whom samples were available. Patients’ median age was 64, and the median incubation period was 47 days. Forty patients had a stroke.
An algorithm may accurately predict time to death, institutionalization, and need for full-time care in patients with Alzheimer’s disease, according to an article published online ahead of print September 24 in the Journal of Alzheimer’s Disease. Investigators followed two study cohorts with mild Alzheimer’s disease for 10 years. The first cohort included 252 patients, and the second included 254 patients. Participants underwent semiannual assessments that included cognition, functional capacity, and medical, psychiatric, and neurologic information. For each of the three outcome measures, the predicted survival curves were well within the 95% confidence intervals of the observed survival curves. The actual and predicted survival curves were statistically equivalent. The algorithm can be adapted to predict other important disease end points, according to the researchers.
High pulse pressure may be associated with increased CSF phosphorylated tau and decreased β-amyloid 1–42 (Aβ1–42) in cognitively normal older adults, according to research published online ahead of print November 13 in Neurology. A total of 177 cognitively normal, stroke-free older adults underwent blood pressure assessment for determination of pulse pressure, as well as lumbar puncture for measurement of CSF Aβ1–42 and phosphorylated tau. High pulse pressure was associated with increased phosphorylated tau, reduced Aβ1–42, and increased phosphorylated tau to Aβ1–42 ratio. After controlling for covariates, the investigators found that pulse pressure remained associated with phosphorylated tau and phosphorylated tau to Aβ1–42 ratio, but was no longer associated with Aβ1–42. The relationship between pulse pressure and CSF biomarkers is age-dependent, said the researchers.
Acute stroke care in hospitals with neurology residency programs may be associated with an increased use of thrombolytics, investigators reported online ahead of print November 1 in Neurology. The disparities between the thrombolysis rates in hospitals with neurology residency programs and those in other teaching hospitals and nonteaching hospitals may be greater among elderly patients. Researchers retrospectively studied a nationally representative sample of patients with ischemic stroke. A total of 712,433 individuals from 6,839 hospital samples were included. Of these patients, 10.1%, 29.1%, and 60.8% were treated in hospitals with neurology residency programs, other teaching hospitals, and nonteaching hospitals, respectively. Patients in hospitals with neurology residency programs received thrombolysis more frequently (3.74%) than those in other teaching hospitals (2.28%) and those in nonteaching hospitals (1.44%).
The FDA has approved Aptiom (eslicarbazepine acetate) as an add-on medication to treat partial-onset seizures associated with epilepsy. In three large, phase III safety and efficacy trials that included more than 1,400 patients with inadequately controlled partial-onset seizures, eslicarbazepine acetate was associated with statistically significant reductions in standardized seizure frequency, compared with placebo. Significantly more patients who received eslicarbazepine acetate had a reduction in seizure frequency of 50% or more, compared with controls. The most common side effects include dizziness, somnolence, nausea, headache, diplopia, vomiting, fatigue, vertigo, ataxia, and blurred vision. Eslicarbazepine acetate will not be classified as a controlled substance. Sunovion (Marlborough, Massachusetts) markets the drug and expects it to be available in the US during the second quarter of 2014.
The FDA has approved the NeuroPace RNS System, a device intended to reduce the frequency of seizures in patients with epilepsy who have not responded well to medications. The device consists of a small neurostimulator implanted within the skull. The neurostimulator is connected to one or two electrodes that are placed where the seizures are suspected to originate within the brain or on the surface of the brain. When it detects abnormal electrical activity, the neurostimulator delivers electrical stimulation to normalize brain activity and prevent seizures. In a randomized study of 191 patients, the average number of seizures per month was reduced by approximately 38% at three months in patients in whom the device was turned on. The RNS System is manufactured by NeuroPace (Mountainview, California).
Reducing blood pressure with antihypertensive medications may not decrease the likelihood of death and major disability among patients with acute ischemic stroke, according to a study published online ahead of print November 17 in JAMA. Researchers studied 4,071 patients with nonthrombolyzed ischemic stroke within 48 hours of onset and elevated systolic blood pressure. Patients were randomized to receive antihypertensive treatment or to discontinue all antihypertensive medications during hospitalization. Mean systolic blood pressure was reduced from 166.7 mm Hg to 144.7 mm Hg within 24 hours in the antihypertensive treatment group and from 165.6 mm Hg to 152.9 mm Hg in the control group within 24 hours after randomization. The researchers found no difference in the rates of death and major disability between the treatment groups.
Persons with high urinary concentrations of tungsten may have an increased risk of stroke, according to a study published November 11 in PLOS One. Investigators analyzed associations between tungsten, commonly used in mobile phones and computers, and cardiovascular disease or stroke using crude and adjusted logistic regression models in a cohort of 8,614 adults (ages 18 to 74) with 193 reported stroke diagnoses and 428 reported diagnoses of cardiovascular disease. The researchers also stratified the data to characterize associations in a subset of individuals between ages 18 and 50. Elevated tungsten concentrations were strongly associated with an increase in the prevalence of stroke, independent of typical risk factors (odds ratio: 1.66). The association between tungsten and stroke in the young age category was still evident (odds ratio: 2.17).
Traumatic brain injury (TBI) may be associated with increased amyloid deposition, according to research published online ahead of print November 11 in JAMA Neurology. Investigators used carbon 11-labeled Pittsburgh Compound B ([11C]PiB) PET to image amyloid deposition in 11 controls and 15 patients between one and 361 days after TBI. Compared with the controls, the patients with TBI had significantly increased [11C]PiB distribution volume ratios in cortical gray matter and the striatum, but not in the thalamus or white matter. The investigators observed increases in [11C]PiB distribution volume ratios in patients with TBI across most cortical subregions. The increases were replicated using comparisons of standardized uptake value ratios and could not be accounted for by methodologic confounders.
Compared with persons who speak only one language, bilingual individuals may have a delayed onset of dementia, according to a study published online ahead of print November 6 in Neurology. Investigators reviewed case records of 648 patients with dementia (391 bilinguals) diagnosed in a specialist clinic. They compared age at onset of first symptoms between monolingual and bilingual groups and examined the influence of the number of languages spoken, education, occupation, and other potentially interacting variables. Bilingual patients developed dementia 4.5 years later than the monolingual patients. The researchers found a significant difference in age at onset of Alzheimer’s disease dementia, frontotemporal dementia, and vascular dementia. The age difference was also observed in illiterate patients. The investigators found no additional benefit to speaking more than two languages.
Temporal lobe epilepsy (TLE) may entail altered structural connectivity in the brain, according to a study published online ahead of print November 8 in Radiology. Investigators analyzed 60-direction diffusion-tensor imaging and magnetization-prepared rapid acquisition gradient-echo (MP-RAGE) MRI volumes for 24 patients with left TLE and 24 healthy control subjects. MP-RAGE volumes were segmented into 1,015 regions of interest that spanned the entire brain. Patients with TLE had 22% to 45% reduced distant connectivity in the medial orbitofrontal cortex, temporal cortex, posterior cingulate cortex, and precuneus, compared with healthy subjects. Local connectivity, as measured by means of network efficiency, was increased by 85% to 270% in the medial and lateral frontal cortices, insular cortex, posterior cingulate cortex, precuneus, and occipital cortex in patients with TLE, compared with healthy subjects.
Gray matter damage may be a key factor associated with long-term accumulation of disability and cognitive impairment in multiple sclerosis (MS), according to research published November 12 in Neurology. Investigators obtained conventional and magnetization transfer (MT) MRI brain scans at baseline and at 12 months for 73 patients with MS, who were followed prospectively with clinical visits and rating of the Expanded Disability Status Scale (EDSS) score and the MS severity score for a median of 13.3 years. At 13-year follow-up, 66% of patients had significant worsening of disability, and 37% had worse cognition. The multivariable model identified baseline gray matter fraction as the only predictor of disability worsening. Baseline disease duration and average gray matter lesion MT ratio were independent variables associated with cognitive deterioration.
—Erik Greb
Senior Associate Editor
Analgesic Overuse May Worsen Chronic Post-Traumatic Headaches in Adolescents With Concussion
AUSTIN—Excessive use of analgesics may exacerbate post-traumatic headaches among adolescents who have had a concussion, according to research presented at the 2013 Annual Meeting of the Child Neurology Society.
“Analgesics should be minimized or discontinued when headaches continue several weeks following concussion,” recommended Geoffrey L. Heyer, MD, of the Division of Pediatric Neurology, Nationwide Children’s Hospital in Columbus, Ohio, and colleagues.
The researchers conducted a retrospective review of 104 adolescents with concussion who had been referred to a pediatric headache clinic for chronic post-traumatic headaches of three to 12 months in duration. The study authors compared concussion symptoms, headache symptoms before and after concussion, demographic data, and headache outcomes between patients who had probable medication-overuse headache and those who did not have probable medication-overuse headache.
A total of 77 patients had chronic post-traumatic headache between three and 12 months, and 54 patients (70%) met the criteria for probable medication-overuse headache. The investigators found that patients with medication overuse were more likely to have had daily headaches, to be female, to have had nausea or throbbing associated with their headaches, to have had increased irritability following concussion, and to have had a longer interval between injury and neurologic evaluation.
“Of the patients with medication overuse, 37 (68.5%) had resolution of headaches or improvements to preconcussion headache patterns after discontinuing analgesics, seven (13%) had no change in headaches or worsening of headaches after discontinuing analgesics, and 10 (18.5%) did not discontinue analgesics or were lost to follow-up,” stated Dr. Heyer.
—Colby Stong
Editor
AUSTIN—Excessive use of analgesics may exacerbate post-traumatic headaches among adolescents who have had a concussion, according to research presented at the 2013 Annual Meeting of the Child Neurology Society.
“Analgesics should be minimized or discontinued when headaches continue several weeks following concussion,” recommended Geoffrey L. Heyer, MD, of the Division of Pediatric Neurology, Nationwide Children’s Hospital in Columbus, Ohio, and colleagues.
The researchers conducted a retrospective review of 104 adolescents with concussion who had been referred to a pediatric headache clinic for chronic post-traumatic headaches of three to 12 months in duration. The study authors compared concussion symptoms, headache symptoms before and after concussion, demographic data, and headache outcomes between patients who had probable medication-overuse headache and those who did not have probable medication-overuse headache.
A total of 77 patients had chronic post-traumatic headache between three and 12 months, and 54 patients (70%) met the criteria for probable medication-overuse headache. The investigators found that patients with medication overuse were more likely to have had daily headaches, to be female, to have had nausea or throbbing associated with their headaches, to have had increased irritability following concussion, and to have had a longer interval between injury and neurologic evaluation.
“Of the patients with medication overuse, 37 (68.5%) had resolution of headaches or improvements to preconcussion headache patterns after discontinuing analgesics, seven (13%) had no change in headaches or worsening of headaches after discontinuing analgesics, and 10 (18.5%) did not discontinue analgesics or were lost to follow-up,” stated Dr. Heyer.
—Colby Stong
Editor
AUSTIN—Excessive use of analgesics may exacerbate post-traumatic headaches among adolescents who have had a concussion, according to research presented at the 2013 Annual Meeting of the Child Neurology Society.
“Analgesics should be minimized or discontinued when headaches continue several weeks following concussion,” recommended Geoffrey L. Heyer, MD, of the Division of Pediatric Neurology, Nationwide Children’s Hospital in Columbus, Ohio, and colleagues.
The researchers conducted a retrospective review of 104 adolescents with concussion who had been referred to a pediatric headache clinic for chronic post-traumatic headaches of three to 12 months in duration. The study authors compared concussion symptoms, headache symptoms before and after concussion, demographic data, and headache outcomes between patients who had probable medication-overuse headache and those who did not have probable medication-overuse headache.
A total of 77 patients had chronic post-traumatic headache between three and 12 months, and 54 patients (70%) met the criteria for probable medication-overuse headache. The investigators found that patients with medication overuse were more likely to have had daily headaches, to be female, to have had nausea or throbbing associated with their headaches, to have had increased irritability following concussion, and to have had a longer interval between injury and neurologic evaluation.
“Of the patients with medication overuse, 37 (68.5%) had resolution of headaches or improvements to preconcussion headache patterns after discontinuing analgesics, seven (13%) had no change in headaches or worsening of headaches after discontinuing analgesics, and 10 (18.5%) did not discontinue analgesics or were lost to follow-up,” stated Dr. Heyer.
—Colby Stong
Editor
More Hospitals Learning to Share; Expanding Research Into PTSD and TBI; ED Visits for CNS Stimulant Abuse on the Rise; Talking About Suicide Matters; Decline in Childhood Obesity
Bright Light Therapy May Improve Sleep and Promote Recovery in Patients With Mild TBI
BALTIMORE—Bright light therapy may improve sleep, cognition, emotion, and brain function following mild traumatic brain injury (TBI), according to research presented at the 27th Annual Meeting of the Associated Professional Sleep Societies.
Results show that six weeks of morning bright light therapy resulted in a marked decrease in subjective daytime sleepiness. This improvement was further associated with improvements in the propensity to fall asleep and nighttime sleep quality. Bright light therapy also affected depressive symptoms.
“Our preliminary data suggest that morning bright light therapy might be helpful to reduce subjective daytime sleepiness and to improve nighttime sleep,” said Mareen Weber, PhD, Instructor in Psychiatry at McLean Hospital/Harvard Medical School in Belmont, Massachusetts. “Importantly, the research also shows changes in brain activation during a demanding cognitive task, suggesting that bright light treatment might yield changes in brain functioning.”
The study group included 18 patients with a documented history of at least one mild TBI and sleep disturbance that either emerged or was aggravated with the most recent injury. Data were gathered using Multiple Sleep Latency Tests (MSLT), actigraphy, and sleep diaries, and all participants underwent MRI and comprehensive psychiatric and neuropsychologic assessments before and after the intervention.
According to the authors, at least 50% of individuals with TBI experience some kind of sleep disturbance following their injury, and sleep has been demonstrated to be essential for brain plasticity and may be important for recovery.
“Improving sleep following mild TBI could prove critical to maximizing recovery from the injury,” said Dr. Weber. “Furthermore, bright light therapy is easy and minimally invasive, requires no medication, and has no known serious side effects.”
Melatonin May Improve Sleep and Cognition at High Altitudes
A new study conducted on North America’s highest mountain peak suggests that melatonin helps improve sleep and cognition at high altitudes.
After taking melatonin, participants fell asleep faster and experienced less wakefulness following sleep onset than after taking a placebo. Furthermore, in comparison with placebo treatment, mean reaction time the day after taking melatonin was significantly improved.
“Surprisingly, climbers in this study who were administered a placebo took approximately 44 minutes to fall asleep,” said Christopher Jung, PhD, Assistant Professor in the Sleep and Chronobiology Lab of the Department of Biological Sciences at the University of Alaska Anchorage. “After taking melatonin, it took them only approximately 20 minutes to fall asleep, and this increase in sleep was likely a significant factor in improving cognitive performance.”
The randomized, placebo-controlled study involved 13 climbers who were evaluated on two consecutive nights at 14,200 feet on Mt. McKinley, which has a summit elevation of 20,320 feet. In the double blind, crossover, within-subjects design, participants took melatonin 90 minutes prior to their chosen bedtime on one night, and they took a placebo at the same time on the other night. Participants slept in their own tents, and a wireless sleep-recording device was used to quantify sleep quality. During the day after the two test nights, cognitive performance was measured using a computerized version of the Stroop test to assess mean reaction time.
According to the authors, high altitude exposure is associated with hypoxia-related sleep disruption and decrements in cognition that can be especially problematic in extreme conditions.
“Many high altitude climates are extreme and dangerous, often requiring split-second decisions to be made during climbing and military operations,” said Dr. Jung. “Based on these results, melatonin is a safe and natural supplement that improves cognitive function and sleep at high altitude.”
Insomnia May Cause Dysfunction in Emotional Brain Circuitry
A new study provides neurobiologic evidence for dysfunction in the neural circuitry underlying emotion regulation in people with insomnia, which may have implications for the risk relationship between insomnia and depression.
“Insomnia has been consistently identified as a risk factor for depression,” said Peter Franzen, PhD, an Assistant Professor of Psychiatry at the University of Pittsburgh School of Medicine. “Alterations in the brain circuitry underlying emotion regulation may be involved in the pathway for depression, and these results suggest a mechanistic role for sleep disturbance in the development of psychiatric disorders.”
The study involved 14 individuals with chronic primary insomnia without other primary psychiatric disorders, as well as 30 good sleepers who served as a control group. Participants underwent an fMRI scan during an emotion regulation task in which they were shown negative or neutral pictures. They were asked to passively view the images or to decrease their emotional responses using cognitive reappraisal, a voluntary emotion regulation strategy in which a person interprets the meaning depicted in the picture to feel less negative.
In the primary insomnia group, amygdala activity was significantly higher during reappraisal than during passive viewing. In analysis between groups, amygdala activity during reappraisal trials was significantly greater in the primary insomnia group, compared with activity in good sleepers. The two groups did not significantly differ when passively viewing negative pictures.
“Previous studies have demonstrated that successful emotion regulation using reappraisal decreases amygdala response in healthy individuals, yet we were surprised that activity was even higher during reappraisal of, versus passive viewing of, pictures with negative emotional content in this sample of individuals with primary insomnia,” said Dr. Franzen.
The American Academy of Sleep Medicine reports that about 10% to 15% of adults have an insomnia disorder with distress or daytime impairment. According to the National Institute of Mental Health, 6.7% of the US adult population has major depressive disorder. Both insomnia and depression are more common in women than in men.
BALTIMORE—Bright light therapy may improve sleep, cognition, emotion, and brain function following mild traumatic brain injury (TBI), according to research presented at the 27th Annual Meeting of the Associated Professional Sleep Societies.
Results show that six weeks of morning bright light therapy resulted in a marked decrease in subjective daytime sleepiness. This improvement was further associated with improvements in the propensity to fall asleep and nighttime sleep quality. Bright light therapy also affected depressive symptoms.
“Our preliminary data suggest that morning bright light therapy might be helpful to reduce subjective daytime sleepiness and to improve nighttime sleep,” said Mareen Weber, PhD, Instructor in Psychiatry at McLean Hospital/Harvard Medical School in Belmont, Massachusetts. “Importantly, the research also shows changes in brain activation during a demanding cognitive task, suggesting that bright light treatment might yield changes in brain functioning.”
The study group included 18 patients with a documented history of at least one mild TBI and sleep disturbance that either emerged or was aggravated with the most recent injury. Data were gathered using Multiple Sleep Latency Tests (MSLT), actigraphy, and sleep diaries, and all participants underwent MRI and comprehensive psychiatric and neuropsychologic assessments before and after the intervention.
According to the authors, at least 50% of individuals with TBI experience some kind of sleep disturbance following their injury, and sleep has been demonstrated to be essential for brain plasticity and may be important for recovery.
“Improving sleep following mild TBI could prove critical to maximizing recovery from the injury,” said Dr. Weber. “Furthermore, bright light therapy is easy and minimally invasive, requires no medication, and has no known serious side effects.”
Melatonin May Improve Sleep and Cognition at High Altitudes
A new study conducted on North America’s highest mountain peak suggests that melatonin helps improve sleep and cognition at high altitudes.
After taking melatonin, participants fell asleep faster and experienced less wakefulness following sleep onset than after taking a placebo. Furthermore, in comparison with placebo treatment, mean reaction time the day after taking melatonin was significantly improved.
“Surprisingly, climbers in this study who were administered a placebo took approximately 44 minutes to fall asleep,” said Christopher Jung, PhD, Assistant Professor in the Sleep and Chronobiology Lab of the Department of Biological Sciences at the University of Alaska Anchorage. “After taking melatonin, it took them only approximately 20 minutes to fall asleep, and this increase in sleep was likely a significant factor in improving cognitive performance.”
The randomized, placebo-controlled study involved 13 climbers who were evaluated on two consecutive nights at 14,200 feet on Mt. McKinley, which has a summit elevation of 20,320 feet. In the double blind, crossover, within-subjects design, participants took melatonin 90 minutes prior to their chosen bedtime on one night, and they took a placebo at the same time on the other night. Participants slept in their own tents, and a wireless sleep-recording device was used to quantify sleep quality. During the day after the two test nights, cognitive performance was measured using a computerized version of the Stroop test to assess mean reaction time.
According to the authors, high altitude exposure is associated with hypoxia-related sleep disruption and decrements in cognition that can be especially problematic in extreme conditions.
“Many high altitude climates are extreme and dangerous, often requiring split-second decisions to be made during climbing and military operations,” said Dr. Jung. “Based on these results, melatonin is a safe and natural supplement that improves cognitive function and sleep at high altitude.”
Insomnia May Cause Dysfunction in Emotional Brain Circuitry
A new study provides neurobiologic evidence for dysfunction in the neural circuitry underlying emotion regulation in people with insomnia, which may have implications for the risk relationship between insomnia and depression.
“Insomnia has been consistently identified as a risk factor for depression,” said Peter Franzen, PhD, an Assistant Professor of Psychiatry at the University of Pittsburgh School of Medicine. “Alterations in the brain circuitry underlying emotion regulation may be involved in the pathway for depression, and these results suggest a mechanistic role for sleep disturbance in the development of psychiatric disorders.”
The study involved 14 individuals with chronic primary insomnia without other primary psychiatric disorders, as well as 30 good sleepers who served as a control group. Participants underwent an fMRI scan during an emotion regulation task in which they were shown negative or neutral pictures. They were asked to passively view the images or to decrease their emotional responses using cognitive reappraisal, a voluntary emotion regulation strategy in which a person interprets the meaning depicted in the picture to feel less negative.
In the primary insomnia group, amygdala activity was significantly higher during reappraisal than during passive viewing. In analysis between groups, amygdala activity during reappraisal trials was significantly greater in the primary insomnia group, compared with activity in good sleepers. The two groups did not significantly differ when passively viewing negative pictures.
“Previous studies have demonstrated that successful emotion regulation using reappraisal decreases amygdala response in healthy individuals, yet we were surprised that activity was even higher during reappraisal of, versus passive viewing of, pictures with negative emotional content in this sample of individuals with primary insomnia,” said Dr. Franzen.
The American Academy of Sleep Medicine reports that about 10% to 15% of adults have an insomnia disorder with distress or daytime impairment. According to the National Institute of Mental Health, 6.7% of the US adult population has major depressive disorder. Both insomnia and depression are more common in women than in men.
BALTIMORE—Bright light therapy may improve sleep, cognition, emotion, and brain function following mild traumatic brain injury (TBI), according to research presented at the 27th Annual Meeting of the Associated Professional Sleep Societies.
Results show that six weeks of morning bright light therapy resulted in a marked decrease in subjective daytime sleepiness. This improvement was further associated with improvements in the propensity to fall asleep and nighttime sleep quality. Bright light therapy also affected depressive symptoms.
“Our preliminary data suggest that morning bright light therapy might be helpful to reduce subjective daytime sleepiness and to improve nighttime sleep,” said Mareen Weber, PhD, Instructor in Psychiatry at McLean Hospital/Harvard Medical School in Belmont, Massachusetts. “Importantly, the research also shows changes in brain activation during a demanding cognitive task, suggesting that bright light treatment might yield changes in brain functioning.”
The study group included 18 patients with a documented history of at least one mild TBI and sleep disturbance that either emerged or was aggravated with the most recent injury. Data were gathered using Multiple Sleep Latency Tests (MSLT), actigraphy, and sleep diaries, and all participants underwent MRI and comprehensive psychiatric and neuropsychologic assessments before and after the intervention.
According to the authors, at least 50% of individuals with TBI experience some kind of sleep disturbance following their injury, and sleep has been demonstrated to be essential for brain plasticity and may be important for recovery.
“Improving sleep following mild TBI could prove critical to maximizing recovery from the injury,” said Dr. Weber. “Furthermore, bright light therapy is easy and minimally invasive, requires no medication, and has no known serious side effects.”
Melatonin May Improve Sleep and Cognition at High Altitudes
A new study conducted on North America’s highest mountain peak suggests that melatonin helps improve sleep and cognition at high altitudes.
After taking melatonin, participants fell asleep faster and experienced less wakefulness following sleep onset than after taking a placebo. Furthermore, in comparison with placebo treatment, mean reaction time the day after taking melatonin was significantly improved.
“Surprisingly, climbers in this study who were administered a placebo took approximately 44 minutes to fall asleep,” said Christopher Jung, PhD, Assistant Professor in the Sleep and Chronobiology Lab of the Department of Biological Sciences at the University of Alaska Anchorage. “After taking melatonin, it took them only approximately 20 minutes to fall asleep, and this increase in sleep was likely a significant factor in improving cognitive performance.”
The randomized, placebo-controlled study involved 13 climbers who were evaluated on two consecutive nights at 14,200 feet on Mt. McKinley, which has a summit elevation of 20,320 feet. In the double blind, crossover, within-subjects design, participants took melatonin 90 minutes prior to their chosen bedtime on one night, and they took a placebo at the same time on the other night. Participants slept in their own tents, and a wireless sleep-recording device was used to quantify sleep quality. During the day after the two test nights, cognitive performance was measured using a computerized version of the Stroop test to assess mean reaction time.
According to the authors, high altitude exposure is associated with hypoxia-related sleep disruption and decrements in cognition that can be especially problematic in extreme conditions.
“Many high altitude climates are extreme and dangerous, often requiring split-second decisions to be made during climbing and military operations,” said Dr. Jung. “Based on these results, melatonin is a safe and natural supplement that improves cognitive function and sleep at high altitude.”
Insomnia May Cause Dysfunction in Emotional Brain Circuitry
A new study provides neurobiologic evidence for dysfunction in the neural circuitry underlying emotion regulation in people with insomnia, which may have implications for the risk relationship between insomnia and depression.
“Insomnia has been consistently identified as a risk factor for depression,” said Peter Franzen, PhD, an Assistant Professor of Psychiatry at the University of Pittsburgh School of Medicine. “Alterations in the brain circuitry underlying emotion regulation may be involved in the pathway for depression, and these results suggest a mechanistic role for sleep disturbance in the development of psychiatric disorders.”
The study involved 14 individuals with chronic primary insomnia without other primary psychiatric disorders, as well as 30 good sleepers who served as a control group. Participants underwent an fMRI scan during an emotion regulation task in which they were shown negative or neutral pictures. They were asked to passively view the images or to decrease their emotional responses using cognitive reappraisal, a voluntary emotion regulation strategy in which a person interprets the meaning depicted in the picture to feel less negative.
In the primary insomnia group, amygdala activity was significantly higher during reappraisal than during passive viewing. In analysis between groups, amygdala activity during reappraisal trials was significantly greater in the primary insomnia group, compared with activity in good sleepers. The two groups did not significantly differ when passively viewing negative pictures.
“Previous studies have demonstrated that successful emotion regulation using reappraisal decreases amygdala response in healthy individuals, yet we were surprised that activity was even higher during reappraisal of, versus passive viewing of, pictures with negative emotional content in this sample of individuals with primary insomnia,” said Dr. Franzen.
The American Academy of Sleep Medicine reports that about 10% to 15% of adults have an insomnia disorder with distress or daytime impairment. According to the National Institute of Mental Health, 6.7% of the US adult population has major depressive disorder. Both insomnia and depression are more common in women than in men.
Blast Injury, Direct Head Trauma Lead to Similar, Long-Term Postconcussion Syndrome Effects
SAN DIEGO—Traumatic brain injury (TBI) resulting from a blast injury and TBI resulting from direct head trauma can lead to similarly significant and long-term effects in military veterans, reported James R. Couch, MD, PhD, at the 65th Annual Meeting of the American Academy of Neurology.
“Postconcussion syndrome produced by blast injury and direct head trauma is essentially the same for up to eight years postinjury,” said Dr. Couch, Professor of Neurology at the University of Oklahoma College of Medicine in Oklahoma City. “As far as gauging the postconcussion syndrome by symptoms related to the domains of postconcussion syndrome, the two modes of brain injury appear to be equivalent in their short- and longer-term effects.”
Postconcussion Syndrome in Military Veterans
Dr. Couch and colleagues analyzed 500 veterans (ages 20 to 62; 474 males) from the conflicts in Iraq and Afghanistan who had had a deployment-related TBI and were referred to a TBI clinic. A neurologist or physician’s assistant with additional training in TBI examined all participants. The TBIs had occurred between one and eight years prior to analysis.
The investigators administered a standard TBI screen concerning events that had occurred around the time of the TBI, and they evaluated the following symptoms to represent postconcussion syndrome: headache, dizziness, balance difficulty, poor coordination, difficulty with decision-making, and depression. These symptoms were measured using a scale of 1 (no symptoms) to 5 (very severe). “The scale reflected the interference in daily life or extent of the problem presented by the symptom and not just the severity of a single headache or other incident,” noted Dr. Couch.
Depression was measured with use of the Beck Depression Inventory. For longitudinal comparison, participants were classified into two groups: those who had had a TBI one to four years prior to analysis and those who had had a TBI five to eight years prior to analysis.
Among the veterans, 383 had a blast injury (247 at one to four years, 136 at five to eight years) and 114 had a direct head trauma (63 at one to four years and 51 at five to eight years), and data were missing from three participants. After comparing the occurrence of neurologic symptoms and depression scores between blast injury and direct head trauma in subjects for the entire group and for subgroups at one to four and five to eight years postinjury, the researchers observed no significant differences.
Of the 474 veterans with mild TBI as measured by loss of consciousness of less than 30 minutes, 357 (75%) had loss of consciousness of less than one minute and could be designated as having very mild TBI, according to Dr. Couch. “This suggests that even very mild TBI, by the measure of duration of loss of consciousness, can produce a significant and prolonged postconcussion syndrome, whether of blast or direct head trauma origin,” he said. Seventeen veterans had loss of consciousness of 30 minutes or greater, and nine were unable to report how long they had lost consciousness.
“The data presented suggest that the postconcussion is a major problem for veterans with mild TBI,” said Dr. Couch. “Only 5% of the subjects in this cohort had TBI consistent with moderate to severe TBI or did not know duration of the loss of consciousness.”
Headache, Cognitive Problems Among Lasting Effects of TBI
Headache was the most commonly reported symptom by the blast and trauma groups, with about half the subjects reporting a severe headache one to four years and five to eight years postinjury. Severe difficulty with decisions was the next most common symptom, followed by balance, dizziness, and coordination problems. Depression was minimal to none in more than 90% of veterans.
“Headache and cognitive problems are major contributors to the continuing postconcussion syndrome problem and can continue to cause significant difficulties for the TBI victim years after the injury,” Dr. Couch concluded. “The other symptoms also present significant problems for periods of up to eight years. Much further study will be needed to define the long-term course of TBI.”
—Colby Stong
Editor
Suggested Reading
Belanger HG, Proctor-Weber Z, Kretzmer T, et al. Symptom complaints following reports of blast versus non-blast mild TBI: does mechanism of injury matter? Clin Neuropsychol. 2011;25(5):702-715.
SAN DIEGO—Traumatic brain injury (TBI) resulting from a blast injury and TBI resulting from direct head trauma can lead to similarly significant and long-term effects in military veterans, reported James R. Couch, MD, PhD, at the 65th Annual Meeting of the American Academy of Neurology.
“Postconcussion syndrome produced by blast injury and direct head trauma is essentially the same for up to eight years postinjury,” said Dr. Couch, Professor of Neurology at the University of Oklahoma College of Medicine in Oklahoma City. “As far as gauging the postconcussion syndrome by symptoms related to the domains of postconcussion syndrome, the two modes of brain injury appear to be equivalent in their short- and longer-term effects.”
Postconcussion Syndrome in Military Veterans
Dr. Couch and colleagues analyzed 500 veterans (ages 20 to 62; 474 males) from the conflicts in Iraq and Afghanistan who had had a deployment-related TBI and were referred to a TBI clinic. A neurologist or physician’s assistant with additional training in TBI examined all participants. The TBIs had occurred between one and eight years prior to analysis.
The investigators administered a standard TBI screen concerning events that had occurred around the time of the TBI, and they evaluated the following symptoms to represent postconcussion syndrome: headache, dizziness, balance difficulty, poor coordination, difficulty with decision-making, and depression. These symptoms were measured using a scale of 1 (no symptoms) to 5 (very severe). “The scale reflected the interference in daily life or extent of the problem presented by the symptom and not just the severity of a single headache or other incident,” noted Dr. Couch.
Depression was measured with use of the Beck Depression Inventory. For longitudinal comparison, participants were classified into two groups: those who had had a TBI one to four years prior to analysis and those who had had a TBI five to eight years prior to analysis.
Among the veterans, 383 had a blast injury (247 at one to four years, 136 at five to eight years) and 114 had a direct head trauma (63 at one to four years and 51 at five to eight years), and data were missing from three participants. After comparing the occurrence of neurologic symptoms and depression scores between blast injury and direct head trauma in subjects for the entire group and for subgroups at one to four and five to eight years postinjury, the researchers observed no significant differences.
Of the 474 veterans with mild TBI as measured by loss of consciousness of less than 30 minutes, 357 (75%) had loss of consciousness of less than one minute and could be designated as having very mild TBI, according to Dr. Couch. “This suggests that even very mild TBI, by the measure of duration of loss of consciousness, can produce a significant and prolonged postconcussion syndrome, whether of blast or direct head trauma origin,” he said. Seventeen veterans had loss of consciousness of 30 minutes or greater, and nine were unable to report how long they had lost consciousness.
“The data presented suggest that the postconcussion is a major problem for veterans with mild TBI,” said Dr. Couch. “Only 5% of the subjects in this cohort had TBI consistent with moderate to severe TBI or did not know duration of the loss of consciousness.”
Headache, Cognitive Problems Among Lasting Effects of TBI
Headache was the most commonly reported symptom by the blast and trauma groups, with about half the subjects reporting a severe headache one to four years and five to eight years postinjury. Severe difficulty with decisions was the next most common symptom, followed by balance, dizziness, and coordination problems. Depression was minimal to none in more than 90% of veterans.
“Headache and cognitive problems are major contributors to the continuing postconcussion syndrome problem and can continue to cause significant difficulties for the TBI victim years after the injury,” Dr. Couch concluded. “The other symptoms also present significant problems for periods of up to eight years. Much further study will be needed to define the long-term course of TBI.”
—Colby Stong
Editor
SAN DIEGO—Traumatic brain injury (TBI) resulting from a blast injury and TBI resulting from direct head trauma can lead to similarly significant and long-term effects in military veterans, reported James R. Couch, MD, PhD, at the 65th Annual Meeting of the American Academy of Neurology.
“Postconcussion syndrome produced by blast injury and direct head trauma is essentially the same for up to eight years postinjury,” said Dr. Couch, Professor of Neurology at the University of Oklahoma College of Medicine in Oklahoma City. “As far as gauging the postconcussion syndrome by symptoms related to the domains of postconcussion syndrome, the two modes of brain injury appear to be equivalent in their short- and longer-term effects.”
Postconcussion Syndrome in Military Veterans
Dr. Couch and colleagues analyzed 500 veterans (ages 20 to 62; 474 males) from the conflicts in Iraq and Afghanistan who had had a deployment-related TBI and were referred to a TBI clinic. A neurologist or physician’s assistant with additional training in TBI examined all participants. The TBIs had occurred between one and eight years prior to analysis.
The investigators administered a standard TBI screen concerning events that had occurred around the time of the TBI, and they evaluated the following symptoms to represent postconcussion syndrome: headache, dizziness, balance difficulty, poor coordination, difficulty with decision-making, and depression. These symptoms were measured using a scale of 1 (no symptoms) to 5 (very severe). “The scale reflected the interference in daily life or extent of the problem presented by the symptom and not just the severity of a single headache or other incident,” noted Dr. Couch.
Depression was measured with use of the Beck Depression Inventory. For longitudinal comparison, participants were classified into two groups: those who had had a TBI one to four years prior to analysis and those who had had a TBI five to eight years prior to analysis.
Among the veterans, 383 had a blast injury (247 at one to four years, 136 at five to eight years) and 114 had a direct head trauma (63 at one to four years and 51 at five to eight years), and data were missing from three participants. After comparing the occurrence of neurologic symptoms and depression scores between blast injury and direct head trauma in subjects for the entire group and for subgroups at one to four and five to eight years postinjury, the researchers observed no significant differences.
Of the 474 veterans with mild TBI as measured by loss of consciousness of less than 30 minutes, 357 (75%) had loss of consciousness of less than one minute and could be designated as having very mild TBI, according to Dr. Couch. “This suggests that even very mild TBI, by the measure of duration of loss of consciousness, can produce a significant and prolonged postconcussion syndrome, whether of blast or direct head trauma origin,” he said. Seventeen veterans had loss of consciousness of 30 minutes or greater, and nine were unable to report how long they had lost consciousness.
“The data presented suggest that the postconcussion is a major problem for veterans with mild TBI,” said Dr. Couch. “Only 5% of the subjects in this cohort had TBI consistent with moderate to severe TBI or did not know duration of the loss of consciousness.”
Headache, Cognitive Problems Among Lasting Effects of TBI
Headache was the most commonly reported symptom by the blast and trauma groups, with about half the subjects reporting a severe headache one to four years and five to eight years postinjury. Severe difficulty with decisions was the next most common symptom, followed by balance, dizziness, and coordination problems. Depression was minimal to none in more than 90% of veterans.
“Headache and cognitive problems are major contributors to the continuing postconcussion syndrome problem and can continue to cause significant difficulties for the TBI victim years after the injury,” Dr. Couch concluded. “The other symptoms also present significant problems for periods of up to eight years. Much further study will be needed to define the long-term course of TBI.”
—Colby Stong
Editor
Suggested Reading
Belanger HG, Proctor-Weber Z, Kretzmer T, et al. Symptom complaints following reports of blast versus non-blast mild TBI: does mechanism of injury matter? Clin Neuropsychol. 2011;25(5):702-715.
Suggested Reading
Belanger HG, Proctor-Weber Z, Kretzmer T, et al. Symptom complaints following reports of blast versus non-blast mild TBI: does mechanism of injury matter? Clin Neuropsychol. 2011;25(5):702-715.
Nyaz Didehbani, PhD
Concussion May Lead to High Depression Rate in Retired NFL Players
SAN DIEGO—Among older retired players from the National Football League (NFL) who have a history of concussion, about 40% have mild to moderate symptoms of depression, a rate nearly three times higher than that of the general population, according to research presented at the 65th Annual Meeting of the American Academy of Neurology.
Concussions in the former football players were specifically related to cognitive symptoms of depression, such as sadness, feelings of worthlessness or self-criticism, and suicidal thoughts, reported Nyaz Didehbani, PhD, and colleagues from the University of Texas at Dallas and University of Texas Southwestern Medical Center. In addition, somatic complaints were more prominent in the athletes compared with other items on the Beck Depression Inventory–II (BDI–II), even though the symptoms were not significantly correlated with concussions.
“Overall, results indicated that individuals having sustained concussions in early adulthood may be at a higher risk for developing depression as they age, compared to the general population,” stated Dr. Didehbani, a research psychologist at the Center for BrainHealth, University of Texas at Dallas. “More specifically, concussions were related to cognitive symptoms of depression, and it is possible that the high endorsement of somatic symptoms may be related to pain or other factors.”
Postconcussion Effects in Former NFL Players
Previous research has shown that concussions can lead to cognitive and mood disturbances, though few studies had explored the effects that may occur as players age. Dr. Didehbani’s group compared 30 retired NFL veterans who had had a concussion with 29 age-, education-, and IQ-matched healthy controls without a history of concussion. In both groups, ages ranged from 41 to 77, with a mean of 59 in the athletes and a mean of 60 in controls.
The investigators performed detailed neuropsychologic examinations in all participants to rule out cognitive impairment. All subjects completed the BDI–II, and participants’ scores were assessed according to a three-factor model of depressive symptoms (cognitive, affective, and somatic). Data regarding concussions were retrospectively obtained with use of the American Academy of Neurology Practice Parameter for grading concussions.
A Significant Correlation Between Concussion and Depression
The researchers found a significant correlation between the number of lifetime concussions in the former players and total scores on the BDI–II. In addition, the number of concussions was significantly correlated with cognitive symptoms on the BDI–II (r = 0.56). BDI-II scores were not associated with age, education, IQ, or the number of years played. Furthermore, the former athletes had significantly higher scores regarding cognitive, affective, and somatic symptoms.
Twelve of the 30 players (40%) had mild to moderate symptoms of depression, compared with the national average rate of 15% in older adults. The athletes had more symptoms on every BDI–II item, and on 13 of the 21 items the rate of symptoms was at least 20% higher, compared with controls. The largest differences between athletes and controls were observed in reports of problems with concentration (53% vs 19%, respectively), changes in appetite (47% vs 13%), loss of energy (60% vs 29%), changes in sleep (57% vs 26%), and decreased interest in sex (43% vs 16%).
Overall, the findings “highlight the need to educate individuals and families about somatic and psychologic symptoms associated with depression and to thoroughly assess depressive symptoms throughout the lifespan in professional athletes,” concluded Dr. Didehbani.
—Colby Stong
Editor
Suggested Reading
Didehbani N, Munro Cullum C, Mansinghani S, et al. Depressive symptoms and concussions in aging retired NFL players. Arch Clin Neuropsychol. 2013 May 3 [Epub ahead of print].
Hart J Jr, Kraut MA, Womack KB, et al. Neuroimaging of cognitive dysfunction and depression in aging retired National Football League players: a cross-sectional study. JAMA Neurol. 2013;70(3):326-335.
[To listen to an audiocast with Nyaz Didehbani, click here.]
SAN DIEGO—Among older retired players from the National Football League (NFL) who have a history of concussion, about 40% have mild to moderate symptoms of depression, a rate nearly three times higher than that of the general population, according to research presented at the 65th Annual Meeting of the American Academy of Neurology.
Concussions in the former football players were specifically related to cognitive symptoms of depression, such as sadness, feelings of worthlessness or self-criticism, and suicidal thoughts, reported Nyaz Didehbani, PhD, and colleagues from the University of Texas at Dallas and University of Texas Southwestern Medical Center. In addition, somatic complaints were more prominent in the athletes compared with other items on the Beck Depression Inventory–II (BDI–II), even though the symptoms were not significantly correlated with concussions.
“Overall, results indicated that individuals having sustained concussions in early adulthood may be at a higher risk for developing depression as they age, compared to the general population,” stated Dr. Didehbani, a research psychologist at the Center for BrainHealth, University of Texas at Dallas. “More specifically, concussions were related to cognitive symptoms of depression, and it is possible that the high endorsement of somatic symptoms may be related to pain or other factors.”
Postconcussion Effects in Former NFL Players
Previous research has shown that concussions can lead to cognitive and mood disturbances, though few studies had explored the effects that may occur as players age. Dr. Didehbani’s group compared 30 retired NFL veterans who had had a concussion with 29 age-, education-, and IQ-matched healthy controls without a history of concussion. In both groups, ages ranged from 41 to 77, with a mean of 59 in the athletes and a mean of 60 in controls.
The investigators performed detailed neuropsychologic examinations in all participants to rule out cognitive impairment. All subjects completed the BDI–II, and participants’ scores were assessed according to a three-factor model of depressive symptoms (cognitive, affective, and somatic). Data regarding concussions were retrospectively obtained with use of the American Academy of Neurology Practice Parameter for grading concussions.
A Significant Correlation Between Concussion and Depression
The researchers found a significant correlation between the number of lifetime concussions in the former players and total scores on the BDI–II. In addition, the number of concussions was significantly correlated with cognitive symptoms on the BDI–II (r = 0.56). BDI-II scores were not associated with age, education, IQ, or the number of years played. Furthermore, the former athletes had significantly higher scores regarding cognitive, affective, and somatic symptoms.
Twelve of the 30 players (40%) had mild to moderate symptoms of depression, compared with the national average rate of 15% in older adults. The athletes had more symptoms on every BDI–II item, and on 13 of the 21 items the rate of symptoms was at least 20% higher, compared with controls. The largest differences between athletes and controls were observed in reports of problems with concentration (53% vs 19%, respectively), changes in appetite (47% vs 13%), loss of energy (60% vs 29%), changes in sleep (57% vs 26%), and decreased interest in sex (43% vs 16%).
Overall, the findings “highlight the need to educate individuals and families about somatic and psychologic symptoms associated with depression and to thoroughly assess depressive symptoms throughout the lifespan in professional athletes,” concluded Dr. Didehbani.
—Colby Stong
Editor
Suggested Reading
Didehbani N, Munro Cullum C, Mansinghani S, et al. Depressive symptoms and concussions in aging retired NFL players. Arch Clin Neuropsychol. 2013 May 3 [Epub ahead of print].
Hart J Jr, Kraut MA, Womack KB, et al. Neuroimaging of cognitive dysfunction and depression in aging retired National Football League players: a cross-sectional study. JAMA Neurol. 2013;70(3):326-335.
[To listen to an audiocast with Nyaz Didehbani, click here.]
SAN DIEGO—Among older retired players from the National Football League (NFL) who have a history of concussion, about 40% have mild to moderate symptoms of depression, a rate nearly three times higher than that of the general population, according to research presented at the 65th Annual Meeting of the American Academy of Neurology.
Concussions in the former football players were specifically related to cognitive symptoms of depression, such as sadness, feelings of worthlessness or self-criticism, and suicidal thoughts, reported Nyaz Didehbani, PhD, and colleagues from the University of Texas at Dallas and University of Texas Southwestern Medical Center. In addition, somatic complaints were more prominent in the athletes compared with other items on the Beck Depression Inventory–II (BDI–II), even though the symptoms were not significantly correlated with concussions.
“Overall, results indicated that individuals having sustained concussions in early adulthood may be at a higher risk for developing depression as they age, compared to the general population,” stated Dr. Didehbani, a research psychologist at the Center for BrainHealth, University of Texas at Dallas. “More specifically, concussions were related to cognitive symptoms of depression, and it is possible that the high endorsement of somatic symptoms may be related to pain or other factors.”
Postconcussion Effects in Former NFL Players
Previous research has shown that concussions can lead to cognitive and mood disturbances, though few studies had explored the effects that may occur as players age. Dr. Didehbani’s group compared 30 retired NFL veterans who had had a concussion with 29 age-, education-, and IQ-matched healthy controls without a history of concussion. In both groups, ages ranged from 41 to 77, with a mean of 59 in the athletes and a mean of 60 in controls.
The investigators performed detailed neuropsychologic examinations in all participants to rule out cognitive impairment. All subjects completed the BDI–II, and participants’ scores were assessed according to a three-factor model of depressive symptoms (cognitive, affective, and somatic). Data regarding concussions were retrospectively obtained with use of the American Academy of Neurology Practice Parameter for grading concussions.
A Significant Correlation Between Concussion and Depression
The researchers found a significant correlation between the number of lifetime concussions in the former players and total scores on the BDI–II. In addition, the number of concussions was significantly correlated with cognitive symptoms on the BDI–II (r = 0.56). BDI-II scores were not associated with age, education, IQ, or the number of years played. Furthermore, the former athletes had significantly higher scores regarding cognitive, affective, and somatic symptoms.
Twelve of the 30 players (40%) had mild to moderate symptoms of depression, compared with the national average rate of 15% in older adults. The athletes had more symptoms on every BDI–II item, and on 13 of the 21 items the rate of symptoms was at least 20% higher, compared with controls. The largest differences between athletes and controls were observed in reports of problems with concentration (53% vs 19%, respectively), changes in appetite (47% vs 13%), loss of energy (60% vs 29%), changes in sleep (57% vs 26%), and decreased interest in sex (43% vs 16%).
Overall, the findings “highlight the need to educate individuals and families about somatic and psychologic symptoms associated with depression and to thoroughly assess depressive symptoms throughout the lifespan in professional athletes,” concluded Dr. Didehbani.
—Colby Stong
Editor
Suggested Reading
Didehbani N, Munro Cullum C, Mansinghani S, et al. Depressive symptoms and concussions in aging retired NFL players. Arch Clin Neuropsychol. 2013 May 3 [Epub ahead of print].
Hart J Jr, Kraut MA, Womack KB, et al. Neuroimaging of cognitive dysfunction and depression in aging retired National Football League players: a cross-sectional study. JAMA Neurol. 2013;70(3):326-335.
[To listen to an audiocast with Nyaz Didehbani, click here.]
DTI May Detect Axonal Injury After Sports-Related Concussion
SAN DIEGO—Diffusion tensor imaging (DTI) may help neurologists detect axonal injury before any symptoms appear in an athlete who has had a concussion, said Jeffrey J. Bazarian, MD, MPH. Neurologists can maximize the technique’s sensitivity by comparing it with a DTI scan taken at baseline, he noted at the 65th Annual Meeting of the American Academy of Neurology.
A pattern of decreased fractional anisotropy and elevated mean diffusivity on DTI suggests axonal loss. The opposite pattern, which suggests axonal edema, may occur at the same time. “We still don’t know the clinical significance of these changes,” said Dr. Bazarian, Associate Professor of Emergency Medicine at the University of Rochester Medical Center in New York. The relationship of these changes to short-term cognitive outcome and neurologic function is uncertain. Similarly unclear is the relationship of these changes to the development of chronic traumatic encephalopathy.
Water Movement Can Reveal Axonal Swelling
Axonal injury is the primary pathophysiologic process that occurs after brain injury. After concussion, the brain rotates and creates shear forces along the length of the axon. “If the axon gets stretched at the right threshold of stretch force, little pores form along the axon, and things start to fall apart,” said Dr. Bazarian. The axon swells, stops functioning, and may disconnect itself from the neuron over time.
CT and MRI scans cannot show axonal injury, but DTI can by illustrating the movement of water in the brain. A DTI scan measures fractional anisotropy, which indicates the degree to which water’s movement in the brain is straight, and mean diffusivity, which reveals the amount of water movement in the brain. “If axons swell up, then we would guess that the straightness of water motion would go up and the overall diffusivity would go down,” said Dr. Bazarian. “Conversely, if the axon degenerated, just the opposite would occur. This might be a nice way to indirectly see axonal swelling or axonal loss.”
Concussion Correlated With Changes on DTI
Dr. Bazarian and his colleagues examined seven high school football players to test whether DTI detects axonal injury after concussion. Each player underwent a DTI scan at the beginning of the football season and another scan at the end of the season. One player had a concussion, and six players served as controls. Players took cognitive exams before and after the football season. During the season, players used a diary to record the number of times they had been hit in the helmet. The investigators used wild bootstrapping to look for statistically significant differences between voxels before and after injury.
The player with concussion was cognitively worse than the other players, said Dr. Bazarian. The investigators found no cognitive difference between the other six players and nonathletes. All of the players were hit in the helmet between 50 and 400 times during the season.
Compared with the other players, the player with concussion had the greatest proportion (3%) of significant changes in fractional anisotropy and mean diffusivity in his brain after the season ended. The controls had nearly as much white-matter change as the player with concussion. The amount of change in fractional anisotropy and mean diffusivity in the players correlated with the number of times they reported being hit in the head and to the increases in their postconcussion symptom score at the end of the season. For the player with concussion, any part of the brain with post-season changes in fractional anisotropy also had changes in mean diffusivity, which suggested that DTI was detecting axonal injury, said Dr. Bazarian.
DTI May Indicate a Threshold for White Matter Damage
In a follow-up study, Dr. Bazarian and colleagues gave 10 college football players helmets with sensors that recorded blows stronger than 10 g. Players wore the helmets during practices and games and underwent a DTI scan at the beginning of the season, at the end of the season, and after six months of rest. Players also underwent cognitive and physical exams at these same three time points. Investigators used wild bootstrapping to compare each player’s three scans.
All players had increases and decreases in fractional anisotropy and mean diffusivity at the end of the season. The percentage of the brain with decreased fractional anisotropy correlated well with almost all of the helmet readings and with some neurologic outcomes. “That may be the important metric, in terms of axonal injury,” said Dr. Bazarian. Three players had a greater proportion of brain with decreased fractional anisotropy than the other players and the controls. Postseason changes correlated well with balance and some aspects of cognition, said Dr. Bazarian.
After six months’ rest, two additional players had increased proportions of brain with decreased fractional anisotropy. One player who had had decreased fractional anisotropy at the end of the season returned to normal after six months’ rest. Another player with decreased fractional anisotropy at the end of the season was unchanged after six months’ rest. A third player seemed to be recovering after six months’ rest, but was still not back to baseline.
“These data allow us to draw some thresholds above which you start to see white matter damage,” said Dr. Bazarian. “The one that stood out was players who had had head hits resulting in rotational acceleration greater than 4,500 radians/s2. Once you got above 40 or 45 hits, the amount of your white matter that has changes went up above what controls’ levels were. What those changes mean over the long term is not clear.”
—Erik Greb
Senior Associate Editor
Suggested Reading
Bazarian JJ, Zhu T, Blyth B, et al. Subject-specific changes in brain white matter on diffusion tensor imaging after sports-related concussion. Magn Reson Imaging. 2012;30(2):171-180.
Henry LC, Tremblay J, Tremblay S, et al. Acute and chronic changes in diffusivity measures after sports concussion. J Neurotrauma. 2011;28(10):2049-2059.
Marchi N, Bazarian JJ, Puvenna V, et al. Consequences of repeated blood-brain barrier disruption in football players. PLoS One. 2013;8(3):e56805
SAN DIEGO—Diffusion tensor imaging (DTI) may help neurologists detect axonal injury before any symptoms appear in an athlete who has had a concussion, said Jeffrey J. Bazarian, MD, MPH. Neurologists can maximize the technique’s sensitivity by comparing it with a DTI scan taken at baseline, he noted at the 65th Annual Meeting of the American Academy of Neurology.
A pattern of decreased fractional anisotropy and elevated mean diffusivity on DTI suggests axonal loss. The opposite pattern, which suggests axonal edema, may occur at the same time. “We still don’t know the clinical significance of these changes,” said Dr. Bazarian, Associate Professor of Emergency Medicine at the University of Rochester Medical Center in New York. The relationship of these changes to short-term cognitive outcome and neurologic function is uncertain. Similarly unclear is the relationship of these changes to the development of chronic traumatic encephalopathy.
Water Movement Can Reveal Axonal Swelling
Axonal injury is the primary pathophysiologic process that occurs after brain injury. After concussion, the brain rotates and creates shear forces along the length of the axon. “If the axon gets stretched at the right threshold of stretch force, little pores form along the axon, and things start to fall apart,” said Dr. Bazarian. The axon swells, stops functioning, and may disconnect itself from the neuron over time.
CT and MRI scans cannot show axonal injury, but DTI can by illustrating the movement of water in the brain. A DTI scan measures fractional anisotropy, which indicates the degree to which water’s movement in the brain is straight, and mean diffusivity, which reveals the amount of water movement in the brain. “If axons swell up, then we would guess that the straightness of water motion would go up and the overall diffusivity would go down,” said Dr. Bazarian. “Conversely, if the axon degenerated, just the opposite would occur. This might be a nice way to indirectly see axonal swelling or axonal loss.”
Concussion Correlated With Changes on DTI
Dr. Bazarian and his colleagues examined seven high school football players to test whether DTI detects axonal injury after concussion. Each player underwent a DTI scan at the beginning of the football season and another scan at the end of the season. One player had a concussion, and six players served as controls. Players took cognitive exams before and after the football season. During the season, players used a diary to record the number of times they had been hit in the helmet. The investigators used wild bootstrapping to look for statistically significant differences between voxels before and after injury.
The player with concussion was cognitively worse than the other players, said Dr. Bazarian. The investigators found no cognitive difference between the other six players and nonathletes. All of the players were hit in the helmet between 50 and 400 times during the season.
Compared with the other players, the player with concussion had the greatest proportion (3%) of significant changes in fractional anisotropy and mean diffusivity in his brain after the season ended. The controls had nearly as much white-matter change as the player with concussion. The amount of change in fractional anisotropy and mean diffusivity in the players correlated with the number of times they reported being hit in the head and to the increases in their postconcussion symptom score at the end of the season. For the player with concussion, any part of the brain with post-season changes in fractional anisotropy also had changes in mean diffusivity, which suggested that DTI was detecting axonal injury, said Dr. Bazarian.
DTI May Indicate a Threshold for White Matter Damage
In a follow-up study, Dr. Bazarian and colleagues gave 10 college football players helmets with sensors that recorded blows stronger than 10 g. Players wore the helmets during practices and games and underwent a DTI scan at the beginning of the season, at the end of the season, and after six months of rest. Players also underwent cognitive and physical exams at these same three time points. Investigators used wild bootstrapping to compare each player’s three scans.
All players had increases and decreases in fractional anisotropy and mean diffusivity at the end of the season. The percentage of the brain with decreased fractional anisotropy correlated well with almost all of the helmet readings and with some neurologic outcomes. “That may be the important metric, in terms of axonal injury,” said Dr. Bazarian. Three players had a greater proportion of brain with decreased fractional anisotropy than the other players and the controls. Postseason changes correlated well with balance and some aspects of cognition, said Dr. Bazarian.
After six months’ rest, two additional players had increased proportions of brain with decreased fractional anisotropy. One player who had had decreased fractional anisotropy at the end of the season returned to normal after six months’ rest. Another player with decreased fractional anisotropy at the end of the season was unchanged after six months’ rest. A third player seemed to be recovering after six months’ rest, but was still not back to baseline.
“These data allow us to draw some thresholds above which you start to see white matter damage,” said Dr. Bazarian. “The one that stood out was players who had had head hits resulting in rotational acceleration greater than 4,500 radians/s2. Once you got above 40 or 45 hits, the amount of your white matter that has changes went up above what controls’ levels were. What those changes mean over the long term is not clear.”
—Erik Greb
Senior Associate Editor
Suggested Reading
Bazarian JJ, Zhu T, Blyth B, et al. Subject-specific changes in brain white matter on diffusion tensor imaging after sports-related concussion. Magn Reson Imaging. 2012;30(2):171-180.
Henry LC, Tremblay J, Tremblay S, et al. Acute and chronic changes in diffusivity measures after sports concussion. J Neurotrauma. 2011;28(10):2049-2059.
Marchi N, Bazarian JJ, Puvenna V, et al. Consequences of repeated blood-brain barrier disruption in football players. PLoS One. 2013;8(3):e56805
SAN DIEGO—Diffusion tensor imaging (DTI) may help neurologists detect axonal injury before any symptoms appear in an athlete who has had a concussion, said Jeffrey J. Bazarian, MD, MPH. Neurologists can maximize the technique’s sensitivity by comparing it with a DTI scan taken at baseline, he noted at the 65th Annual Meeting of the American Academy of Neurology.
A pattern of decreased fractional anisotropy and elevated mean diffusivity on DTI suggests axonal loss. The opposite pattern, which suggests axonal edema, may occur at the same time. “We still don’t know the clinical significance of these changes,” said Dr. Bazarian, Associate Professor of Emergency Medicine at the University of Rochester Medical Center in New York. The relationship of these changes to short-term cognitive outcome and neurologic function is uncertain. Similarly unclear is the relationship of these changes to the development of chronic traumatic encephalopathy.
Water Movement Can Reveal Axonal Swelling
Axonal injury is the primary pathophysiologic process that occurs after brain injury. After concussion, the brain rotates and creates shear forces along the length of the axon. “If the axon gets stretched at the right threshold of stretch force, little pores form along the axon, and things start to fall apart,” said Dr. Bazarian. The axon swells, stops functioning, and may disconnect itself from the neuron over time.
CT and MRI scans cannot show axonal injury, but DTI can by illustrating the movement of water in the brain. A DTI scan measures fractional anisotropy, which indicates the degree to which water’s movement in the brain is straight, and mean diffusivity, which reveals the amount of water movement in the brain. “If axons swell up, then we would guess that the straightness of water motion would go up and the overall diffusivity would go down,” said Dr. Bazarian. “Conversely, if the axon degenerated, just the opposite would occur. This might be a nice way to indirectly see axonal swelling or axonal loss.”
Concussion Correlated With Changes on DTI
Dr. Bazarian and his colleagues examined seven high school football players to test whether DTI detects axonal injury after concussion. Each player underwent a DTI scan at the beginning of the football season and another scan at the end of the season. One player had a concussion, and six players served as controls. Players took cognitive exams before and after the football season. During the season, players used a diary to record the number of times they had been hit in the helmet. The investigators used wild bootstrapping to look for statistically significant differences between voxels before and after injury.
The player with concussion was cognitively worse than the other players, said Dr. Bazarian. The investigators found no cognitive difference between the other six players and nonathletes. All of the players were hit in the helmet between 50 and 400 times during the season.
Compared with the other players, the player with concussion had the greatest proportion (3%) of significant changes in fractional anisotropy and mean diffusivity in his brain after the season ended. The controls had nearly as much white-matter change as the player with concussion. The amount of change in fractional anisotropy and mean diffusivity in the players correlated with the number of times they reported being hit in the head and to the increases in their postconcussion symptom score at the end of the season. For the player with concussion, any part of the brain with post-season changes in fractional anisotropy also had changes in mean diffusivity, which suggested that DTI was detecting axonal injury, said Dr. Bazarian.
DTI May Indicate a Threshold for White Matter Damage
In a follow-up study, Dr. Bazarian and colleagues gave 10 college football players helmets with sensors that recorded blows stronger than 10 g. Players wore the helmets during practices and games and underwent a DTI scan at the beginning of the season, at the end of the season, and after six months of rest. Players also underwent cognitive and physical exams at these same three time points. Investigators used wild bootstrapping to compare each player’s three scans.
All players had increases and decreases in fractional anisotropy and mean diffusivity at the end of the season. The percentage of the brain with decreased fractional anisotropy correlated well with almost all of the helmet readings and with some neurologic outcomes. “That may be the important metric, in terms of axonal injury,” said Dr. Bazarian. Three players had a greater proportion of brain with decreased fractional anisotropy than the other players and the controls. Postseason changes correlated well with balance and some aspects of cognition, said Dr. Bazarian.
After six months’ rest, two additional players had increased proportions of brain with decreased fractional anisotropy. One player who had had decreased fractional anisotropy at the end of the season returned to normal after six months’ rest. Another player with decreased fractional anisotropy at the end of the season was unchanged after six months’ rest. A third player seemed to be recovering after six months’ rest, but was still not back to baseline.
“These data allow us to draw some thresholds above which you start to see white matter damage,” said Dr. Bazarian. “The one that stood out was players who had had head hits resulting in rotational acceleration greater than 4,500 radians/s2. Once you got above 40 or 45 hits, the amount of your white matter that has changes went up above what controls’ levels were. What those changes mean over the long term is not clear.”
—Erik Greb
Senior Associate Editor
Suggested Reading
Bazarian JJ, Zhu T, Blyth B, et al. Subject-specific changes in brain white matter on diffusion tensor imaging after sports-related concussion. Magn Reson Imaging. 2012;30(2):171-180.
Henry LC, Tremblay J, Tremblay S, et al. Acute and chronic changes in diffusivity measures after sports concussion. J Neurotrauma. 2011;28(10):2049-2059.
Marchi N, Bazarian JJ, Puvenna V, et al. Consequences of repeated blood-brain barrier disruption in football players. PLoS One. 2013;8(3):e56805