Outcomes in Patients With Mild Traumatic Brain Injury Without Acute Intracranial Traumatic Injury

Predictive Utility of Diffusion MRI After Mild Traumatic Brain Injury in Civilian Populations: A Systematic Review

OBJECTIVE

A considerable number of people experience persisting symptoms and functional limitations after mild traumatic brain injury (mTBI). It is unclear whether subtle white matter changes contribute to this phenomenon. In this systematic review, the authors evaluated whether microstructural white matter indices on advanced MRI are related to clinical dysfunction among patients without abnormalities on standard brain computed tomography (CT) or MRI (uncomplicated mTBI).

METHODS

A search of multiple databases was performed. Studies with individuals who experienced blast-related, sports-related, or multiple mTBIs were excluded. Diffusion tensor imaging (DTI) and susceptibility-weighted imaging (SWI) metrics and cognitive, neuropsychiatric, or functional outcome measures were extracted from each study.

RESULTS

Thirteen studies were selected (participants with mTBI, N=553; healthy control group, N=438). Seven DTI studies evaluated cognitive function, with five reporting significant correlations between reduced white matter integrity and deficits in attention, processing speed, and executive function at 6-12 months after injury (three studies included only individuals with uncomplicated mTBI). Four studies found significant correlations between DTI metrics and persistent postconcussive symptoms after 3-12 months (one study included only individuals with uncomplicated mTBI). Two SWI studies reported conflicting findings regarding the relationship between the presence of microbleeds and postconcussive symptoms.

CONCLUSIONS

The results revealed that indices of microstructural white matter integrity may relate to clinical presentation 3-12 months after injury in uncomplicated mTBI. However, analysis methods and brain regions studied varied across studies. Further research is needed to identify relationships between white matter indices in specific brain regions and symptom persistence beyond 12 months.

Cognitive impairment in Chinese traumatic brain injury patients: from challenge to future perspectives

Traumatic Brain Injury (TBI) is a prevalent form of neurological damage that may induce varying degrees of cognitive dysfunction in patients, consequently impacting their quality of life and social functioning. This article provides a mini review of the epidemiology in Chinese TBI patients and etiology of cognitive impairment. It analyzes the risk factors of cognitive impairment, discusses current management strategies for cognitive dysfunction in Chinese TBI patients, and summarizes the strengths and limitations of primary testing tools for TBI-related cognitive functions. Furthermore, the article offers a prospective analysis of future challenges and opportunities. Its objective is to contribute as a reference for the prevention and management of cognitive dysfunction in Chinese TBI patients.

Isolated Traumatic Subarachnoid Hemorrhage on Head Computed Tomography Scan May Not Be Isolated: A TRACK-TBI Study

Isolated traumatic subarachnoid hemorrhage (tSAH) after traumatic brain injury (TBI) on head computed tomography (CT) scan is often regarded as a "mild" injury, with reduced need for additional workup. However, tSAH is also a predictor of incomplete recovery and unfavorable outcome. This study aimed to evaluate the characteristics of CT-occult intracranial injuries on brain magnetic resonance imaging (MRI) scan in TBI patients with emergency department (ED) arrival Glasgow Coma Scale (GCS) score 13-15 and isolated tSAH on CT. The prospective, 18-center Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study (TRACK-TBI; enrollment years 2014-2019) enrolled participants who presented to the ED and received a clinically-indicated head CT within 24 hours (h) of TBI. A subset of TRACK-TBI participants underwent venipuncture within 24h for plasma glial fibrillary acidic protein (GFAP) analysis, and research MRI at 2-weeks post-injury. In the current study, TRACK-TBI participants aged ≥17 years with ED arrival GCS 13-15, isolated tSAH on initial head CT, plasma GFAP level, and 2-week MRI data were analyzed. In 57 participants, median age was 46.0 years [quartile 1 to 3 (Q1-Q3): 34-57] and 52.6% were male. At ED disposition, 12.3% were discharged home, 61.4% were admitted to hospital ward, and 26.3% to intensive care unit. MRI identified CT-occult traumatic intracranial lesions in 45.6% (26 of 57 participants; 1 additional lesion type: 31.6%; 2 additional lesion types: 14.0%); of these 26 participants with CT-occult intracranial lesions, 65.4% had axonal injury, 42.3% had subdural hematoma, and 23.1% had intracerebral contusion. GFAP levels were higher in participants with CT-occult MRI lesions compared to without (median: 630.6 pg/ml, Q1-Q3: [172.4-941.2] vs. 226.4 [105.8-436.1], p=0.049), and were associated with axonal injury (no: median 226.7 pg/ml [109.6-435.1], yes: 828.6 pg/ml [204.0-1194.3], p=0.009). Our results indicate that isolated tSAH on head CT is often not the sole intracranial traumatic injury in GCS 13-15 TBI. Forty-six percent of patients in our cohort (26 of 57 participants) had additional CT-occult traumatic lesions on MRI. Plasma GFAP may be an important biomarker for the identification of additional CT-occult injuries, including axonal injury. These findings should be interpreted cautiously given our modest sample size and await validation from larger studies.

Unravelling the current shortfalls, challenges, and opportunities in traumatic brain injury

The brain is the control centre of the human body. Injury to the brain can have diverse and disabling effects. Yet there remain important unanswered questions for clinicians, those affected and their families. This special collection aims to advance understanding of how we can better diagnose, treat and support those affected by brain injury across the severity spectrum.

Clinical Grading Scales and Neuroprognostication in Acute Brain Injury

Prediction of neurological clinical outcome after acute brain injury is critical because it helps guide discussions with patients and families and informs treatment plans and allocation of resources. Numerous clinical grading scales have been published that aim to support prognostication after acute brain injury. However, the development and validation of clinical scales lack a standardized approach. This in turn makes it difficult for clinicians to rely on prognostic grading scales and to integrate them into clinical practice. In this review, we discuss quality measures of score development and validation and summarize available scales to prognosticate outcomes after acute brain injury. These include scales developed for patients with coma, cardiac arrest, ischemic stroke, nontraumatic intracerebral hemorrhage, subarachnoid hemorrhage, and traumatic brain injury; for each scale, we discuss available validation studies.

Rehabilitation interventions for oculomotor deficits in adults with mild traumatic brain injury: a systematic review protocol

INTRODUCTION

Mild traumatic brain injury (mTBI) is the most common form of TBI with many individuals suffering from symptoms suggestive of deficits in oculomotor function. Although the symptoms are often experienced transiently, almost 50% of individuals will experience persistent symptoms. Oculomotor deficits can last months after injury and decrease function and the ability to participate in work, school and sport. To date, rehabilitation interventions targeting oculomotor deficits in mTBI have been reported on in several studies with varying study designs; however, the effectiveness of these interventions on measures of oculomotor function has not been established. The purpose of this paper is to present a protocol for a systematic review that aims to examine the effectiveness of rehabilitation interventions for improving function in adults with oculomotor deficits after mTBI.

METHODS AND ANALYSIS

Systematic searches in Medline Ovid, EMBASE, PsycINFO, CINAHL and Scopus will be conducted to identify experimental studies published in English from each databases inception date to present, involving adult patients with mTBI and oculomotor deficits. Citations will be saved and managed in EndNote V.20. Two independent reviewers will identify eligible studies and perform data abstraction. Any discrepancies will be solved by discussion, and a third reviewer will be consulted if necessary. A meta-analysis will be conducted for outcomes reported in two or more studies. The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol guidelines will be followed for reporting.

ETHICS AND DISSEMINATION

This study does not involve primary data collection; therefore, formal ethical approval by an institutional review board is not required. Final results will be disseminated through open-access peer-reviewed publications. Abstracts will be presented at suitable national and international conferences or workshops. Furthermore, important information will be shared with clinical authorities, clinicians and at affiliated research institution-based websites and relevant servers.

PROSPERO REGISTRATION NUMBER

CRD42022352276.

Longitudinal Recovery Following Repetitive Traumatic Brain Injury

Importance

One traumatic brain injury (TBI) increases the risk of subsequent TBIs. Research on longitudinal outcomes of civilian repetitive TBIs is limited.

Objective

To investigate associations between sustaining 1 or more TBIs (ie, postindex TBIs) after study enrollment (ie, index TBIs) and multidimensional outcomes at 1 year and 3 to 7 years.

Design, Setting, and Participants

This cohort study included participants presenting to emergency departments enrolled within 24 hours of TBI in the prospective, 18-center Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study (enrollment years, February 2014 to July 2020). Participants who completed outcome assessments at 1 year and 3 to 7 years were included. Data were analyzed from September 2022 to August 2023.

Exposures

Postindex TBI(s).

Main Outcomes and Measures

Demographic and clinical factors, prior TBI (ie, preindex TBI), and functional (Glasgow Outcome Scale-Extended [GOSE]), postconcussive (Rivermead Post-Concussion Symptoms Questionnaire [RPQ]), psychological distress (Brief Symptom Inventory-18 [BSI-18]), depressive (Patient Health Questionnaire-9 [PHQ-9]), posttraumatic stress disorder (PTSD; PTSD Checklist for DSM-5 [PCL-5]), and health-related quality-of-life (Quality of Life After Brain Injury-Overall Scale [QOLIBRI-OS]) outcomes were assessed. Adjusted mean differences (aMDs) and adjusted relative risks are reported with 95% CIs.

Results

Of 2417 TRACK-TBI participants, 1572 completed the outcomes assessment at 1 year (1049 [66.7%] male; mean [SD] age, 41.6 [17.5] years) and 1084 completed the outcomes assessment at 3 to 7 years (714 [65.9%] male; mean [SD] age, 40.6 [17.0] years). At 1 year, a total of 60 participants (4%) were Asian, 255 (16%) were Black, 1213 (77%) were White, 39 (2%) were another race, and 5 (0.3%) had unknown race. At 3 to 7 years, 39 (4%) were Asian, 149 (14%) were Black, 868 (80%) were White, 26 (2%) had another race, and 2 (0.2%) had unknown race. A total of 50 (3.2%) and 132 (12.2%) reported 1 or more postindex TBIs at 1 year and 3 to 7 years, respectively. Risk factors for postindex TBI were psychiatric history, preindex TBI, and extracranial injury severity. At 1 year, compared with those without postindex TBI, participants with postindex TBI had worse functional recovery (GOSE score of 8: adjusted relative risk, 0.57; 95% CI, 0.34-0.96) and health-related quality of life (QOLIBRI-OS: aMD, -15.9; 95% CI, -22.6 to -9.1), and greater postconcussive symptoms (RPQ: aMD, 8.1; 95% CI, 4.2-11.9), psychological distress symptoms (BSI-18: aMD, 5.3; 95% CI, 2.1-8.6), depression symptoms (PHQ-9: aMD, 3.0; 95% CI, 1.5-4.4), and PTSD symptoms (PCL-5: aMD, 7.8; 95% CI, 3.2-12.4). At 3 to 7 years, these associations remained statistically significant. Multiple (2 or more) postindex TBIs were associated with poorer outcomes across all domains.

Conclusions and Relevance

In this cohort study of patients with acute TBI, postindex TBI was associated with worse symptomatology across outcome domains at 1 year and 3 to 7 years postinjury, and there was a dose-dependent response with multiple postindex TBIs. These results underscore the critical need to provide TBI prevention, education, counseling, and follow-up care to at-risk patients.

Beyond symptomatic diagnosis of mild traumatic brain injury

It is commonly assumed that there is no brain injury if there are no noticeable symptoms following a head impact. There is growing evidence that traumatic brain injuries can occur with no outward symptoms and that the damage from these injuries can accumulate over time resulting in disease and impairment later in life. It is time to rethink the role that symptoms play in traumatic brain injury and adopt a quantitative understanding of brain health at the cellular level to improve the way we diagnose, prevent, and ultimately heal brain injury.

Traumatic Brain Injury: Contemporary Challenges and the Path to Progress

Traumatic brain injury (TBI) remains a leading cause of death and disability worldwide, and its incidence is increasing [...].

Clinical Updates in Mild Traumatic Brain Injury (Concussion)

Traumatic brain injury (TBI) affects > 3 million people in the United States annually. Although the number of deaths related to severe TBIs has stabalized, mild TBIs, often termed concussions, are increasing. As evidence indicates that a significant proportion of these mild injuries are associated with long-lasting functional deficits that impact work performance, social integration, and may predispose to later cognitive decline, it is important that we (a) recognize these injuries, (b) identify those at highest risk of poor recovery, and (c) initiate appropriate treatments promptly. We discuss the epidemiology of TBI, the most common persistent symptoms, and treatment approaches.

Research on the Potential Biomarkers of Mild Traumatic Brain Injury: a Systematic Review and Bibliometric Analysis

Reliable diagnostic methods for mild traumatic brain injury (mTBI) are lacking, and many researchers continue to search for objective biomarkers that can both define and detect mTBI. Although much research has been conducted in this field, there have not been many bibliometric studies. In this study, we aim to analyze the development over the last two decades in scientific output relating to the diagnosis of mTBI. To do this, we extracted documents from Web of Science, PubMed, and Embase and performed descriptive analysis (number of publications, primary journals, authors, and countries/regions), trend topics analysis, and citation analysis for papers across the globe, with a particular focus on molecular markers. One thousand twenty-three publications spanning 390 journals were identified on Web of Science, PubMed, and Embase for the period from 2000 to 2022. The number of publications increased every year (from 2 in 2000 to 137 in 2022). Of all the publications we analyzed, 58.7% had authors from the USA. Our analysis shows that molecular markers are the most studied markers in the field of mTBI diagnostics, accounting for 28.4% of all publications, and that the number of studies focused on this specific aspect has increased sharply in the past 5 years, indicating that molecular markers may become a research trend in the future.

The SUCCESS Peer Mentoring Program for College Students with Concussion: Preliminary Results of a Mobile Technology Delivered Intervention

Concussions are caused by a hit or blow to the head that alters normal brain functioning. The Success in College after Concussion with Effective Student Supports (SUCCESS) program was developed to provide students with psychosocial support and resources-both key components of concussion management-to assist in recovery and return-to-learn following concussion. In this preliminary evaluation of intervention efficacy, SUCCESS was delivered through a mobile application connecting mentors (students who have recovered from concussion and successfully returned to school) with mentees who were currently recovering. Mentor-mentee pairs met virtually through the app, using chat and videoconferencing features to share support, resources, and program-specific educational materials. Results from 16 mentoring pairs showed that mentee symptoms (V = 119, p = 0.009) and academic problems decreased (V = 114.5, p = 0.002), while academic self-efficacy increased (V = 13.5, p = 0.009) following mentoring. As expected, mentor measures were stable, indicating that providing mentoring did not exacerbate previously resolved concussion complaints. Virtual peer mentoring provided through a mobile application may be a feasible intervention to support academic success and psychosocial processing during recovery for college students with concussion.

Neuroworsening in the Emergency Department Is a Predictor of Traumatic Brain Injury Intervention and Outcome: A TRACK-TBI Pilot Study

INTRODUCTION

Neuroworsening may be a sign of progressive brain injury and is a factor for treatment of traumatic brain injury (TBI) in intensive care settings. The implications of neuroworsening for clinical management and long-term sequelae of TBI in the emergency department (ED) require characterization.

METHODS

Adult TBI subjects from the prospective Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot Study with ED admission and disposition Glasgow Coma Scale (GCS) scores were extracted. All patients received head computed tomography (CT) scan <24 h post-injury. Neuroworsening was defined as a decline in motor GCS at ED disposition (vs. ED admission). Clinical and CT characteristics, neurosurgical intervention, in-hospital mortality, and 3- and 6-month Glasgow Outcome Scale-Extended (GOS-E) scores were compared by neuroworsening status. Multivariable regressions were performed for neurosurgical intervention and unfavorable outcome (GOS-E ≤ 3). Multivariable odds ratios (mOR) with [95% confidence intervals] were reported.

RESULTS

In 481 subjects, 91.1% had ED admission GCS 13-15 and 3.3% had neuroworsening. All neuroworsening subjects were admitted to intensive care unit (vs. non-neuroworsening: 26.2%) and were CT-positive for structural injury (vs. 45.4%). Neuroworsening was associated with subdural (75.0%/22.2%), subarachnoid (81.3%/31.2%), and intraventricular hemorrhage (18.8%/2.2%), contusion (68.8%/20.4%), midline shift (50.0%/2.6%), cisternal compression (56.3%/5.6%), and cerebral edema (68.8%/12.3%; all p < 0.001). Neuroworsening subjects had higher likelihoods of cranial surgery (56.3%/3.5%), intracranial pressure (ICP) monitoring (62.5%/2.6%), in-hospital mortality (37.5%/0.6%), and unfavorable 3- and 6-month outcome (58.3%/4.9%; 53.8%/6.2%; all p < 0.001). On multivariable analysis, neuroworsening predicted surgery (mOR = 4.65 [1.02-21.19]), ICP monitoring (mOR = 15.48 [2.92-81.85], and unfavorable 3- and 6-month outcome (mOR = 5.36 [1.13-25.36]; mOR = 5.68 [1.18-27.35]).

CONCLUSIONS

Neuroworsening in the ED is an early indicator of TBI severity, and a predictor of neurosurgical intervention and unfavorable outcome. Clinicians must be vigilant in detecting neuroworsening, as affected patients are at increased risk for poor outcomes and may benefit from immediate therapeutic interventions.

Feasibility of Using a Mobile App Supported Executive Function Intervention in Military Service Members and Veterans with mTBI and Co-Occurring Psychological Conditions

This pilot study assessed the feasibility of using SwapMyMood, a smartphone application supporting evidence-based strategies for emotion regulation and problem-solving as a supplement to conventional care for military service members and veterans (SM/Vs) experiencing chronic symptoms of mild traumatic brain injury (mTBI) and co-occurring psychological conditions. Eight military SM/Vs were recruited from an intensive outpatient program. Participants were block randomized to an experimental group (conventional care plus use of the SwapMyMood app) or a conventional care only group for six weeks. Conventional care included instruction on problem-solving and emotion regulation strategies using traditional paper manuals and protocols. Effects on the knowledge and use of strategies and related goal attainment were measured. Patient-reported outcomes were measured via several validated problem-solving and emotion regulation scales. No differences were found between groups in goal attainment, global executive function, problem-solving, emotion regulation, and knowledge of how to use the problem-solving and emotion regulation strategies targeted. Experimental group participants rated the application positively, demonstrating feasibility of integration of the app into clinical care. The implementation of SwapMyMood is feasible in a clinical setting. SwapMyMood may be a clinically effective supplemental tool for supporting executive function in SM/Vs with mTBI and co-occurring psychological conditions.

Persistent hypersomnia following repetitive mild experimental traumatic brain injury: Roles of chronic stress and sex differences

Traumatic brain injury (TBI) is often more complicated than a single head injury. An extreme example of this point may be military service members who experience a spectrum of exposures over a prolonged period under stressful conditions. Understanding the effects of complex exposures can inform evaluation and care to prevent persistent symptoms. We designed a longitudinal series of non-invasive procedures in adult mice to evaluate the effects of prolonged mild stress and head injury exposures. We assessed anxiety, depression, and sleep-wake dysfunction as symptoms that impact long-term outcomes after mild TBI. Unpredictable chronic mild stress (UCMS) was generated from a varied sequence of environmental stressors distributed within each of 21 days. Subsequently, mice received a mild blast combined with closed-head mild TBI on 5 days at 24-h intervals. In males and females, UCMS induced anxiety without depressive behavior. A major finding was reproducible sleep-wake dysfunction through 6- to 12-month time points in male mice that received UCMS with repetitive blast plus TBI events, or surprisingly after just UCMS alone. Specifically, male mice exhibited hypersomnia with increased sleep during the active/dark phase and fragmentation of longer wake bouts. Sleep-wake dysfunction was not found with TBI events alone, and hypersomnia was not found in females under any conditions. These results identify prolonged stress and sex differences as important considerations for sleep-wake dysfunction. Furthermore, this reproducible hypersomnia with impaired wakefulness is similar to the excessive daytime sleepiness reported in patients, including patients with TBI, which warrants further clinical screening, care, and treatment development.

Sport-related concussion disclosure in women's rugby-A social identity approach

Introduction

Sport-related concussion (SRC) is a risk of collision sports such as women's rugby. To support appropriate SRC diagnosis and management, an understanding of the factors that encourage SRC disclosure is necessary. To date, research has focused on ascertaining individual player knowledge and attitudes towards SRC disclosure.

Methods

We chose to investigate the potential influence of group identification effects by examining the role of social identity on SRC disclosure in elite women's rugby. Seventeen elite players from the United Kingdom and Ireland were interviewed and their transcripts thematically analysed.

Results

The data highlighted that the players shared a very strong social identity as women in rugby and were acutely aware that their experiences were different to their male counterparts. The shared social identity had both positive and negative implications for SRC disclosure. The players interviewed did not feel comfortable disclosing their symptoms to their coach and often felt that medical staff either did not listen to them or were unavailable to them. Mediators such as communication, trust in medical teams, perceived pressure, positive injury management experience, and player role models were identified.

Discussion

This research could be utilised to inform sport psychology interventions to enhance SRC disclosure in elite women's rugby.