Comparing the Westmead Posttraumatic Amnesia Scale, Galveston Orientation and Amnesia Test, and Confusion Assessment Protocol as Measures of Acute Recovery Following Traumatic Brain Injury

Characterization of responders to transcranial direct current stimulation in disorders of consciousness: A retrospective study of 8 clinical trials

The treatment for patients with disorders of consciousness challenges researchers and clinicians. The stimulation of the left dorsolateral prefrontal cortex with transcranial direct current stimulation (tDCS) may enhance behavioral responsiveness of a subset of patients in a minimally conscious state, while having limited effects in unresponsive patients. However, heterogeneity in responses raises questions about the effectiveness of tDCS. Our objective was to explore the characteristics of responders to tDCS based on previously published RCTs and investigate the heterogeneity of treatment effect to better direct future tDCS studies towards patient profiles that appear to be more responsive to the treatment. We explored clinical and demographical differences between responders (i.e., recovery of a new sign of consciousness after active stimulation) and non-responder and the predictors of treatment response with a LASSO logistic regression. We included 131 patients (44 women, 61 traumatic brain injury, 90 minimally conscious, mean age 46.13 years [SD ​= ​16], median time since injury 12.84 months [IQR: 5.25-35.10]) of which 33 responded to tDCS. While 32 ​% of minimally conscious patients responded to tDCS (95%CI 0.24, 0.43), 10 ​% (95%CI 0.04, 0.25) of those unresponsive responded. The regression model, using diagnosis at baseline, Coma Recovery Scale-Revised Index at baseline, age, sex and time since injury correctly discriminated between tDCS responders and non-responders (area under the curve of 0.77). Our findings suggest that patients in minimally conscious state, with a better cognitive profile and longer TSI respond better to tDCS, making them better candidates for the treatment.

Microglial Autophagic Dysregulation in Traumatic Brain Injury: Molecular Insights and Therapeutic Avenues

Traumatic brain injury (TBI) is a complex and multifaceted condition that can result in cognitive and behavioral impairments. One aspect of TBI that has received increasing attention in recent years is the role of microglia, the brain-resident immune cells, in the pathophysiology of the injury. Specifically, increasing evidence suggests that dysfunction in microglial autophagy, the process by which cells degrade and recycle their own damaged components, may contribute to the development and progression of TBI-related impairments. Here, we unravel the pathways by which microglia autophagic dysregulation predisposes the brain to secondary damage and neurological deficits following TBI. An overview of the role of autophagic dysregulation in perpetuation and worsening of the inflammatory response, neuroinflammation, and neuronal cell death in TBI follows. Further, we have evaluated several signaling pathways and processes that contribute to autophagy dysfunction-mediated inflammation, neurodegeneration, and poor outcome in TBI. Additionally, a discussion on the small molecule therapeutics employed to modulate these pathways and mechanisms to treat TBI have been presented. However, additional research is required to fully understand the processes behind these underlying pathways and uncover potential therapeutic targets for restoring microglial autophagic failure in TBI.

Clinical application of recommendations for neurobehavioral assessment in disorders of consciousness: an interdisciplinary approach

Accurate diagnosis, prognosis, and subsequent rehabilitation care planning for persons with Disorders of Consciousness (DoC) has historically posed a challenge for neurological care professionals. Evidence suggests rates of misdiagnosis may be as high as 40% when informal beside evaluations are used to determine level of consciousness. The presence of myriad medical, neurological, functional (motor, sensory, cognitive) and environmental confounds germane to these conditions complicates behavioral assessment. Achieving diagnostic certainty is elusive but critical to inform care planning, clinical decision making, and prognostication. Standardized neurobehavioral rating scales has been shown to improve accuracy in distinguishing between coma, unresponsive wakefulness syndrome/vegetative state and minimally consciousness state as compared to informal assessment methods. Thus, these scales are currently recommended for use as the informal "gold standard" for diagnostic assessment in DoC. The following paper will present an evidence-based approach to neurobehavioral assessment for use in clinical practice. Strategies for optimizing assessment and aiding in identification and management of confounds that can limit diagnostic accuracy will be provided. Finally, clinical application of an interdisciplinary approach to identifying and managing confounds will be discussed and how assessment results can be used to identify trends in performance and guide prognostic counseling with families.

INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury: Methods, Overview, and Principles

INTRODUCTION

Moderate to severe traumatic brain injury (TBI) results in complex cognitive sequelae. Despite hundreds of clinical trials in cognitive rehabilitation, the translation of these findings into clinical practice remains a challenge. Clinical practice guidelines are one solution. The objective of this initiative was to reconvene the international group of cognitive researchers and clinicians (known as INCOG) to develop INCOG 2.0: Guidelines for Cognitive Rehabilitation Following TBI.

METHODS

The guidelines adaptation and development cycle was used to update the recommendations and derive new ones. The team met virtually and reviewed the literature published since the original INCOG (2014) to update the recommendations and decision algorithms. The team then prioritized the recommendations for implementation and modified the audit tool accordingly to allow for the evaluation of adherence to best practices.

RESULTS

In total, the INCOG update contains 80 recommendations (25 level A, 15 level B, and 40 level C) of which 27 are new. Recommendations developed for posttraumatic amnesia, attention, memory, executive function and cognitive-communication are outlined in other articles, whereas this article focuses on the overarching principles of care for which there are 38 recommendations pertaining to: assessment (10 recommendations), principles of cognitive rehabilitation (6 recommendations), medications to enhance cognition (10 recommendations), teleassessment (5 recommendations), and telerehabilitation intervention (7 recommendations). One recommendation was supported by level A evidence, 7 by level B evidence, and all remaining recommendations were level C evidence. New to INCOG are recommendations for telehealth-delivered cognitive assessment and rehabilitation. Evidence-based clinical algorithms and audit tools for evaluating the state of current practice are also provided.

CONCLUSIONS

Evidence-based cognitive rehabilitation guided by these recommendations should be offered to individuals with TBI. Despite the advancements in TBI rehabilitation research, further high-quality studies are needed to better understand the role of cognitive rehabilitation in improving patient outcomes after TBI.

Post-traumatic amnesia

Post-traumatic amnesia is the transient state of altered brain function that may follow a traumatic brain injury. At a practical level, an individual has emerged from post-traumatic amnesia when he or she is fully orientated and with return of continuous memory. However, the clinical manifestations are often more complex, with numerous cognitive domains commonly affected, as well as behaviour. In the acute setting, post-traumatic amnesia may easily go unrecognised; this is problematic as it has important implications for both immediate management and for longer-term prognosis. We therefore recommend its careful clinical assessment and prospective evaluation using validated tools. Patients in post-traumatic amnesia who have behavioural disturbance can be particularly challenging to manage. Behavioural and environmental measures form the mainstay of its treatment while avoiding pharmacological interventions where possible, as they may worsen agitation. Patients need assessing regularly to determine their need for further rehabilitation and to facilitate safe discharge planning.