Behavioral and Psychiatric Symptoms in Patients with Severe Traumatic Brain Injury: A Comprehensive Overview

Rehabilitation Considerations in Women with Traumatic Brain Injury

This review highlights the physiological, hormonal, and hematological changes following traumatic brain injury (TBI) in women. Younger women may experience worse outcomes due to higher cerebral pressures, while hormonal changes during menstruation, pregnancy, and menopause further influence TBI recovery. Postmenopausal women face higher risks of osteoporosis and fall-related TBIs. Psychological impacts include higher rates of depression, anxiety, and posttraumatic stress disorder. Social challenges and sexual dysfunction are prevalent, impacting community and vocational reintegration. Tailored rehabilitation addressing these gender-specific factors is crucial for improving outcomes for female patients with TBI across their lifespan.

Ticagrelor alleviates neuroinflammation after traumatic brain injury by inhibiting NLRP3 inflammasome-mediated pyroptosis

Traumatic brain injury (TBI) is often accompanied by secondary brain injury (SBI), with neuroinflammation being a core mechanism of SBI. Pyroptosis is a key driver of neuroinflammatory responses, and inhibiting pyroptosis can reduce neuroinflammation after TBI and promote tissue and functional recovery. The activation of the NLRP3 inflammasome mediates the classical pyroptosis pathway, and ticagrelor can inhibit NLRP3 inflammasome activation. This study aimed to investigate the differences in pyroptosis inhibition induced by TBI with different doses of ticagrelor by targeting the activation of the NLRP3 inflammasome. Mice were randomly divided into four groups: sham, TBI, 50 mg/kg ticagrelor treatment, and 150 mg/kg ticagrelor treatment. After 24 h of treatment, brain tissue surrounding the injury was collected for immunoblot detection of pyroptosis-related protein expression and ELISA detection of inflammatory cytokine release. On day 3 after treatment, BBB permeability and brain edema were assessed by injection of Evans blue and measurement of brain tissue water content. On day 7 after treatment, mice were sacrificed, and the extent of injury was assessed through hematoxylin and eosin and Nissl staining, while the levels of pyroptosis markers and neuroinflammation in brain tissue were detected by immunohistochemistry. On day 21 after treatment, the Morris water maze was used to evaluate neural function recovery. Compared with the TBI group, high-dose ticagrelor treatment inhibited pyroptosis in mouse brain tissue, reduced the release of inflammatory cytokines, alleviated brain edema, lowered neuroinflammation levels, and promoted neural function recovery (P < 0.05). Therefore, ticagrelor holds promise as a clinical drug for treating TBI.

Animal Models of Traumatic Brain Injury and Their Relevance in Clinical Settings

BACKGROUND

Traumatic brain injury (TBI) is a significant concern that often goes overlooked, resulting from various factors such as traffic accidents, violence, military services, and medical conditions. It is a major health issue affecting people of all age groups across the world, causing significant morbidity and mortality. TBI is a highly intricate disease process that causes both structural damage and functional deficits. These effects result from a combination of primary and secondary injury mechanisms. It is responsible for causing a range of negative effects, such as impairments in cognitive function, changes in social and behavioural patterns, difficulties with motor skills, feelings of anxiety, and symptoms of depression.

METHODS

TBI associated various animal models were reviewed in databases including PubMed, Web of Science, and Google scholar etc. The current study provides a comprehensive overview of commonly utilized animal models for TBI and examines their potential usefulness in a clinical context.

RESULTS

Despite the notable advancements in TBI outcomes over the past two decades, there remain challenges in evaluating, treating, and addressing the long-term effects and prevention of this condition. Utilizing experimental animal models is crucial for gaining insight into the development and progression of TBI, as it allows us to examine the biochemical impacts of TBI on brain mechanisms.

CONCLUSION

This exploration can assist scientists in unraveling the intricate mechanisms involved in TBI and ultimately contribute to the advancement of successful treatments and interventions aimed at enhancing outcomes for TBI patients.

Chronic traumatic brain injury induces neurodegeneration, neuroinflammation, and cognitive deficits in a T cell-dependent manner

Traumatic brain injury (TBI) can lead to chronic neuroinflammation, and neurodegeneration associated with long-term cognitive deficits. Following TBI, the acute neuroinflammatory response involves microglial activation and the release of proinflammatory cytokines and chemokines which induce the recruitment of peripheral immune cells such as monocytes and ultimately T cells. Persistent innate and adaptive immune cell responses can lead to chronic neurodegeneration and functional deficits. Therefore, understanding the dynamic interaction between chronic immune responses and TBI-related pathogenesis and progression of the disease is crucial. We hypothesized that T cells have an essential role in TBI severity and recovery. We used generic T cell deletion mice (TCRβ-/-δ-/-) vs Wild-type mice that underwent controlled cortical impact assessing behavioral, histological, and immune system response outcomes at 3 months post-TBI. The absence of T cells reduced neurodegeneration and was associated with improved neurological outcomes 3 months post-injury. Furthermore, the absence of T cells enhanced an anti-inflammatory phenotype in peripheral myeloid cells in the injured brain. Collectively, these data indicate that T cells promote persistent neuropathology and functional impairments chronically after TBI.

The Relationship Between Traumatic Brain Injury and Suicide: A Systematic Review of Risk Factors

Objective

Traumatic brain injury (TBI) significantly increases the risk of suicidal ideation (SI) and behaviors due to neurobiological changes, cognitive impairments, and emotional dysregulation. This review consolidates current evidence on the relationship between TBI and suicide, identifying key risk factors and underlying mechanisms, and highlights the need for further research, especially in civilian populations.

Method

Studies were identified from an online search of PubMed, Web of Science, Cochrane Library, Embase, and Scopus databases with studies published from 2014 to 2024. This review has been registered on Prospero (number CRD42024574643).

Results

Factors indicated such as external causes of injury, comorbidities like depression and substance use disorders, and post-TBI symptoms consistently influence suicide risk. Advanced predictive models emphasize the role of psychological symptoms, particularly depressive features, in forecasting SI post-TBI, underscoring the need for targeted interventions and early symptom management.

Conclusions

The seriousness of TBI significantly impacts the probability of SI and suicide attempts (SA). Research consistently shows that patients with more severe TBIs tend to have higher rates of SI and SA. Psychological disorders, such as depression and substance abuse disorders, greatly increase the likelihood of suicidal actions after a TBI. These conditions not only raise the occurrence of SI but also lead to earlier and more regular SA.

Chronic glial activation and behavioral alterations induced by acute/subacute pioglitazone treatment in a mouse model of traumatic brain injury

Traumatic brain injury (TBI) is a disabling neurotraumatic condition and the leading cause of injury-related deaths and disability in the United States. Attenuation of neuroinflammation early after TBI is considered an important treatment target; however, while these inflammatory responses can induce secondary brain injury, they are also involved in the repair of the nervous system. Pioglitazone, which activates peroxisome proliferator-activated receptor gamma, has been shown to decrease inflammation acutely after TBI, but the long-term consequences of its use remain unknown. For this reason, the impacts of treatment with pioglitazone during the acute/subacute phase (30 min after injury and each subsequent 24 h for 5 days) after TBI were interrogated during the chronic phase (30- and 274-days post-injury (DPI)) in mice using the controlled cortical impact model of experimental TBI. Acute/subacute pioglitazone treatment after TBI results in long-term deleterious consequences, including disruption of tau homeostasis, chronic glial cell activation, neuronal pathology, and worsened injury severity particularly at 274 DPI, with male mice being more susceptible than female mice. Further, male pioglitazone-treated TBI mice exhibited increased dominant and offensive-like behavior while having a decreased non-social exploring behavior at 274 DPI. After TBI, both sexes exhibited glial activation at 30 DPI when treated with pioglitazone; however, while injury severity was increased in females it was not impacted in male mice. This work reveals that although pioglitazone has been shown to lead to attenuated TBI outcomes acutely, sex-based differences, timing and long-term consequences of treatment with glitazones must be considered and further studied prior to their clinical use for TBI therapy.

'Would you take a drug for this?': attitudes by individuals with traumatic brain injury towards medication to improve social functioning

Background Many people with traumatic brain injury (TBI) report problems with social functioning that can have immediate and enduring impacts. We aimed to explore perceptions of social functioning after TBI and understand attitudes towards medication that could improve long-term social outcomes. Method A qualitative descriptive approach using interview methods was conducted in Victoria, Australia. Using purposive sampling we conducted 15 semi-structured interviews with people with moderate to severe TBI between July and September 2021. Results Using a framework approach, we thematically identified three themes: (1) impacts of TBI on social roles and activities, including changes in recreational activities and role changes in family units; (2) change in social networks, resulting from shifts in attitudes to social activities and mental health issues; and (3) openness to novel treatments to improve social functioning - willingness to take potential medication to improve social functioning and the factors that have an impact on decision making. Conclusion Our results highlight that people with TBI experience a range of changes in social participation post-TBI, and that they have a strong interest in improving their social functioning. Such insights provide opportunities to tailor patient-centric treatments and circumnavigate barriers in the early stages of medication development for successful translation into practice in this population.

Effect of receptive provocation as a therapeutic approach for cognitive and consciousness improvement among traumatic brain injury patients in India

Traumatic brain injury (TBI) is a global health concern, often resulting in cognitive deficits and altered states of consciousness. This study evaluated the effectiveness of Receptive Provocation (RP) therapy in improving mental function and consciousness levels among TBI patients. 70 patients were randomly assigned to experimental and control groups, with the experimental group undergoing RP therapy for 20-25 minutes daily over seven days, while the control group received routine care. Post-test assessments on day 8 revealed significant improvements in the experimental group's cognitive function and consciousness levels (p=0.001), whereas no significant changes were observed in the control group. These findings suggest that RP therapy is an effective intervention for enhancing cognitive and consciousness outcomes in TBI patients.

Brain Injury and Neurodegeneration: Molecular, Functional, and Translational Approach 2.0

The brain is composed of different cells, such as neurons, glia, endothelial cells, etc [...].

Efficacy of transcranial magnetic stimulation treatment in reducing neuropsychiatric symptomatology after traumatic brain injury

Background

Neuropsychiatric disorders are highly disabling in traumatic brain injury (TBI) patients, and psychopharmacological treatments often fail to adequately mitigate their detrimental effects. Repetitive transcranial magnetic stimulation (rTMS) is an emerging treatment in neurology and psychiatry, showing potential in treating psychiatric disorders.

Objective

This study investigates the efficacy of a novel, dual-site sequential rTMS protocol designed to treat neuropsychiatric symptoms in a TBI patient who was refractory to conventional treatments.

Methods

A 34-year-old woman with severe head trauma and complex psychopathology underwent 20 daily sessions of focal-coil rTMS, combining inhibitory stimulation (1 Hz) on the right dorsolateral prefrontal cortex (DLPFC) and excitatory (10 Hz) on the left DLPFC, guided by a neuronavigation system. Psychiatric and neurocognitive assessments were conducted at baseline and at 2, 4, and 8 weeks following the beginning of rTMS treatment.

Results

After 2 weeks of treatment, the patient showed decreased impulsivity and obsessive-compulsive symptoms, along with improvements in attention and processing speed. After 4 weeks, impulsivity further declined, though no other significant changes were noted. At 8 weeks, a persistent positive effect was observed, including enhanced positive emotions.

Discussion

These findings suggest that guided, alternating neurostimulation of the DLPFC may modulate activity within cortico-striato-thalamo-cortical circuits, providing a promising alternative for managing neuropsychiatric symptoms in TBI patients who are resistant to traditional treatments.

Updated Canadian Clinical Practice Guideline for the Rehabilitation of Adults With Moderate to Severe Traumatic Brain Injury: Mental Health Recommendations

OBJECTIVE

Objective: After sustaining a moderate to severe traumatic brain injury (MSTBI), individuals often experience comorbid mental health conditions that can impair the rehabilitation and recovery process. The objective of this initiative was to update recommendations on the assessment and management of mental health conditions for the Canadian Clinical Practice Guideline for the Rehabilitation of Adults with MSTBI (CAN-TBI 2023).

OBJECTIVE

Design: A systematic search was conducted by the Evidence-Based Review of Moderate to Severe Acquired Brain Injury to identify new and relevant articles. Expert Panel reviewed and discussed the new and existing evidence, evaluated its quality, and added, removed, or modified recommendations and tools as needed. A consensus process was followed to achieve agreement on recommendations.

OBJECTIVE

Results: CAN-TBI 2023 includes 20 recommendations regarding best practices for the assessment and management of mental health conditions post-MSTBI. About 17 recommendations were updated, 1 new recommendation was formed, and 2 recommendations remained unchanged. The Guideline emphasizes the importance of screening and assessment of mental health conditions throughout the rehabilitation continuum. The Expert Panel recommended incorporating multimodal treatments that include pharmacological and nonpharmacological approaches to manage mental health concerns.

OBJECTIVE

Conclusion: The CAN-TBI 2023 recommendations for the assessment and management of mental health conditions should be used to inform clinical practice. Additional high-quality research in this area is needed, as 13 recommendations are based on level C evidence, 4 on level B evidence, and 3 on level A evidence.

Inflammatory biomarkers for neurobehavioral dysregulation in former American football players: findings from the DIAGNOSE CTE Research Project

BACKGROUND

Traumatic encephalopathy syndrome (TES) is defined as the clinical manifestation of the neuropathological entity chronic traumatic encephalopathy (CTE). A core feature of TES is neurobehavioral dysregulation (NBD), a neuropsychiatric syndrome in repetitive head impact (RHI)-exposed individuals, characterized by a poor regulation of emotions/behavior. To discover biological correlates for NBD, we investigated the association between biomarkers of inflammation (interleukin (IL)-1β, IL-6, IL-8, IL-10, C-reactive protein (CRP), tumor necrosis factor (TNF)-α) in cerebrospinal fluid (CSF) and NBD symptoms in former American football players and unexposed individuals.

METHODS

Our cohort consisted of former American football players, with (n = 104) or without (n = 76) NBD diagnosis, as well as asymptomatic unexposed individuals (n = 55) from the DIAGNOSE CTE Research Project. Specific measures for NBD were derived (i.e., explosivity, emotional dyscontrol, impulsivity, affective lability, and a total NBD score) from a factor analysis of multiple self-report neuropsychiatric measures. Analyses of covariance tested differences in biomarker concentrations between the three groups. Within former football players, multivariable linear regression models assessed relationships among log-transformed inflammatory biomarkers, proxies for RHI exposure (total years of football, cumulative head impact index), and NBD factor scores, adjusted for relevant confounding variables. Sensitivity analyses tested (1) differences in age subgroups (< 60, ≥ 60 years); (2) whether associations could be identified with plasma inflammatory biomarkers; (3) associations between neurodegeneration and NBD, using plasma neurofilament light (NfL) chain protein; and (4) associations between biomarkers and cognitive performance to explore broader clinical symptoms related to TES.

RESULTS

CSF IL-6 was higher in former American football players with NBD diagnosis compared to players without NBD. Furthermore, elevated levels of CSF IL-6 were significantly associated with higher emotional dyscontrol, affective lability, impulsivity, and total NBD scores. In older football players, plasma NfL was associated with higher emotional dyscontrol and impulsivity, but also with worse executive function and processing speed. Proxies for RHI exposure were not significantly associated with biomarker concentrations.

CONCLUSION

Specific NBD symptoms in former American football players may result from multiple factors, including neuroinflammation and neurodegeneration. Future studies need to unravel the exact link between NBD and RHI exposure, including the role of other pathophysiological pathways.

Effects of Virtual Reality Cognitive Training on Neuroplasticity: A Quasi-Randomized Clinical Trial in Patients with Stroke

Cognitive Rehabilitation (CR) is a therapeutic approach designed to improve cognitive functioning after a brain injury, including stroke. Two major categories of techniques, namely traditional and advanced (including virtual reality-VR), are widely used in CR for patients with various neurological disorders. More objective outcome measures are needed to better investigate cognitive recovery after a stroke. In the last ten years, the application of electroencephalography (EEG) as a non-invasive and portable neuroimaging method has been explored to extract the hallmarks of neuroplasticity induced by VR rehabilitation approaches, particularly within the chronic stroke population. The aim of this study is to investigate the neurophysiological effects of CR conducted in a virtual environment using the VRRS device. Thirty patients with moderate-to-severe ischemic stroke in the chronic phase (at least 6 months after the event), with a mean age of 58.13 (±8.33) for the experimental group and 57.33 (±11.06) for the control group, were enrolled. They were divided into two groups: an experimental group and a control group, receiving neurocognitive stimulation using VR and the same amount of conventional neurorehabilitation, respectively. To study neuroplasticity changes after the training, we focused on the power band spectra of theta, alpha, and beta EEG rhythms in both groups. We observed that when VR technology was employed to amplify the effects of treatments on cognitive recovery, significant EEG-related neural improvements were detected in the primary motor circuit in terms of power spectral density and time-frequency domains. Indeed, EEG analysis suggested that VR resulted in a significant increase in both the alpha band power in the occipital areas and the beta band power in the frontal areas, while no significant variations were observed in the theta band power. Our data suggest the potential effectiveness of a VR-based rehabilitation approach in promoting neuroplastic changes even in the chronic phase of ischemic stroke.

Neuropsychological Assessment in Patients with Traumatic Brain Injury: A Comprehensive Review with Clinical Recommendations

Traumatic brain injury is damage to the brain occurring after birth, often resulting in the deterioration of cognitive, behavioural, and emotional functions. Neuropsychological evaluation can assist clinicians to better assess the patient's clinical condition, reach differential diagnoses, and develop interventional strategies. However, considering the multiple rating scales available, it is not easy to establish which tool is most suitable for the different brain injury conditions. The aim of this review is to investigate and describe the most used neurocognitive assessment tools in patients with traumatic brain injury to provide clinicians with clear indications on their use in clinical practice. Indeed, during the acute phase, after the head trauma, alertness and wakefulness of the patients affected by a disorder of consciousness can be assessed using different scales, such as the Coma Recovery Scale-Revised. In both postacute and chronic phases after traumatic brain injury, general cognitive assessment tools (such as the Mini Mental State Examination) or more specific cognitive tests (e.g., Wisconsin Card Sorting Test and Trail Making Test) could be administered according to the patient's functional status. In this way, clinicians may be aware of the patient's neuropsychological and cognitive level, so they can guarantee a personalized and tailored rehabilitation approach in this frail patient population.