Brain Trauma Foundation

Intracranial pressure (ICP) monitoring is widely practiced, but the indications are incompletely developed, and guidelines are poorly followed. To study the monitoring practices of an established expert panel (the clinical working group from the Seattle International Brain Injury Consensus Conference effort) to examine the match between monitoring guidelines and their clinical decision-making and offer guidance for clinicians considering monitor insertion. We polled the 42 Seattle International Brain Injury Consensus Conference panel members' ICP monitoring decisions for virtual patients, using matrices of presenting signs (Glasgow Coma Scale [GCS] total or GCS motor, pupillary examination, and computed tomography diagnosis). Monitor insertion decisions were yes, no, or unsure (traffic light approach). We analyzed their responses for weighting of the presenting signs in decision-making using univariate regression. Heatmaps constructed from the choices of 41 panel members revealed wider ICP monitor use than predicted by guidelines. Clinical examination (GCS) was by far the most important characteristic and differed from guidelines in being nonlinear. The modified Marshall computed tomography classification was second and pupils third. We constructed a heatmap and listed the main clinical determinants representing 80% ICP monitor insertion consensus for our recommendations. Candidacy for ICP monitoring exceeds published indicators for monitor insertion, suggesting the clinical perception that the value of ICP data is greater than simply detecting and monitoring severe intracranial hypertension. Monitor insertion heatmaps are offered as potential guidance for ICP monitor insertion and to stimulate research into what actually drives monitor insertion in unconstrained, real-world conditions.

This study aimed to re-evaluate the possible differences between attention-deficit/hyperactivity disorder (ADHD) subjects and healthy controls in the context of a standard Go/NoGo task (visual continuous performance test [VCPT]), frequently used to measure executive functions. In contrast to many previous studies, our sample comprises children, adolescents, and adults. We analyzed data from 447 ADHD patients and 227 healthy controls. By applying multivariate linear regression analyses, we controlled the group differences between ADHD patients and controls for age and sex. As dependent variables we used behavioral (number of omission and commission errors, reaction time, and reaction time variability) and neurophysiological measures (event-related potentials [ERPs]). In summary, we successfully replicated the deviations of ADHD subjects from healthy controls. The differences are small to moderate when expressed as effect size measures (number of omission errors: d = 0.60, reaction time variability: d = 0.56, contingent negative variation (CNV) and P3 amplitudes: −0.35 < d < −0.47, ERP latencies: 0.21 < d < 0.29). Further analyses revealed no substantial differences between ADHD subtypes (combined, inattentive, and hyperactive/impulsive presentation), subgroups according to high- and low-symptomatic burden or methylphenidate intake for their daily routine. We successfully replicated known differences between ADHD subjects and controls for the behavioral and neurophysiological variables. However, the small-to-moderate effect sizes limit their utility as biomarkers in the diagnostic procedure. The incongruence of self-reported symptomatic burden and clinical diagnosis emphasizes the challenges of the present clinical diagnosis with low reliability, which partially accounts for the low degree of discrimination between ADHD subjects and controls.

Proper triage of critically injured trauma patients to accredited trauma centers (TCs) is essential for survival and patient outcomes. We sought to determine the percentage of patients meeting trauma criteria who received care at non-TCs (NTCs) within the statewide trauma system that exists in the state of Pennsylvania. We hypothesized that a substantial proportion of the trauma population would be undertriaged to NTCs with undertriage rates (UTR) decreasing with increasing severity of injury. All adult (age ≥15) hospital admissions meeting trauma criteria (ICD-9, 800-959; Injury Severity Score [ISS], > 9 or > 15) from 2003 to 2015 were extracted from the Pennsylvania Health Care Cost Containment Council (PHC4) database, and compared with the corresponding trauma population within the Pennsylvania Trauma Systems Foundation (PTSF) registry. PHC4 contains all hospital admissions within PA while PTSF collects data on all trauma cases managed at designated TCs (Level I-IV). The percentage of patients meeting trauma criteria who are undertriaged to NTCs was determined and Network Analyst Location-Allocation function in ArcGIS Desktop was used to generate geospatial representations of undertriage based on ISSs throughout the state. For ISS > 9, 173,022 cases were identified from 2003 to 2015 in PTSF, while 255,263 cases meeting trauma criteria were found in the PHC4 database over the same timeframe suggesting UTR of 32.2%. For ISS > 15, UTR was determined to be 33.6%. Visual geospatial analysis suggests regions with limited access to TCs comprise the highest proportion of undertriaged trauma patients. Despite the existence of a statewide trauma framework for over 30 years, approximately, a third of severely injured trauma patients are managed at hospitals outside of the trauma system in PA. Intelligent trauma system design should include an objective process like geospatial mapping rather than the current system which is driven by competitive models of financial and health care system imperatives. Epidemiological study, level III; Therapeutic, level IV.

ObjectiveTo conduct a systematic review and meta-analysis evaluating the role of exercise or rest in patients with concussion or mild traumatic brain injury.DesignSystematic review and meta-analysis.Data sourcesMedline, PsychInfo, Scopus, Cochrane Controlled Trials Registers and Sport Discus, till March 2016 and hand search of some articles.Study selectionRandomised controlled trials (RCTS) and observational studies (OBS) comparing the effect of exercise or rest in patients with concussion, on different outcomes.ParticipantsChildren and adults with concussion or mild traumatic brain injury.InterventionExercise or Rest.OutcomesPost concussive symptoms (PCCS), balance error scoring system (BESS), immediate post concussion assessment and cognitive testing (ImPACT).Main resultsOur search generated 921 studies. Of these, 5 RCTs and 12 OBS met our inclusion criteria. Methodological quality of most of the studies was poor. Meta-analysis of 6 studies involving more than 556 patients showed statistical significant decrease in PCCS with exercise compared to control, Mean Difference (MD) [95% Confidence Interval (CI)], −14.6 [−17.8, −11.3], p<0.001. There was some clinical, but no statistical heterogeneity among the studies (I2=32%). Exercise did not affect BESS, neuropsychological scale and ImPACT score.There was not effect of rest on total symptoms in patients with concussion and number of patients with symptoms.ConclusionOur systematic review and meta-analysis showed clear benefits of exercise in PCCS. However, the evidence was based on poor quality studies that vary in duration, frequency and intensity of exercise. A good quality RCT needs to be conducted to evaluate a clear effect of exercise and rest in patients with concussion.Competing interestsNone.

Objective: We sought to examine the relationship between a validated visual attention measure (Spatial Span) and a circular visual tracking (CVT) paradigm that has shown sensitivity to attentional degradation. Background: Oculomotor assessment is useful in characterizing visual attention due to the large overlap between the neural networks for attentional and oculomotor controls. Therefore, it can be a valuable supplement to conventional neurocognitive assessments of attention and executive function. Methods: 137 healthy adults without history of head injury, sensory impairment, substance abuse, neurological, or psychiatric disorders completed a circular visual tracking task and the Spatial Span task. Pearson correlations were used to examine the relationship between these two assessments of visual-spatial attention. Results: Results showed weak correlations between target measures. Some correlations were statistically significant (p<.05), particularly between Spatial Span backward scores and CVT parameters, suggesting shared commonalities between tasks involving mental manipulation of visual information. Conclusions: CVT and Spatial Span are conceptually related as visual attention metrics given shared underlying neural mechanisms. While results showed weak, albeit significant correlations, some differences in performance may be accounted for by differences in testing modality. As part of a separate multi-site study of predictive attention, we will further examine the relationship between CVT and Spatial Span using an alternate modality of Spatial Span (electronic version) to provide additional conceptual support for CVT as an attention metric. Our efforts will contribute to a growing literature on the assessment of attention and cross-modality validation, with applications to the assessment of populations in which attention is vulnerable to impairment.

Accurate prediction of brain dysfunction caused by disease or injury requires the quantification of resultant neural connectivity changes compared with the normal state. There are many methods with which to assess anatomical changes in structural or diffusion magnetic resonance imaging, but most overlook the topology of white matter (WM) connections that make up the healthy brain network. Here, a new neuroimaging software pipeline called the Network Modification (NeMo) Tool is presented that associates alterations in WM integrity with expected changes in neural connectivity between gray matter regions. The NeMo Tool uses a large reference set of healthy tractograms to assess implied network changes arising from a particular pattern of WM alteration on a region- and network-wise level. In this way, WM integrity changes can be extrapolated to the cortices and deep brain nuclei, enabling assessment of functional and cognitive alterations. Unlike current techniques that assess network dysfunction, the NeMo tool does not require tractography in pathological brains for which the algorithms may be unreliable or diffusion data are unavailable. The versatility of the NeMo Tool is demonstrated by applying it to data from patients with Alzheimer's disease, fronto-temporal dementia, normal pressure hydrocephalus, and mild traumatic brain injury. This tool fills a gap in the quantitative neuroimaging field by enabling an investigation of morphological and functional implications of changes in structural WM integrity.