Diffusion tensor imaging (DTI) is a relatively newer diagnostic tool that measures white matter tracts in the brain and is useful for assessing axonal damage after a traumatic brain injury. Much research has shown the efficacy of DTI in the prediction of outcome after a brain injury, however, most of that research has been limited to single clinical sites. DTI, like any other technology, is vulnerable to slight changes in user technique and hardware or software disparities.

A recent study looked at the DTI scores of 105 people with severe traumatic brain injury from ten different sites to measure how well DTI could accurately predict outcome after one year. They confirmed that the probability of a negative outcome (coma or death) was highly related to higher DTI scores (higher rate of white matter damage).

It is possible to use larger DTI studies, such as this one, to create a standardized DTI prediction system that will help clinicians determine outcome potential in cases of severe traumatic brain injury.

Galanaud D, Perlberg V, Gupta R, et al. Assessment of white matter injury and outcome in severe brain trauma. Anesthesiology. (December 2012).

Concussion on the sports field is often undiagnosed because of bias in self-report, ambiguity in symptoms, and the lack of loss of consciousness (which does not always occur in a concussion). In the days that follow, however, the athlete that has sustained a head impact may develop delayed symptoms of a concussion, further confounding an accurate diagnosis.

A recent study looked at the types of impact that commonly occur to the head, as well as timing and frequency, and the relationship to concussion diagnosis. They found that an immediate diagnosis of concussion after head impact was highly associated with high kinematic metrics (peak linear and rotational acceleration, velocity, injury severity). Delayed concussion diagnosis was associated with higher numbers of head impacts on the day of injury. Impacts most associated with concussion diagnosis occurred to the front of the head (46%) followed by the top of the head (25%), side (16%), and back (13%).

These results suggest that different head impact measures can result in different clinical presentations, which should be considered during diagnosis.

Beckwith JG, Greenwald RM, Chu JJ, et al. Timing of concussion diagnosis is related to head impact exposure prior to injury. Sports & Exercise. (January 2012).

Magnetic resonance imaging (MRI) is one of the more common diagnostic tools used to assess brain injury. Using conventional diagnostic guidelines in MRI, however, often fails to show evidence of damage related to mild traumatic brain injury.

Mild traumatic brain injury sometimes results in post-concussion syndrome—a set of symptoms such as depression and insomnia—that lingers in the weeks and months after the injury. Using a baseline measurement of the brain at rest (default mode network), researchers recently discovered a difference in the MRIs of people who suffered from post-concussion syndrome and those who did not. The resting state MRI shows that there was less communication between neural areas in the posterior area of the brain, and increased communication in the anterior area of the brain.

These differences in brain communication may correlate with the various symptoms of post-concussion syndrome, and important distinction not only for diagnosis, but also for potential rehabilitation or other treatments.

Zhou Y, Milham MP, Lui YW, et al. Default-mode network disruption in mild traumatic brain injury. Radiology. (December 2012).

Insomnia, fatigue, and excessive daytime sleepiness are common problems after a traumatic brain injury. However, it can be difficult to determine if sleep problems are a primary disorder or a symptom of something else. For instance, daytime fatigue could be a symptom of insomnia, or a primary problem caused by biological changes from the injury.

A recent study looked at the relationship between insomnia and fatigue in the two years after a brain injury. They found that insomnia without concurrent fatigue was rare at 2%. However, fatigue that occurred without insomnia was more common at 23%. This means that post-traumatic fatigue was often not the result of insomnia, but was instead a primary problem related to the injury.

In addition, most people (93%) who suffered from insomnia after the injury had not suffered from insomnia before the injury. Anxiety and depression was strongly associated with both insomnia and fatigue. Both insomnia and fatigue were related to higher disability and lowered quality of life.

Cantor JB, Bushnik T, Cicerone K, et al. Insomnia, fatigue, and sleepiness in the first 2 years after traumatic brain injury. An NIDRR TBI model system module study. Journal of Head Trauma Rehabilitation. (December 2012).

Although many more people today are surviving a traumatic brain injury than ever before, a brain injury is still a significant risk factor for death, even years after the injury. Age at the time of injury can also be related to the risk of death (or decreased life expectancy) after a brain injury.

A recent study found that age group, as it interacted with injury severity, had a significant influence on mortality. These findings showed that:

1. Injury at ages 15-24 years put males at a higher risk of death.
2. Injury at ages 24-34 put both genders at a 13% higher risk of death for every year past 24. The risk of death was 1% lower for every 1-point increase in the Functional Independence Scale of motor skills.
3. Injury at ages 35-44 put both genders at an 8% higher risk of death for every year past 35. People who were retired or unemployed at the time of injury had 2-4 times greater risk of death after injury.
4. Injury at ages 45-64 put women at a 41% lower risk of death than men. People who were divorced or widowed at the time of injury were almost twice as likely to have a decreased life expectancy than those who were married. People who had used illegal or prescription drugs before the injury were 1.5 times likely to have an increased risk of death.
5. Injury at age 65 years and older put women at a 48% lower risk of death than men. Those who were never married before the injury were at a 48% lower risk of death. Those whose injury was due to a fall were 1.5 times more likely to die than injury related to a car accident.
6. Injury at age 85 and older did not show a significantly greater risk of death, as compared to other age groups.

Harrison-Felix C, Kolakowsky-Haynor SA, Hammond FM, et al. Mortality after surviving traumatic brain injury: Risks based on age groups. Journal of Head Trauma Rehabilitation. (December 2012).

Happy New Year! The Brain Injury Association of America welcomes the new and returning members to the 113th Congress. BIAA is poised to take on both the opportunities and difficulties this new Congress presents.

With the 2012 election behind us, President Obama maintained his job as Commander in Chief; the Senate remained a Democratic majority and the House of Representatives remained Republican, BIAA looks forward to the challenges ahead. With the fiscal cliff averted, policymakers are focused on the debt ceiling and resolving the sequester. The Continuing Resolution (CR) that is funding the federal government will expire on March 27, 2013. BIAA will continue to monitor all budget discussions moving forward in the new Congress.

Amidst the politicking, BIAA will continue to advocate with the support of the Congressional Brain Injury Task Force (CBITF), a bi-partisan caucus of more than 120 members of Congress, led by Rep. Bill Pascrell, Jr. (NJ-D). Congressman Todd Platts (PA-R), the previous co-chair of the CBITF retired at the end of the 112th Congress. BIAA thanks Rep. Platts for his tireless work for individuals with brain injury and their families. BIAA looks forward to working with the CBITF to advocate for all individuals that are impacted by brain injury.

Our goals this year are to sustain and bolster brain injury programs, increase access to care and preserve vital brain injury research. As in 2012, appropriations increases in 2013 are unlikely, but there are still many opportunities to advance our cause.

This year, BIAA will continue to collaborate with the Health Resources and Services Administration, the National Institute on Disability and Rehabilitation Research, the Centers for Disease Control and Prevention, the National Institutes of Health , the Food and Drug Administration, and the Administration for Community Living, a new partnership that was developed in 2012.

BIAA will also continue to monitor and comment on the Department of Defense and the Department of Veterans Affairs’ research and treatment for active duty military, their dependents and Veterans.

This year more than ever, BIAA will count on its grassroots advocates to show members of Congress how important brain injury is to their constituents. Thank you to everyone who participated in our action alerts last year. You helped make Congress aware of TBI Act reauthorization and repealing the therapy cap which limits the amount of therapy an individual can receive. You have all truly made a difference and we hope to continue that excitement and dedication in 2013!

A theory called the left-dominant brain immune network states that certain brain areas form a network that dominates interaction with the body’s immune system. This theory has recently been supported by a study in which people with an injury to the left side of their brain were found to be at greater risk for acquiring a hospital acquired infection during their inpatient rehabilitation program.

The study looked at the medical records of 163 patients with either left or right brain injury. The researchers found that 61% of the left brain injury patients developed an infection within the first few days as an inpatient.

Left brain injury may not only put an immediate immune risk on a person, but possibly a long-term vulnerability as well. People who suffer an injury to the left side of their brain should therefore be carefully monitored for potential infection.

Frisina PG, Kutlic AM, & Barrett AM. Left brain injury associated with more hospital-acquired infections during inpatient rehabilitation. Archives of Physical Medicine and Rehabilitation. (December 2012.)

It has become increasingly clear in research that a traumatic brain injury, even a mild one, can trigger an earlier onset of neurodegenerative disorders such as Alzheimer’s disease or Parkinson’s disease. However, the exact mechanism of how these triggers occur is not well understood.

Glutamate, which is a neurotransmitter found in great abundance in the brain, is important for stimulating neurons, especially for brain functions such as memory and learning. An event such as a traumatic brain injury can cause a sharp peak in glutamate, creating an overstimulated environment in which neurons cannot cope or survive.

The sharp peak of glutamate also triggers changes in brain metabolism, calcium levels, and mitochondrial function—creating a toxic environment in the brain. Certain drugs, supplements and foods, such as metformin, curcumin, vitamin K2, or statins have been shown to stabilize glutamate and may provide preventative strategy for reducing the risk of developing neurodegenerative disorders after traumatic brain injury.

Mehta A, Prabhakar M, Kumar P, et al. Excitotoxicity: Bridge to various triggers in neurodegenerative disorders. European Journal of Pharmacology. (December 2012).

A traumatic brain injury puts a person at a significant risk for developing hypopituitarism, a disorder in which the pituitary gland of the brain produces insufficient hormones. Although many recent studies have focused on this increased risk, there has not previously been many studies the effect on long-term outcome.

A recent study of 51 people with severe traumatic brain injury between 2 and 10 years after the traumatic event found that 28% had hypopituitarism and 22% specifically had growth hormone deficiency. As a result of the hormone deficiencies, these patients were also more likely to be overweight. Besides increased weight, however, there was no other significant quality of life change related to hormone deficiencies.

The researchers suggested that people who suffered from a traumatic brain injury and who had gain significant weight in the years after the injury should be specifically screened for pituitary gland dysfunction.

Ulfarsson T, Gudnason GA, Rosen T, et al. Pituitary function and functional outcome in adults after severe traumatic brain injury: The long-term perspective. Journal of Neurotrauma. (December 2012).

There are many straight-forward choices of technology today that can assist people with various disabilities, such as walking support, hearing enhancers, or memory aides. However, the needs of people who have disabilities related to a brain injury are far from simple. A brain injury can cause various changes in awareness, mood, or cognitive ability that contribute to how well a technology will work or be used.

Making a selection of supportive technology therefore requires careful consideration. In a recent review of the Cognitive Support Technology Predisposition Assessment tool, several decision-making factors were highlighted. The first factor that should be considered is the patient’s personal expectations, personality, and mood. Questions such as “How comfortable am I emotionally, physically, and socially in using this support?” or “Will this technology contribute to my quality of life?” can help a patient decide whether or not the supportive technology is one that will be useful.

In addition, family members, friends, and employers also bring expectations to the selection of supportive technologies. Questions that should be considered include, “Will the environment of the home/workplace facilitate the use of this technology?” and “How will the use of this technology affect other people?”

The introduction of new supportive technologies needs to integrate well with technologies that are already in place. They need to be easy to access and use, and not create barriers in care or lifestyle. Follow-up after implementing a new technology is critical for assessing how well it works. Optimal use of the technology indicates that it is being used in all recommended situations with no resistance from the patient. Partial use, non-use, avoidance, or abandonment of the technology indicates that the tool is no longer useful or may be of annoyance to either the patient or the family/workplace.

Continued assessment is also important because recovery of awareness or changes in mood may alter the need for technological support. A person who was initially reluctant to use a tool at the beginning of recovery may become more open to use it over time. Other tools may become irrelevant as the person recovers abilities.

Technologies can greatly enhance the quality of life for someone who has suffered from a brain injury, but only if that person, his preferences, and lifestyle are included in the selection process.

Scherer MJ. How can we best match the person with a brain injury with the most appropriate technology support? Brain Injury Professional. (November 2012).

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Scarlett Law Group, Attorneys, San Francisco, CA

Contact Us

Scarlett Law Group

536 Pacific Avenue
Barbary Coast Bldg
San Francisco, CA 94133


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