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PubMed1999

Neuropsychological, MRI and EEG findings after very mild traumatic brain injury.

Neuropsychological performance, magnetic resonance imaging (MRI) and electroencephalography (EEG) were investigated in 12 consecutive patients with very mild traumatic brain injury (MTBI) (Glasgow coma score 15) within 24 hours and 6 weeks after injury. The data were compared to 14 control subjects. There was a significant impairment in neuropsychological performance (verbal memory, arithmetic abilities and psychomotor reaction time) at onset and after 6 weeks, whereas verbal fluency and non-verbal memory test revealed no significant differences matching the control values. In MRI scans, three patients showed traumatic lesions (slight epidural haematoma, haemorrhagic contusions and white matter lesions indicating diffuse axonal injury). In the EEG recordings, no generalized slowing or focal changes were found. Structural and functional impairment can be identified using neuroimaging and neuropsychological examination, even in very MTBI patients.

Adolescent↗
PubMed2001

Neuroimaging findings in mild traumatic brain injury.

The role of neuroimaging in the diagnosis and management of mild traumatic brain injury (TBI) is evolving. In general, the structural imaging techniques play a role in acute diagnosis and management, while the functional imaging techniques show promise for clarification of pathophysiology, symptom genesis, and mechanisms of recovery. A wide array of neuropathological processes are involved in mild TBI including changes in bone (e.g., a skull fracture), tissue density and water content (edema), blood flow, white matter integrity and pathway connectivity (diffuse axonal injury), and subtle changes in the neuronal and extracellular biochemical milieu. No single imaging technique is capable of addressing all these processes. It is, therefore, important to be aware of the advantages and limitations of the various available imaging modalities. This paper selectively reviews the pertinent literature on the structural and functional imaging in mild TBI.

Brain↗
PubMed1988

Controlled cortical impact: a new experimental brain injury model.

A new experimental model of mechanical brain injury was produced in the laboratory ferret (Mustela putorius furo) using a stroke-constrained pneumatic impactor. Cortical impacts were made on vertex to the intact dura mater overlying the cerebral cortex with contact velocities ranging from 2.0 to 4.0 m/sec and with deformations of 2.0 to 5.0 mm. The dwell time of the impact and the stability of the skull during impact were verified with high speed (1000 to 3000 frames/sec) cineradiography. Systemic arterial blood pressure, heart rate, and respiration were monitored, and postinjury changes were recorded. Anatomic brain injury, including subdural hematoma, subarachnoid hemorrhage, tears or rents of the dura mater, and contusions of the cortex, brainstem, cervical spinal cord, and cerebellum was observed. Injury responses ranged from no apparent anatomic injury or alterations in the systemic physiology at low severity impact (2.0 m/sec, 2.0 mm) to immediate fatality in the highest severity impact groups (4.0 m/sec, 4.0 mm). The range of changes in systemic physiology and of pathology in the brain, brainstem, and spinal cord was a function of both contact velocity and the amount of brain deformation. In two cases where postinjury time was 8-10 h, diffuse axonal injury, indicated by beaded axons and retraction balls, was present in subcortical regions underlying the site of impact. The spectrum of anatomic injury and systemic physiologic responses closely resembled aspects of closed head injury seen clinically. This procedure complements and improves on existing techniques by allowing independent control of contact velocity and level of deformation of the brain to facilitate biomechanical and analytic modeling of brain trauma. Graded cortical contusions and subcortical injury are produced by precisely controlled brain deformations, thereby allowing questions to be addressed regarding the influence of contact velocity and level of deformation on the anatomic and functional severity of brain injury.

Animals↗
PubMed2001

Magnetic resonance spectroscopy in traumatic brain injury.

Magnetic resonance spectroscopy (MRS) offers a unique non-invasive approach for assessing the metabolic status of the brain in vivo and is particularly suited to studying traumatic brain injury (TBI). In particular, MRS provides a noninvasive means for quantifying such neurochemicals as N-acetylaspartate (NAA), creatine, phosphocreatine, choline, lactate, myo-inositol, glutamine, glutamate, adenosine triphosphate (ATP), and inorganic phosphate in humans following TBI and in animal models. Many of these chemicals have been shown to be perturbed following TBI. NAA, a marker of neuronal integrity, has been shown to be reduced following TBI, reflecting diffuse axonal injury or metabolic depression, and concentrations of NAA predict cognitive outcome. Elevation of choline-containing compounds indicates membrane breakdown or inflammation or both. MRS can also detect alterations in high energy phosphates reflecting the energetic abnormalities seen after TBI. Accordingly, MRS may be useful to monitor cellular response to therapeutic interventions in TBI.

Animals↗
PubMed1991

Neuroplasticity following traumatic brain injury: a study of GABAergic terminal loss and recovery in the cat dorsal lateral vestibular nucleus.

Terminal loss and recovery were assessed in the cat dorsal lateral vestibular nucleus (dLVN) following diffuse axonal damage caused by experimental traumatic brain injury. Using sterile technique, anesthetized adult cats received a moderate fluid-percussion traumatic brain injury. After predetermined survival periods of 7-368 days, the animals were perfused and the dLVN prepared for the immunocytochemical visualization of GABAergic puncta/terminals at the light (LM) and electron (EM) microscopic levels. In controls, the Deiters' neuronal somata within the dLVN were encompassed by numerous GABA-immunoreactive puncta/terminals. Within 7 days of injury, axonal damage was seen scattered throughout the dLVN, and associated with this, some neuronal somata demonstrated a dramatic loss of perisomatic GABA-immunoreactive puncta, while other somata appeared unchanged. Ultrastructural examination demonstrated that the loss of immunoreactive puncta observed with LM was directly correlated with the presence of degenerating GABAergic terminals. Overall, these neuronal somata showed a reduction of perisomatic puncta/terminals to values approximately 25% of controls. Over a thirty day posttraumatic course, this pattern of scattered perisomatic puncta/terminal loss persisted, with some puncta/terminal return by 60 days postinjury. During the next six months, a recovery of the immunoreactive puncta/terminals was observed in relation to the deafferented somata, with perisomatic terminal numbers now reaching 75% of control values. Over the 7 to 12 month postinjury period, recovery continued, with virtually complete recovery observed in the later phases of this period. Importantly, throughout this recovery period, there was a consistent correlation between the light and electron microscopic findings. The observed diffuse pattern of terminal loss, followed a prolonged adaptive recovery process, suggests that traumatic injury with its attendant diffuse axonal injury and related diffuse deafferentation creates a unique environment for rather complete and adaptive synaptic recovery. As diffuse axonal injury is a common feature of human traumatic brain injury, we believe that these studies, performed in cat, help explain some of the initial morbidity as well as some of the partial recovery seen in head-injured man.

Animals↗
PubMed1998

Modelling recovery of cognitive function after traumatic brain injury: spatial navigation in the Morris water maze after complete or partial transections of the perforant path in rats.

The Morris water maze (MWM) has been used to assess cognitive function in rats after a variety of lesions designed to model brain damage and to assess the effects of drugs, growth factors, and neural transplants on post-operative deficits. The present study examined recovery of spatial navigation in the MWM over time in order to model the spontaneous recovery of cognitive function seen in humans. Diffuse axonal injury, a neuropathology commonly associated with traumatic brain injury (TBI), was modelled by transecting the perforant path (PP) bilaterally, either caudal to the hippocampus or dorsal to it at the decussation of the dorsal hippocampal commissure. Both groups with PP cuts showed substantial deficits initially, but spatial performance recovered with time and training. Recovery of platform finding was nearly complete within 14 days of testing, but recovery of platform searching did not occur for 2 or 3 more weeks. When the platform was moved to a new location, a continuing deficit in learning rate was revealed. When the platform was moved to a new position every day, this deficit was even more evident. These results illustrate the multi-faceted nature of recovery after brain injury and provide a new model for assessing the effects of manipulations designed to modulate recovery.

Animals↗
PubMed1999

[Usefulness of T2* weighted magnetic resonance image in the diagnosis of head injury on chronic stage].

T2* weighted gradient echo image has heightened diagnostic sensitivity to hemorrhage, which is attributed to magnetic susceptibility-induced static field inhomogeneities arising from paramagnetic blood breakdown products such as hemosiderin, which shorten T2*. We examined 4 cases of head injury in chronic stage by T2* weighted images and assessed the clinical application of this sequence for diagnosis of the intracranial lesion. All patients underwent CT scan on acute stage and long-term follow up was performed. In all cases, abnormally low signals in the brain and subarachnoid space were more conspicuous with the T2* weighted image than with any of the conventional sequences. In 2 cases with diffuse axonal injury, of which lesions were not detected on acute stage CT scan, hypointensity area was clearly demonstrated in the cerebral peduncle and corpus callosum on T2* weighted images. Selection of T2* weighted image into the routine MR examination of patients with chronic stage of the head injury is recommended.

Adult↗
PubMed2001

Brain injury after survived gunshot to the head: reactive alterations at sites remote from the missile track.

Gunshot wounds to the brain usually lead to acute respiratory arrest or death after a brief survival period, even in cases involving only slight direct tissue damage. It can be assumed therefore that the damage extends beyond the zone of recognizable destruction and hemorrhages. To determine the true extent of the tissue injury resulting from gunshot wounds to the brain, we carried out microscopic investigations for reactive changes (emigration of leukocytes and macrophages, axonal expression of beta-amyloid precursor protein (beta-APP) in 10 cases of gunshot wound to the narrow channel of the brain with survival times >2h. Demonstration of leukocytes expressing naphthol AS-D chloroacetate esterase activity in the brain tissue at the border of the missile track established the vitality of the gunshot effect. The presence of macrophages (CD68-epitope) allowed demarcation of a 1-2mm wide necrotic zone around the permanent cavity. Within this zone and beyond, beta-APP showed an initial increase followed by a decline in the number of injured axons. Three types of beta-APP positive staining could be differentiated. In the immediate vicinity of the missile track beta-APP positive neurons were present at a distance of 2-4mm from the margin of the permanent cavity (type 1) as a result of primary injured neuronal tissue by the gunshot itself. At longer distances from the narrow channel and the permanent cavity single beta-APP positive axons or axon fragments and two additional types were found; type 2 shows a parallel, wave-like arrangement of the damaged fibers, which suggests that the injury was produced by mechanical acceleration of the brain tissue created by the energy the projectile expended within the brain; irregular aggregation of beta-APP positive axons or axon fragments within a local edema represents type 3, which may be attributed to secondary ischemia or edema.

Adult↗
PubMed1996

[Clinical utility of MR FLAIR imaging for head injuries].

To study the utility of fluid attenuated inversion recovery (FLAIR)MR images in the evaluation of traumatic head injury, 56 patients with traumatic head injuries were examined with long TR/TE spin-echo(SE)sequences and FLAIR sequences. In 40 of them, long TR/short TE images were added to those sequences. Careful readings of MR images were done by two well-trained neuroradiologists. The chi square test was used for statistical evaluation of our results. The relative sensitivities of FLAIR images were significantly better than those of long TR/TE, long TR/short TE images for the detection of diffuse axonal injury (p < 0.01), cortical contusion (p < 0.01), and subdural hematoma (p < 0.01) for long TR/TE, p < 0.05 for long TR/short TE). The number of cases of epidural hematoma and brainstem injury was too small for statistical significance to be determined. In 9 patients with corpus callosum injuries. FLAIR images demonstrated the lesions as abnormally high signal intensity in the septum pellucidum and fornix. Only sagittal FLAIR images could definitely discriminate the traumatic lesions of the fornix from the surrounding CSF. In addition, FLAIR images could easily discriminate DAI of the corpus callosum from CSF of the cavum velli interpositi. MR FLAIR images were found to be useful for detecting traumatic head injuries.

Adolescent↗
PubMed1999

[Burst lobe in victims of fatal road traffic accident. Frequency and association with other head injury].

A morphological study, macro and microscopical, was made of brain lesions in 120 victims of fatal road traffic accidents. Burst lobes were identified in 12 (10.0%) of the patients. It occurred in the frontal lobe in 6 (50.0%) patients, in the temporal lobe in 2 (16.7%) and in both lobes in 4 (33.3%) patients. A skull fracture occurred in 8 (66.7%) patients and intracranial hypertension occurred in half of cases. Nine patients were admitted in coma and three patients died immediately after the road traffic accident. All cases of burst lobes were associated with diffuse axonal injury, which explains the severe alteration of consciousness observed at the patients' admission.

Accidents, Traffic↗
PubMed2005

[Value of serial CT scanning and intracranial pressure monitoring for detecting new intracranial mass effect in severe head injury patients showing lesions type I-II in the initial CT scan].

OBJECTIVE: To determine the incidence of pathological and intracranial pressure (ICP) changes during the acute posttraumatic period in severe head injury patients presenting with lesions Types I-II (TCDB classification) in the admission CT scan with the aim of defining the most appropriate strategy of sequential CT scanning and ICP monitoring for detecting new intra-cranial mass effect and improving the final outcome. MATERIAL AND METHODS: 56 patients (ages 15-80 years) consecutively admitted during a 2 years period were included. All had the initial CT scan < 24 hours after injury (mean interval = 150 min), several CT controls within the first days of the course and ICP monitoring after admission. Different epidemiological, clinical and radiological variables were recorded and deterioration defined as the development of sustained ICP over 20 mmHg requiring aggressive medical and/or surgical treatment was considered the dependent variable. Uni and multivariate analyses were made for determining the correlation between different parameters and the occurrence of deterioration and the final outcome as assessed with the GOS. RESULTS: The mean GCS score was 5 and 37% of the patients showed pupillary changes; 52.3% had peritraumatic hypotension-hypoxemia, 16.1% anemia and 12.3% coagulation changes. 50% of the patients showed petechial hemorrhages in the white matter or the brainstem, 66% SAH, 40% HIV, 39.3% brain contusion and 21.4% small extraaxial hematomas. 57.1% of the patients showed CT changes through the acute post-traumatic period consisting of new contusion (26.8% of the cases), growing of previous contusion (68.2%) or previous extraaxial hematoma (10.7%), and generalized brain swelling (10.7%). 64.9% of the patients made a favourable and 35.7% an unfavourable outcome. Overall, 27 (48.9%) patients developed deterioration, 21 (37.5%) with concurrent CT changes and 6 (10.7%) without new pathology as seen by the CT control. The remaining 29 (51.7%) patients in this series did not develop deterioration in spite that 11(19.6%) showed CT changes. The age, the initial score, the occurrence of peritraumatic hypotension-hypoxemia and coagulation disorders did not correlate with the risk of deterioration. By contrast, the presence of contusion at the initial CT scan (p= 0.01) and the occurrence of CT change (only generalized brain swelling, p= 0.003) significantly correlated with the risk of deterioration; in his turn deterioration increased by a factor of 10 (OR = 9.8) the risk of death and 7 out of the 8 patients who died developed intractable intracranial hypertension. The 8 (14.2%) patients requiring surgery showed simultaneous ICP deterioration and CT changes, but another 11 patients in a similar condition could be managed without surgery. With or without ICP deterioration, patients showing CT changes had a worse outcome than those without new pathologies, but the difference did not reach statistical significance, DISCUSSION AND CONCLUSIONS: Over 50% of the patients with initial Type I-II lesions developed new CT changes and nearly 50% showed intracranial hypertension during the acute posttraumatic period. Considering the high incidences of ICP and CT deterioration through the course, along with the absence of strong predictors and the discordances between CT and ICP changes (which were seen in 30.3% of the cases) we recommend ICP monitoring after admission in all patients and serial CT scanning at 2-4, 12, 24, 48 and 72 hours after injury with additional controls as indicated by clinical or ICP changes in all cases. Though it is clear that the presence of severe intra-cranial hypertension significantly increased the risk of death, the small size of the sample in this series prevented to assess to what extent the occurrence of new mass effect and/or raised ICP contributed to the development of moderate and severe disability in the survivors which were mainly due to the occurrence of diffuse axonal injury. Finally, demonstrating that sequential CT scanning and ICP monitoring improve the final outcome in this type of patients would require a prospective randomized trial which is impracticable for different reasons, among them the ethical ones.

Adolescent↗
PubMed1994

[Traumatic hematoma in the basal ganglia (caudate) with favorable prognosis: report of two cases].

Two cases of traumatic basal ganglial hematoma with fairly good prognosis were reported. Several cases with similarly favorable prognosis could be also found in the recent literature. In these cases, post-traumatic disturbance in consciousness was mostly slight or moderate and the patients were rarely comatose. The inquiries in these cases were commonly associated with superficial injuries such as skull fracture, epi-or sub-dural hematoma, brain contusion, or another traumatic ICH. The hematomas in the basal ganglia usually showed a mass effect causing focal neurological signs such as hemiparesis. Neurological improvement was achieved in the operated cases, and final outcome was mostly fair with some fully recovered cases. These clinical features are quite different from those of most cases of traumatic basal ganglial hematoma reported so far, which closely resemble diffuse axonal injury and whose prognoses are extremely poor. There may be two different categories in the traumatic basal ganglial hematomas, those with fair outcomes, and those with poor outcomes.

Aged↗
PubMed2005

Severe brain injuries in children.

Authors present a seven years retrospective study on 85 cases of severe brain injuries (SBI) in children (GCS </= 8) treated in the Pediatric and ICU Departments of the Clinic Hospital "Bagdasar-Arseni" Bucharest, Romania. The relationship between ICP, GCS on admission, the CT-scan/MRI alteration and the outcome evaluated by the Glasgow Outcome Scale (GOS) were studied in order to highlight the most important factors to improve prognosis. An overall mortality of 25.9% was found in this series. Authors concluded that the ICP values at admission >/= 20 mmHg, the Diffuse Axonal Injury (DAI) on MRI and the GCS on admission are factors of prognosis in SBI in children. The politrauma context is an aggravating factor for SBI in this age group. Other factors which influence GCS on admission may have prognostic importance i.e.: prehospital care, transport time and adequate transport conditions.

Adolescent↗
PubMed1994

Axonal injury and membrane alterations in Alzheimer's disease suggested by in vivo proton magnetic resonance spectroscopic imaging.

We used spin-echo magnetic resonance imaging and proton magnetic resonance spectroscopic imaging in 8 patients with probable Alzheimer's disease and in 10 age-matched elderly control subjects to assess the effects of Alzheimer's disease on the brain. On magnetic resonance images the patients showed significant ventricular enlargements relative to the control subjects. We measured the distribution and relative signal intensities of N-acetylaspartate (a putative neuronal marker), of choline residues representing lipid metabolites, and of creatine-containing metabolites in a large section of the centrum semiovale containing white and mesial gray matter. Throughout the white matter of the patients with Alzheimer's disease compared to elderly control subjects, N-acetylaspartate was decreased relative to choline (N-acetylaspartate-choline ratio) and creatine-containing metabolites (N-acetylaspartate-creatine ratio) with no changes in the choline-creatine ratio. The N-acetylaspartate-choline ratio was lower and choline-creatine higher in the mesial gray matter of AD patients relative to elderly controls. The posterior section of the centrum semiovale in the patients showed increased choline-creatine and choline-N-acetylaspartate ratios with the N-acetylaspartate-creatine ratio unchanged between the patients and control subjects. These spectroscopic findings give suggestive evidence of diffuse axonal injury and membrane alterations in gray and white matter of the centrum semiovale in patients with Alzheimer's disease.

Aged↗
PubMedDate not supplied

The ataxic subgroup: a discrete outcome after traumatic brain injury.

We have observed five individuals who appear to represent a unique subgroup of patients with traumatic brain injury (TBI). Because of the prominence of severe ataxia, this group has been labelled the 'ataxic subgroup'. These individuals are distinguished by both clinical course and outcome, including severe ataxia, prolonged coma and prolonged post-traumatic amnesia (PTA). They distinguish themselves from other severely impaired TBI patients in that they spend a relatively longer length of time prior to the establishment of volition, but progress rapidly through the period of confusion. We hypothesized that this group is unique in that they have suffered Grade III diffuse axonal injury (DAI) with no or minimal complications due to other primary or secondary brain damage. In order to investigate these hypotheses, a retrospective file review of a selected group of 72 patients was undertaken to determine the specificity and sensitivity of two diagnostic criteria. The existence of severe Grade III DAI without other primary or secondary brain damage was presumed if severe ataxia was present in conjunction with normal CT scans. Results of this review indicated that 33% of the population demonstrated severe ataxia, although only 11% also had normal CT scans. These dual criteria were neither adequately sensitive nor specific to define the five patients who comprised the 'ataxic subgroup'. When rate of clearing the confused period of PTA was added to the diagnostic criteria, specificity improved. Although this attempt to define this subgroup empirically was not entirely successful, further attempts to delineate this group are important in that prognosis for clearing PTA is good despite early indicators of poor outcome.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2004

Role of brain perfusion single-photon emission tomography in traumatic head injury.

This investigation examined the role of brain perfusion single-photon emission tomography (SPET) in traumatic head injury in 35 patients. The results were compared with those of X-ray computerized tomography (CT) and magnetic resonance imaging (MRI). CT and MRI detected brain contusions in seven patients, subarachnoid haemorrhage in one patient and both in nine patients. In 16 of the 17 subjects (94%), SPET with technetium-99m-hexamethylpropyleneamine oxime (Tc-HMPAO) revealed CT/MRI-negative abnormalities, such as hypoperfusion in the contre-coup region, frontal hypoperfusion related to personality change and cerebellar hypoperfusion associated with vertigo. In two patients presenting with diffuse axonal injury in the brainstem, hypoperfusion in the frontal cortex on the affected side was observed on SPET. SPET demonstrated hypoperfusion in the adjacent cortex, with no abnormality on either CT or MRI, in six of seven patients exhibiting acute epidural haematoma. SPET failed to provide additional information in two of five patients with acute subdural haematoma and in one of two patients displaying chronic subdural haematoma. In four of nine patients with post-traumatic amnesia, SPET detected hypoperfusion in the temporal lobe, with no abnormality on either CT or MRI. In five of eight patients with vertigo, SPET detected hypoperfusion in the morphologically normal cerebellum. In seven cases involving personality change, frontal hypoperfusion was observed in four; moreover, a markedly non-homogeneous pattern was evident in the remaining three. Overall, SPET afforded additional information in 26 patients (74%). CT possesses an advantage with respect to the detection of haemorrhagic lesions. MRI provides more precise information regarding contusions and axonal injury. Frequently, SPET may be the only examination to reveal perfusion abnormalities which are related to symptoms in the absence of other objective findings, such as post-traumatic amnesia, vertigo or personality change.

Adolescent↗
PubMed1996

Recovery of automatic and cognitive functions in traumatic brain injury using the functional independence measure.

Automatic tasks are performed with minimal attentional guidance. Neural pathways subserving attention are often impaired in traumatic brain injury (TBI). Therefore, the process of automatization is crucial in skill development, due to the fact that it allows attention to be directed towards the more abstruse components of task [1]. Automatic and cognitive categories were created by aggregating three of the motor items and three of the cognitive items respectively of the Functional Independence Measure (FIM). The averages of these categories were calculated for every evaluation of the FIM, and their relationship to each other was examined. Over a 9-month period 24 patients were selected from a TBI population with a major component of diffuse axonal injury (DAI). Eighty-eight per cent (n = 21) of the patients reached independence for the automatic category, but only 29% (v = 7) reached this level for the cognitive category. When independence was achieved, the average time to do so for the automatic category 6.7 weeks) was not significantly different from the time it took to reach cognitive independence (6.9 weeks). It was found that there were significant statistical differences in the scores between the two categories. Premorbid IQ had no effect on these categories. However, the rate which these two categories increased, from the time of admission to discharge, was not significantly different.

Activities of Daily Living↗
PubMed2004

[Alterations of symptoms with borderline personality disorder after fronto-temporal traumatic brain injury. A case study].

We report a case of borderline personality disorder in which severe self-mutilation, sense of futility and tendency to manipulate others disappeared after fronto (orbital cortex and dorso-lateral surface) temporal traumatic brain injury. The patient, a right-handed 34 year-old woman began having severe depressive moods, irritability, and performed recurrent self-mutilation by wrist cutting after her marriage at age 20. She was diagnosed as having borderline personality disorder. At the age of 30, she attempted to kill herself by leaping from a building, and sustained a frontotemporal traumatic brain injury. After 5 years of follow-up, she recovered from Wernicke's-like aphasia, but could not understand anything complex. She also showed disturbances of writing, calculating, attention, working memory, recent and remote memories, motivation, and sense of self. The results of tests of higher brain function were as follows: Wisconsin card sorting test (Keio version), C = 1, D = 2, P = 23; FAB (Frontal Assessment Battery) = 7/18; Trail making test B = impossible. Brain MRI demonstrated left frontal lobe (orbital cortex and dorso-lateral surface) contusions, severe atrophy in the left temporal cortex including the hippocampus and amygdala, and diffuse axonal injury in the left frontal white matter. Although her recurrent self-mutilation had disappeared after brain injury, a certain type of anxiety, which occasionally induced irritability, unstable moods and devaluation of others, occurred without any trigger once or twice a month. This anxiety continued two or three days and faded away within a week. Because of its frequency and duration, this anxiety can be considered to originate not from the traumatic brain injury, but from her intrinsic nature, and seems to be parallel to annihilation anxiety (Reich A, Klein M) and abandonment anxiety (DSM-IV). Because she showed this anxiety after a severe higher brain dysfunction including disturbances of language, attention, working memory, recent and remote memories, motivation, and sense of self, we considered this anxiety to be an unarticulated form of annihilation anxiety and abandonment anxiety.

Adult↗