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We studied the utility of fluid-attenuated inversion-recovery (FLAIR) MRI in the investigation of head injury. We examined 56 patients with head injuries with T2-weighted spin-echo (SE) and FLAIR sequences. In all cases, the sensitivity of FLAIR images to equal or superior to that of conventional SE images to the traumatic lesions. In 9 cases, central diffuse axonal injury of the fornix and corpus callosum could be seen only on sagittal FLAIR images.
The relationship between impairment of consciousness and quantitative cerebral blood flow (CBF) was investigated. The mean CBF of the whole brain was measured by the Patlak-plot method using technetium-99m hexamethylpropylene amine oxime single-photon emission tomography (99mTc-HMPAO SPET) in patients with the following diseases: cerebral infarction, intraparenchymal haemorrhage, subarachnoid haemorrhage, brain tumour and cerebral contusion. The clinical symptoms were evaluated according to the severity of impaired consciousness, aphasia and dementia. Four hundred and eighty-five CBF measurements were performed. Patients with alert consciousness showed an age-related decline in mean CBF. Patients with aphasia showed a significant reduction in mean CBF compared with those without aphasia. Impaired consciousness was proportional to reduction in mean CBF regardless of types of pathology, and the size of lesion did not influence the mean CBF. Patients with dementia showed a significant reduction in mean CBF proportional to the severity of dementia. The quantitative measurement of CBF using 99mTc-HMPAO SPET is reliable in clinical evaluations.
The purpose of our work was to compare the MR imaging findings of obvious hippocampal and/or juxtahippocampal lesions with corresponding clinical features. Magnetic resonance images of 63 patients with obvious lesions in the hippocampal and/or juxtahippocampal regions were reviewed and their findings were correlated with patients' clinical characteristics. Based on the MR and clinical findings, the patients were divided into four groups: (a) 26 patients with space occupying lesions or suspected vascular malformation frequently causing symptomatic temporal epilepsy; (b) 14 with hippocampal infarcts, which when left-sided or bilateral caused amnesia; (c) 11 with encephalitis and 5 with old temporal contusion usually accompanied by both amnesia and epilepsy; and (d) 7 with temporal atrophy and progressive dementia of subacute onset. Magnetic resonance imaging allows precise localization and evaluation of the clinical correlates of hippocampal and juxtahippocampal lesions, which frequently caused symptomatic temporal epilepsy and/or amnesic syndrome.
OBJECT: In 1991 a new pioneering classification of severe head injuries had been proposed, based on CT findings. Unfortunately CT cannot visualise all lesions. Especially brain stem lesions may escape CT in spite of modern equipment, but may be demonstrated by MRI. The high incidence of CT negative but MRI positive posttraumatic brain stem lesions has already been demonstrated in a limited number of cases. A statistically significant evaluation is still missing. Therefore we have investigated a series of 102 comatose patients, in whom a statistical evaluation of MRI findings and their correlation with mortality and outcome of survivors was possible. PATIENTS AND METHODS: MRI was obtained within 8 days after servere head injury in 102 patients with a minimum of 24 hours of coma. The location of the lesions. identified by a neuroradiologist who was unaware of the clinical findings, was correlated with mortality, outcome of surviors and duration of coma. The correlation was analysed statistically. Follow-up ranged from 3 months to 3 years with a mean of 22 months. Four groups of lesions gave significant correlations: Grade I lesions were lesions of the hemispheres only; Grade II lesions were unilateral lesions of the brain stem at any level with or without supratentorial lesions; Grade III lesions were bilateral lesions of the mesencephalon with or without supratentorial lesions. Grade IV lesions were bilateral lesion of the pons with or without any of the foregoing lesions of lesser grades. RESULTS: Mortality increased from 14% in grade I lesions to 100% in grade IV lesions. The Glasgow outcome score differed significantly for each grade. The mean duration of coma increased from 3 days in grade I patients to 13 days in grade III. The correlations between the lesions grade I to IV with mortality, outcome of survivors and duration of coma were highly significant. CONCLUSION: The statistically significant correlations between the 4 groups of severe head injury patients, as identified by MRI, with mortality and outcome of survivors justify a new classification based on early MRI findings.
Numerous concussions/mild traumatic brain injuries occur each year during athletic participation by a variety of athletes not only in the United States but around the globe. A variety of standards-type statements have been developed by various athletic and sports medicine groups that can be used to improve and standardize the diagnosis and treatment of these injuries. These standards can also be used to assist practitioners in sports medicine clearance for participation and return-to-play decisions. In a medical-legal arena these statements can be used to support the care that is provided to athletes and thus serve as a "shield" to medical-legal claims and suits. However, these standards can also be used to attack the service that is provided and then be used as a "sword." Legal issues surrounding standards statements regarding these injuries and the diagnosis and management of them should be recognized and appreciated by sports medicine providers and used to balance the applicable medical and legal risks associated with their practices.
A brain injured male hoarded large quantities of unuseable items at every opportunity. The treatment consisted of two phases. First, he was taught to collect baseball cards. Second, after each meal, the client was provided with an apron and a glove and asked to pick up trash in the area and deposit the trash in an appropriate receptacle. If he hoarded, he was told not to pick up trash without his apron and glove and escorted to a quiet area for about 10 seconds. The procedure was successful in suppressing the behavior within 8 days.
In 3 decades 1550 patients showed 6/sec spike and wave complexes; 839 were chosen for computer-analyzed electroclinical correlations. Control groups (each 500) included patients (1) randomly selected from EEG files, (2) with normal EEGs, (3) with only slow wave abnormalities, and (4) with only spike abnormalities. In the experimental group more females and Caucasians were found with peak age distribution at 11--15 years. The major symptoms were seizures (53%), neurovegetative (51%) and psychological complaints (24%), all significantly different from control groups, except for seizures in control group 4. Seizures were mainly generalized motor attacks, neurovegetative symptoms included headaches, dizziness and blackouts and psychological symptoms were mainly behavior disorders. As a presumed etiology head injury was noted in over 25% with this complex, which was maximal either on the anterior or occipital areas. Further computer analysis shows that two extreme forms can be identified: (1) the WHAM form, seen mainly in waking records, high amplitude, anterior location, more males, and (2) the FOLD form, seen mainly in females, occipital location, low amplitude, in drowsy states. The WHAM form appears primarily in patients with seizures, and the FOLD form in patients with neurovegetative and psychological complaints.
A special type of delta waves with a duration of 1-3 sec which, because of their saw-tooth or zed shape in the EEG, we have named 'zeta waves' has been described. They occur particularly in cases with rather severe brain lesions, usually with an acute or subacute onset and a space occupying character. In a period of 2 years during which 2500 EEGs have been reported we have seen zeta waves in 20 patients in whom 76 EEGs have been recorded. The characteristics of these waves and the types of lesions with which they occurred are described. The importance of an adequate recording technique for proper presentation of this EEG pattern is emphasized.
Haemodynamic studies were made in 34 patients with severe head injury. The changes of cardiac output were noteworthy and correlated well with the clinical course and the prognosis of the patients. Marked systemic hypotension at the moment of brain death was mainly caused by the decrease of cardiac output. At this moment, peripheral resistance fell only to normal limits from the raised level. In the patients who survived, the cardiac output increased in proportion to the respiratory insufficiency, that is, the increased A-aDO2 and Qs/Qt. The increase of oxygen consumption was also accompanied by an increased cardiac output, but in the patients with the severest head injury who died, the cardiac output remained low. It failed to respond to increased A-aDO2 and Qs/Qt, and oxygen consumption remained low.
Two hundred-eighteen acutely brain-injured trauma patients with confirmed diagnosis of initial closed head injury completed two types of word fluency generation tasks, animal naming and single-letter-based word generation. Numbers of responses and inferred strategy utilizations were examined and compared with established norms for non-brain-injured individuals using frequency counts and chi 2 analyses. Significant differences were noted in response quantity and quality between closed head-injury patients and normals. A positive relationship was noted between level of cognitive functioning and number of word associates generated. Same initial consonant-vowel syllable (see-seed), semantic association (ship-sail), and same initial consonant-consonant blend (tree-trick) strategies were used by all subjects regardless of severity of injury. Quantitative and qualitative differences were noted as a function of severity of cognitive disruption.
Current models of post-concussional symptoms after mild head injury rest on the dichotomy between organic and psychogenic factors, which underpins Lishman's formulation; organic genesis and psychologically-driven persistence (Br J Psychiatry 1988; 153: 460-469). Recent prospective neuropsychological and bio-social studies of mild head injury, and perspectives from cognitive behavioural and health psychology, are reviewed. It is argued that the organic-psychogenic conceptualization inadequately explains chronic post-concussional symptoms. Psychosocial and cognitive-behavioural factors and the coping process may influence post-concussional symptoms over their entire time course, in particular the late phase. A multifactorial model of chronic post-concussional symptoms is proposed which integrates biological processes with these factors. It is through the recognition and identification of separate processes that questions about outcome, the limits of the impact of organic and psychosocial factors, the nature of exaggeration, and appropriate therapy, may be resolved.
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Previous research has demonstrated that patients with memory disorders resulting from closed-head injury can acquire the complex knowledge and skills necessary for the use of a microcomputer. The present paper extends the generality of those findings by showing that (1) amnesic patients with other etiologies could similarly learn how to operate a computer and (2) the knowledge and skills acquired were retained over intervals of up to 9 months.
Studies of agnosia have revealed two apparently orthogonal dimensions along which knowledge may break down. In some cases, knowledge of specific categories (such as living things) seems lost, regardless of the modality being tested. In other cases, knowledge in specific modalities (such as vision) seems lost, regardless of the category of stimuli being tested. These different sets of phenomena suggest different organizations for knowledge in the brain, the first by category and the second by modality. Unfortunately, possible confoundings between category, modality, and difficulty level in the previous studies prevent us from drawing strong conclusions from these data. The present study was aimed at assessing the nature of the breakdown in the semantic memory of a prosopagnosic patient, by orthogonally varying category and modality, while assessing difficulty level. The findings do not implicate a simple categorical or modality-dependent organization of his knowledge, but rather an organization in which both category and modality play a role.
We describe a patient with a selective impairment in naming and pointing to emotional facial expressions following damage to the right temporal lobe. His language functions were otherwise intact, and he performed well on a variety of perceptual and associative emotional facial tasks. We propose that his inability to match facial expressions with their names was induced by a disconnection between visual semantic and verbal semantic representations for facial emotions.
The aim of this study was to demonstrate that focal frontal lobe lesions and closed head injuries cause a deficit in the deliberate minimizing of dual task decrements that follow when two separate tasks should be done concurrently. In single tasks, subjects counted backwards and cancelled visual targets as quickly and accurately as possible on separate 1 min trials. In the dual task, they were required to do both tasks simultaneously, taking care that performance on neither task would be notably more impaired than on the other, as only the performance showing a larger percentage decrement from the corresponding single task performance was taken into account as the result of the test. Patients with acute closed head injury displayed more pronounced dual task decrement than the controls. This deficit was not secondary to inefficiency on the single tasks but was related to the depth of coma at admission, the acuteness of injury and age. Contrary to expectation, patients with focal frontal lobe lesions or patients with subacute closed head injury did not demonstrate abnormal dual task decrement.
Several years after sustaining head injuries, two patients developed oligodendrogliomas in the scar of brain contusions. Both cases seem to fulfill the criteria currently established for accepting the traumatic origin of a brain tumor. The literature concerning the relationship between head injury and intracranial tumor is reviewed.
Pragmatic communication or discourse was studied in 33 children and adolescents following closed head injury. Three-quarters of the sample was impaired on at least one of four discourse tests (knowing the alternate meanings of ambiguous words in context; getting the point of figurative or metaphoric expressions; bridging the inferential gaps between events in stereotyped social situations; and producing speech acts that express the apparent intentions of others). Resolution of ambiguity was correlated with word fluency and verbal domain knowledge, but not with object naming; understanding of metaphor was correlated with verbal domain knowledge, but not with literal sentence comprehension or with the formation of analogies; making inferences was correlated with working memory capacity but not with social knowledge; and producing speech acts was not correlated either with sentence construction or with social knowledge. These associations and dissociations reveal some of the correlates of impaired discourse processing after closed head injury in childhood and adolescence, as well as bearing on theoretical questions concerning the nature of normally developing discourse processes.