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PubMed2004

Medical risks in epilepsy: a review with focus on physical injuries, mortality, traffic accidents and their prevention.

The present review aims at highlighting selective aspects of the medical risks in epilepsy and their prevention. Emphasis is put on accidents and physical injuries, including risk factors and effectiveness of prevention; mortality, its causes, risk factors and prevention of seizure-related deaths, as well as traffic accidents, their risk factors and the effectiveness of prevention. Accidents and injuries are slightly more frequent among people with epilepsy than in the general population. This increased risk is probably most prevalent in patients with symptomatic epilepsy and frequent seizures, most often in combination with associated handicaps. The majority of accidents are trivial and occur at home. The most frequent injuries among patients with epilepsy are contusions, wounds, fractures, abrasions and brain concussions. The standardised mortality ratio (SMR; the ratio of observed number of deaths in a population with epilepsy to that expected, based on age and sex-specific mortality rates in a reference population) in population-based studies of epilepsy is 2-3 compared to the general population. This increased mortality is largely related to the etiology of the epilepsy and is probably not influenced by the treatment of the epilepsy. On the other hand, most fatalities in patients with chronic, therapy resistant epilepsy seem to be seizure-related and often sudden unexpected deaths (SUDEP). The frequency of such seizure-related deaths is most likely to be reduced by intensified treatment aiming at early seizure control, although appropriate studies for definitive evidence are still lacking. Apparently, there is an increased rate of traffic accidents in drivers with epilepsy, even if population-based prospective data are lacking. Many of these accidents are seizure-related. Probably, the extent to which physicians report their patients with uncontrolled epilepsy to the authorities is too low, but this has not yet been explored. Moreover, the preventive measures in legislation may be ignored by many people with epilepsy.

Accidents, Traffic↗
PubMed2006

In vivo imaging of rapid deformation and strain in an animal model of traumatic brain injury.

In traumatic brain injury (TBI) rapid deformation of brain tissue leads to axonal injury and cell death. In vivo quantification of such fast deformations is extremely difficult, but important for understanding the mechanisms of degeneration post-trauma and for development of numerical models of injury biomechanics. In this paper, strain fields in the brain of the perinatal rat were estimated from data obtained in vivo during rapid indentation. Tagged magnetic resonance (MR) images were obtained with high spatial (0.2 mm) and temporal (3.9 ms) resolution by gated image acquisition during and after impact. Impacts were repeated either 64 or 128 times to obtain images of horizontal and vertical tag lines in coronal and sagittal planes. Strain fields were estimated by harmonic phase (HARP) analysis of the tagged images. The original MR data was filtered and Fourier-transformed to obtain HARP images, following a method originally developed by Osman et al. (IEEE Trans. Med. Imaging 19(3) (2000) 186). The displacements of material points were estimated from intersections of HARP contours and used to generate estimates of the deformation gradient and Lagrangian strain tensors. Maximum principal Lagrangian strains of >0.20 at strain rates >40/s were observed during indentations of 2 mm depth and 21 ms duration.

Animals↗
PubMed2006

Knowledge and expectation of postconcussion symptoms in the general population.

OBJECTIVE: Beliefs about mild traumatic brain injury (MTBI) may affect complaints and their persistence. This study investigates the relationships between knowledge, experience, and expectation in the general population. METHODS: One hundred seventy-one people reported symptoms expected from vignettes about MTBI, depression, posttraumatic stress disorder (PTSD), and orthopedic injury. Then they completed a postconcussional syndrome (PCS) checklist about these vignettes and about personal symptoms. RESULTS: The ability to generate symptoms from vignettes was poor for PCS, depression, and PTSD, and was greatly improved using a PCS checklist, probably by symptom guessing. No postconcussion symptoms were associated specifically with MTBI. Those with more personal symptoms expected more symptoms. Past experience of MTBI did not improve symptom knowledge. Beliefs about the 'undesirability' of conditions were associated with expected outcomes. CONCLUSIONS: People know little about PCS. Expectations about MTBI are influenced by psychological factors that are relevant if we consider information given in hospitals. Symptom overlap means that psychological conditions such as depression may be misdiagnosed as PCS, and checklists should not be used for diagnosis.

Accidents, Traffic↗
PubMed1997

Serious brain injury from traffic-related causes: priorities for primary prevention.

This study evaluated the incidence and outcome of serious brain injury from traffic-related causes in 695 patients admitted to the Department of Neurosurgery at Karolinska Hospital during 1981-1992. A total of 37.3% of patients were car occupants, 28.1% pedestrians, 12.9% bicyclists, 12.2% car-bicycle/car-moped and 9.5% motorcycle riders. The dominating injury was brain contusion (61.6%) verified with computerized tomography. The level of consciousness was evaluated by the Glasgow Coma Scale (GCS) and outcome by the Glasgow Outcome Scale (GOS) at discharge and 6-36 months thereafter. The final outcome was 67.5% good recovery (GOS 4-5), 11.5% severely disabled (GOS 2-3) and 21.0% GOS 1 or brain dead. Patients with GOS < 4 (32.5%) were severely disabled and motivate priorities for injury prevention. Car occupants represent 40.7% of the total, followed by pedestrians at 33.6% and bicyclists at 18.2%. Much remains to be done in the primary prevention of disabling brain injury to car occupants and pedestrians. In order to achieve a more-effective primary prevention, future research should be directed toward biomechanical aspects of brain contusion as a dominating brain injury.

Accidents, Traffic↗
PubMed1998

Recovery of arm function in patients with paresis after traumatic brain injury.

OBJECTIVE: To characterize the frequency of recovery of arm paresis in patients with traumatic brain injury (TBI) admitted to rehabilitation. DESIGN: Retrospective review identifying a cohort of patients with moderate or severe arm paresis after TBI followed at least 6 months postinjury. SETTING: Freestanding acute rehabilitation hospital TBI unit. PATIENTS AND METHODS: Forty-four patients with moderate to severe arm paresis were selected from 264 consecutive admissions and characterized by injury pathology subtype, injury severity (duration of unconsciousness [loss of consciousness, LOC] and posttraumatic amnesia [PTA]), age, and level of paresis according to Brunnstrom Stages of Recovery (BS 1 to 6). Patient groups with and without arm paresis were compared according to these variables (t tests and chi(2)). MAIN OUTCOME MEASURES: Recovery of arm paresis to isolated motor function (BS 5 or 6) and time to achieve recovery. Recovered and nonrecovered patients were compared (Mann-Whitney, t tests, and chi(2)) on injury severity, initial level of paresis, age, time to rehabilitation admission, and pathology subtype. Time to recovery was compared for patients at different levels of initial paresis, ranges of LOC, and pathology subtypes (Mann-Whitney and Kruskal-Wallis tests). RESULTS: Forty-four patients (17%) had moderate (BS 3 to 4) or severe (BS 1 to 2) paresis at rehabilitation admission. They were more severely injured than nonparetic patients based on longer LOC (p < .002) and PTA (p < .009). Thirty-six patients (82%) recovered by 6 months; 72% of these recovered by 2 months. If still paretic at 2 months, only 56% recovered. Mean recovery time was 6.9 weeks (SD, 6.1) from injury. Time to recovery was best predicted by initial level of paresis and injury severity (r2 = .48), but not age. Patients with diffuse injury tended towards a more protracted recovery (7.9 weeks, SD 6.5) than patients with focal injury (4.2 weeks, SD 3.9) (p = .08) and only those with diffuse injury showed further recovery after 3 months. CONCLUSIONS: Arm paresis after TBI is relatively infrequent. Most patients recover by 2 months but later recovery is possible, especially in patients with primarily diffuse brain damage. Recovery is highly related to initial impairment, injury severity, and distribution of brain injury.

Adolescent↗
PubMed1999

Is postural control associated with mental functioning in the persistent postconcussion syndrome?

OBJECTIVE: To investigate whether balance is associated with mental functioning after mild traumatic brain injury (MTBI). DESIGN: Experimental two-group design. SETTING: Outpatient rehabilitation department. PATIENTS AND OTHER PARTICIPANTS: From a consecutive sample of referred MTBI patients, 15 subjects who complained of imbalance were included (8 men and 7 women, age 35.9+/-8.6yrs). Subjects with detectable neurologic impairments were excluded. Twenty healthy control subjects of the same age group also were tested. MAIN OUTCOME MEASURES: In both groups, a force platform recorded center-of-pressure (CP) fluctuations during standing and weight shifting in different conditions. For the patients, attention and mental speed were assessed with the Symbol-Digit Substitution Test of the Wechsler Adult Intelligence Scale (Dutch version), verbal learning and memory were assessed with the 15-Words Test, and emotional distress was assessed with the Symptom Checklist-90. RESULTS: Compared with controls, patients showed an overall increase of 60% in CP velocity and an overall weight-shifting speed 25% slower (p < .005), indicating static and dynamic postural instability. Only performance on the Symbol-Digit Substitution Test was associated with both static and dynamic balance (p < .02), giving an explained variance of over 40%. CONCLUSION: The results indicate a possible association of balance with cognitive performance but not with emotional well-being after MTBI, suggesting an organic rather than a functional cause of postural instability. Further research is needed to assess the possible clinical implications.

Adult↗
PubMed1997

Evaluation of learning and memory dysfunction and histological findings in rats with chronic stage contusion and diffuse axonal injury.

We previously reported a modified fluid percussion device capable of consistently producing experimental cortical contusion (CC) and diffuse axonal injury (DAI) in separate groups of rats by lateral and midline fluid percussion, respectively. The purpose of the present study was to compare the differences in learning acquisition and memory retention impairments between these two types of injured rats in the chronic stage using the Morris water maze technique. We also compared the histological differences between these two different types of traumatic brain injury. The results showed a statistically significant difference in learning acquisition impairment between the sham and CC rats and also between the sham and DAI rats. However, a significant difference in memory retention impairment was observed only between the sham and DAI rats. Histologically, the neuronal cell loss of CA3 pyramidal cells in the hippocampus was observed on the ipsilateral side in the CC and bilaterally in DAI. The neuronal cell loss was seen in bilateral entorhinal cortex layer II in DAI, but it was not seen in CC. From these results, we speculate that the marked cell loss in the hippocampus CA3 region in both CC and DAI rats was related to the impairment of spatial learning acquisition. The marked cell loss in entorhinal cortex layer II in DAI rats may be one of the important factors in the impairment of spatial memory retention.

Animals↗
PubMed1997

d-Amphetamine attenuates decreased cerebral glucose utilization after unilateral sensorimotor cortex contusion in rats.

Unilateral contusion injury to the sensorimotor cortex causes, among other symptoms, a transient contralateral hindlimb hemiparesis in rats. A single i.p. 2 mg/kg dose of d-amphetamine (d-AMPH) 24 h after injury accelerates spontaneous recovery from this particular deficit. The mechanism(s) of spontaneous and d-AMPH enhanced recovery are unknown but alleviation of a neuronal depression has been proposed. This quantitative CMRglu study was designed to determine effects of cortical contusion injury and d-AMPH on CMRglu in cortical and subcortical structures. At 2 days after injury, CMRglu was significantly reduced compared to sham-operated controls only in structures ipsilateral to contusion. Affected structures included the caudate putamen, medial geniculate nucleus, lateral geniculate nucleus and the parietal cortex immediately posterior to injury. By 6 days post-contusion, the hypometabolism partially reversed in all structures. A single low dose of d-AMPH significantly alleviated the post-traumatic CMRglu reduction at 2 days after injury. Importantly, while this alleviation was not significant for any single structure, the main effect of treatment was highly significant. d-AMPH increased CMRglu at 2 days post-injury by 18-33% compared to contused/saline-treated rats. These results suggest that alleviation of neuronal metabolic depression may contribute to spontaneous and d-AMPH enhanced recovery.

Animals↗
PubMed1998

Norepinephrine and traumatic brain injury: a possible role in post-traumatic edema.

Unilateral cerebral contusion is associated with an early (30 min) increase in norepinephrine (NE) turnover followed by a later (6-24 h) depression of turnover which is bilateral and widespread throughout the brain. Blockade of NE function during the first few hours after traumatic brain injury (TBI) impedes subsequent recovery of function without enlarging the size of the lesion. The current studies were carried out to characterize further the timing of the switch from increased to decreased NE turnover and to investigate the pathogenesis of the delayed recovery of function associated with blocking NE function. Adult male rats had unilateral somatosensory cortex contusions made with a 5 mm diameter impact piston. They were killed after 2 h and their brains analyzed for NE turnover by HPLC with electrochemical detection. In general, NE turnover (the ratio of 3-methoxy-4-hyroxyphenylglycol to NE levels) had returned to sham-lesion control levels in most brain regions by 2 h after either left or right sided contusions. The only exceptions were a persistent 87% increase at the lesion site after right-sided contusions and 22% and 32% increases in the contralateral cerebellum after right- and left-sided contusions, respectively. Blockade of alpha1-adrenoceptors by treatment with prazosin (3 mg/ kg, i.p.) 30 min prior to TBI produced edema in the striatum and hippocampus at 24 h which was not seen saline-treated rats nor in rats where NE reuptake was blocked with desmethylimipramine (DMI; 10 mg/kg, i.p.). DMI increased edema at the lesion site at 24 h, however. These data suggest that the early increase in NE release following unilateral cerebral contusion is protective and that this may act to stabilize the blood-brain barrier in areas adjacent to the injury site. Drugs that interfere with this enhanced noradrenergic function might enhance the damage caused by TBI.

3,4-Dihydroxyphenylacetic Acid↗
PubMed1990

CT scanning and surgical treatment of 1551 head injured patients admitted to a regional neurosurgical unit.

Computed tomographic (CT) scans of 1551 recently head injured patients transferred to a regional neurosurgical unit (NSU) were reviewed. Some 90% of first scans were done outside normal working hours. More than a third of first scans were normal including a fifth of the patients who were in deep coma. Haematoma was found in 50%, contusion 28%, shearing injuries 13% and general swelling in 9%. In 22% the first scan led to urgent surgical evacuation of an intracranial haematoma. More than one scan was done in 41% of patients and more than two in 10%, making 2608 scans in all. Repeat scans were more often done when the first scan was abnormal. In only five of 554 patients (1%) whose first scan had been normal were contusions or haematomas seen on subsequent scans, and in none of these was surgery required. Of 997 patients whose first scan had been abnormal a new lesion (contusion, haematoma and/or infarction) was seen on a subsequent scan in 103 cases (10%). Surgery was required (for the first time), in 57 patients whose abnormal first scans had not indicated the necessity for surgery at that time. The implications of these and other findings for the scanning of recently head injured patients in general hospitals, as scanners become more widely available, are discussed in our accompanying paper on p. 88.

Brain Concussion↗
PubMed1999

Multiple fregoli delusions after traumatic brain injury.

A 61 year old man after a traumatic brain injury resulting in right frontal and left temporoparietal contusions developed florid Fregoli-type misidentifications. Extensive neuropsychological testing demonstrated significant deficits in executive and memory functions. The patient's neuropsychological profile closely resembled that seen in previously reported patients with Capgras syndrome. Our findings are consistent with the hypothesis that a combination of executive and memory deficits may account for cases of delusional misidentification associated with brain lesions. However, the form which the delusion takes may be influenced by other factors including motivation.

Brain Concussion↗
PubMed1995

Persistent retrograde, amnesia following a minor trauma.

A 19-year-old man showed dense retrograde amnesia (RA) for autobiographical and public events covering his entire life, following a motor car accident that caused no apparent brain damage. His learning abilities remained excellent and permitted him to recover knowledge of the past, based on information gathered from other people and the media, although he never reacquired the sense of personal experience. At the onset he also showed occasional gaps in his semantic memory, e.g., he failed to recognize a few objects and was unable to provide factual information about sports he had long been playing. Eventually, his amnesia was predominantly restricted to autobiographical events or facts. After 29 months the deficit has remained unchanged. CT, MRI and PET were negative. Psychogenic amnesia was considered, but eventually ruled out for want of any evidence pointing to emotional problems, stressful situations or secondary gains. We posit that for reasons unknown a mild trauma can cause functional inhibition of the access to the engrams that are already stored, leaving intact the ability to encode and retrieve new memories.

Adult↗
PubMed1995

Vestibular stimulation, spatial hemineglect and dysphasia, selective effects.

The selectivity of the effects of vestibular stimulation was investigated in a left brain-damaged patient suffering from right visuo-spatial hemineglect and severe dysplasia. Vestibular stimulation temporarily improved the former but not the latter disorder. These results support the view that this treatment improves hemineglect by a specific effect, running counter the rightward distortion of egocentric co-ordinates, rather than by a general hemispheric activation.

Aged↗
PubMed1993

Perceptual and associative knowledge in category specific impairment of semantic memory: a study of two cases.

We report two head-injured patients whose knowledge of living things was selectively disrupted. Their semantic knowledge was tested with naming and verbal comprehension tasks and a verbal questionnaire. In all of them there was consistent evidence that knowledge of living things was impaired and that of non-living things was relatively preserved. The living things deficit emerged irrespective of whether the question tapped associative or perceptual knowledge or required visual or non visual information. In all tasks the category effect was still significant after the influence on the performance of the following variables was partialled out: word frequency, concept familiarity, prototypicality, name agreement, image agreement and visual complexity. In the verbal questionnaire dissociations were still significant even after adjustment for the difficulty of questions for normals, that had proven greater for living things. Besides diffuse brain damage, both patients presented with a left posterior temporo-parietal lesion.

Adult↗
PubMed1979

Lateralized psychological impairment associated with CT lesions in head injured patients.

Twenty-six adult patients with CT scans were given the Wechsler Adult Intelligence Scale (WAIS) during recovery from an acute head injury. Focal lesions were observed on the initial CT scans of 24 patients. These included 13 in the right hemisphere, 8 in the left hemisphere and 3 in both hemispheres. Diffuse cerebral swelling was observed in the remaining 2 patients. Both the standard WAIS examination (11 subtests) and a shorter version described by McFie (7 subtests) were used to assess psychological impairment associated with CT documented lesions. The McFie method involved a special scoring procedure that utilized reference subtests as an index of premorbid functioning. When mean algebraic differences between Verbal and Performance subtests were used, both methods differentiated left and right-sided lesions to a highly significant degree (p less than .001). Lateralized lesions yielded significant differences on 3 individual subtests (1 Verbal and 2 Performance) with the McFie method and on 6 individual subtests (all Verbal) with the standard WAIS procedure. Wechsler's Deterioration Quotient did not discriminate between groups. It was concluded that the traditional distinction between Verbal and Performance subtests on the WAIS was valid for CT documented lesions, and the shorter McFie version was as effective as the standard WAIS in lateralizing psychological dysfunction. Acknowledgements. This research was supported by Contract NS 5-2316 and Grant NS 08803 from the National Institutes of Health. We are grateful to Drs. Thomas A. Gennarelli and Howard I. Hurtig for patient referrals and neurological evaluations.

Adult↗