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Latest Medical Research about Brain Injury


SLEEP APNEA AND HEAD INJURY A NEW RISK

It is well known that a large percentage of those with mild or moderate brain injury can suffer from sleep apnea. I has also been observed that people with obstructive sleep apnea have a marked increase in the risk of severe motor crashes. A group of sleep apnea sufferers suffered 250 crashes over 3 years compared to 123 crashes in the group without sleep apnea.

TREATING SLEEP DISORDERS IN TBI DOES NOT ELIMINATE SYMPTOMS

Sleep disorders are common with TBI, but a recent study showed that after three months treatment with continuous positive air pressure (CPAP) reduced the severity of obstructive sleep apnea significantly. The participants suffering from TBI experienced no significant changes in the quality of life or cognitive performance after the treatment. Researchers believe that the other problems associated with traumatic brain injury may be continuing to effect the individuals even when they are largely eliminated. This is bad news for sufferers associated with TBI.

PINPOINTING THE SOURCE OF EPILEPSY

Scientist are using a new kind of scan called magnetoencephalopathy (MEG) in association with MRI to generate a detailed map that allows them to locate precise areas of the brain dysfunction and have them removed to stop epilepsy. Chronic epilepsy can be fatal and the ability of MEG to pinpoint the source of the seizure more accurately than the traditional method of EEG is a breakthrough that should help many patients with chronic epilepsy. The costs benefit analysis of doing brain surgery for epilepsy is now greater on the benefit side.

BIOMARKER IN BRAIN FOUND FOR IDENTIFYING POST TRAUMATIC STRESS DISORDER

Seventy-four U.S. vets who were diagnosed with PTSD were scanned by a magnetoencephalopathy (MEG), a new non-evasive type of brain scan with more than 90% accuracy. Researchers were able to differentiate PTSD from health control. In addition, the MEG can show how badly the patients are impacted by the PTSD, possibly opening up the door to showing how badly patients are impacted by other brain disorders.

EEG SCREENING FOR ONSET OF ALZHEIMER

Using a non-evasive and relatively inexpensive EEG analysis and software, scientist have shown that an accurate diagnosis of early Alzheimer's can be made. A seven year NYU study revealed the program is 95% accurate in predicting cognitive decline. A brain wave called Theta was much more prominent in people likely to decline and was especially abnormal in the frontal regions of the brain. Especially the hippocampus.

NEW TREATMENT FOR ACUTE BRAIN INJURY

Researchers at Clemson University in South Carolina have developed a gel, made partially of stem cells, that they are injecting into the brains of injured patients. People with combat wounds, car accident or gun shot wounds have been injected with the gel which has been shown to promote healing and limit the amount of secondary injury from the trauma. This is an exciting new method of reducing injury and improving outcome that has never been available before. The gel is expected to be ready for testing in humans in about three years.

TEN YEAR RECOVERY FROM TBI: CHILDREN AND YOUNG ADULTS

A Swedish study (Horneman, G. 2009) followed 165 survivors of TBI and tested them 10 years after injury. The results showed poor performance in intellectual function, low results in verbal tests and tests of verbal learning and memory, visual ability and executive functioning. When compared to healthy controls, these deficits persisted. It again noted that it is difficult to predict the outcome in children and young adults until years after the injury.

NEW MARKER FOR TBI

Yet another biological marker for the presence of traumatic brain injury has been found. In a Chinese study (Huang, M. et al. 2009) the changes in plasma micro particle procoagulant activity in patients was correlated with brain injury and is thought to contribute to the inflammatory reaction after trauma. The higher presence of this product is associated with poorer clinical outcome.

CONTINUED DEBATE OVER THERAPEUTIC HYPOTHERMIA

For the past ten years the topic of whether or not lowering the body temperature of a recent victim of brain trauma, is or is not clinically helpful. This latest study (deDeyne, C.S. 2010) suggests that the clinical advantages of this procedure are not necessarily out weighted by the negative effects of cooling and re-warming a patient whose has been severely injured. The battle goes on and it is unclear where this one will end. Families of the patients who were offered this procedure need to make their own informed decision.

CAREFUL ABOUT SLEEP MEDICATIONS

The Journal of Head Trauma Rehabilitation reported in 2010 (Larson, E.B.) that a negative effect on cognition was reported for TBI patients who were treated for insomnia with Benzodiazepins after injury. Furthermore, GABA antagonist agonists were found to possibly interfere with neuro-rehabilitation after injury. These types of medications should be avoided in the recovery phase of TBI. Pharmaceutical help in aiding sleep should be tailored to avoid these families of medications.

THE PSYCHIATRIC INJURIES OF TBI

Although it is generally held that psychiatric conditions can be created or aggravated after TBI, there is a lot of research going on at the present time to quantify this. In the American Journal of Psychiatry, (Bryant R. A. et al. 2010) a study involving patients who had suffered mild traumatic brain injury (MmTBI) studied to see if new psychiatric disorders occurred after injury. Measurements three and twelve months post injury showed that 22% of the patients developed a psychiatric disorder they had not experience before injury, the most common being depression 9%, generalized anxiety disorder 9%, post traumatic stress disorder 6% and agoraphobia 6%. Other studies have shown higher rates.

GENETIC ASSOCIATION WITH TBI OUTCOME

It remains a mystery why certain individuals who suffer a mild or moderate TBI can have an excellent outcome, while others can suffer devastating effects. Comparing MRI or CT scans between the patients offers little to support the differences. Studies are now (Dardiotis, E. et al 2010) starting to accumulate evidence which implicates various genetic elements in the injury and recovery process of brain trauma. They note that "the extent of brain injury after TBI seems to be modulated to some degree by genetic variance." Further research on this important issue will be forthcoming. Patients should take comfort in these studies in cases where hope for recovery does not occur, as it is in some instances beyond the patients control.

DATA ON DECOMPRESSIVE CRANIOTOMY

The benefits of decompressive crainotomy (DC) in the treatment of traumatic brain injury patients with increased intracranial pressure (ICP) is controversial. A recent study Williams R. F. et al. 2009, showed that DC resulted in good functional outcome in over 50% of patients with severe TBI. The maximum benefit was observed in younger patients with demonstrable reduction in ICP after decompression. These are factors to consider when the choice of DC arises after injury.

PROBABILITY OF LATE ONSET SEIZURES

Late onset seizures following moderate to severe brain injury are of great concern. They can emerge a year or two or more after the initial injury. A study (Englander, J. et al. 2003) showed that the highest probability for post traumatic seizures included biparietal contusions (66%), dural penetration with bone and metal fragments (62.5%), multiple intracranial operations (36%), multiple subcortical contusions (33%), subdural hematoma with evacuation (27%), midline shift greater than 5mm (25%). The initial Glasgow Coma Scale was associated with the following probabilities for developing late post traumatic seizures at 24-months: a score of 3 to 8, 17%, a score of 9 to 12, 24%, a score of 13 to 15, 8%.

NEW IMAGING HELPFUL IN CHILD BRAIN INJURY CASES

Two new types of MRI of the brain - Diffusion Weighted Imaging (DWI) and Consequent Apparent Diffusion Coefficient (ADC) have been used as predictors of outcome in adults, and a recent study (Galloway, NR 2008), shows that these tools have excellent predictive capability in regards to children with traumatic brain injury. That found that ADC values in the peripheral white matter were significantly reduced in children with severe TBI with poor outcomes compared to those with severe TBI and good outcomes. They also found that the total brain ADC value alone had the greatest ability to predict outcome and correctly predicted outcome in 84% of cases. Thus, early identification of children in high risk for poor outcomes can be obtained using these tools and an assist in aggressive clinical management of these patients.

FACE RECOGNITION IMPAIRMENT WITH TBI

A review of the literature done in the journal Brain Injury (Radice-Meumann, D. et al 2007) shows that the TBI population often suffers from an impairment of their ability to determine the emotion of others from facial expressions. While this sounds odd, the results of this deficit result in poor interpersonal skills, which can affect social relationships, marriage, and rehabilitation. They suggest treatment approaches similar to those previously designed for autism to be considered with PT.

NO MALINGERING DETECTION IN WISCONSIN CARD SORT TEST

A large test of patients with mild traumatic brain injury and uninjured controls(Grebe, KW, 2009) showed that the widely used neuropsychological battery instrument tests, the "Wisconsin Card Sorting Test" failed to detect patients with a plan to perform below their ability or falsely on the tests. The scores were ineffective in discriminating malingering from non-malingering mild TBI patients.

STUDIES ON POST CONCUSSIVE SYMPTOMS
Study in Norway (Siqurdardottir, S. 2009) studied post concussive symptoms from 3 to 12 months post injury in adults with TBI. Of the whole sample, 28% of cases developed those concussive syndromes at 3 months and 24% at 12 months post injury. The mild and moderate group showed a decline of symptoms over time in contrast to the severe TBI group. Greater levels of anxiety at 3 months, as well as shortness of post traumatic amnesia duration were found to be important predictors of the severity of these symptoms at 12 months. Interestingly, one year after injury, no differences were found between the TBI groups mild, moderate and severe on the presence of post concussive symdrome (PCS).

The second Norwegian study (Roe, C. et al. 2009) found that post concussive syndrome cognitive difficulties persisted for 12 months in a large percentage of the patients and that the cognitive symptoms persisted and were considered a ?considerable? problem even one-year after injury.

COOLING PROTECTS BRAIN IN INJURED CHILDREN

This is a well known phenomenon, a Chinese study from 2009 showed that moderate hypothermia (lowering the core temperature of the patient 10-degrees or so) showed improvements in intracranial temperature, intracranial pressure and other markers after severe brain injury. The temperature lowering was done for 72 hours after admission to the hospital and was considered safe in that clinical setting and successful.

Another study from 2009 shows that hypothermia when used with children suffering from brain injury reduces the damage caused to the brain post accident by "oxidative stress" which is a secondary form of injury that goes on in the brain following traumatic injury and which could have severe effects. The lowering of the temperature lowered the rate at which oxidated stress occurred and thus resulted in a better outcome for those treated with hypothermia.

BLAST VICTIMS AND VISUAL IMPAIRMENT

The study following Iraq veterans suffering from TBI from blast injuries showed ongoing visual problems in a significant number (over 80%) following injury. The visual dysfunctions included problems with convergence, accommodative and ocular motor dysfunction, visual field defects and night vision. The study is important in that it validates, in a group in which no one can attack, the presence of these troubling visual problems often found in non-military brain injury settings. Insurance companies commonly scoff at these types of complaints, which are very real and objective.

THE BENEFITS OF ALPHA LIPOIC ACID IN TBI

A Turkish study from 2009 showed that the ingestion of alpha-lipoic acid (LA) produced inflamation and other symptoms after brain injury. It also reversed swelling due to increased water content. It is thought to exert its influence by helping preserve the brain blood barrier permeability and by its antioxidant properties.

BLOOD TEST PREDICTS BRAIN INJURY OUTCOME

A team at University of Pittsburgh has found that measuring the initial blood magnesium level of patients with brain injury indicted outcome from the injury. They found that patients who had a low magnesium level upon arrival at the hospital had significantly worse outcome than those with a normal magnesium level. It is hoped that more hospitals will begin to take this important measurement in the future.

POSITIVE EFFECTS OF HEMOGLOBIN SOLUTION

It has been noted that resuscitation with a special hemoglobin oxygen-carrying solution may reduce the effects of secondary brain injury in patients who have had traumatic brain injury and bleeds. The solution called HBOC-201, is a salt solution that increases oxygen delivery to tissues. The studies are human should be taken soon.

THE DRUG USEFUL FOR AGGRESSION

A pallet study for the use of Quetiapine for treatment of aggression secondary to traumatic brain injury showed that it was effective in reducing irritability and aggression in such patients. Patients also reported an associated improvement in cognitive functioning.

ACCELERATED DAMAGE IN ELDERLY

The destructive cellular action known as Excitotoxicity occurs after TBI and results in brain cell death. A recent study in rats showed that older animals showed earlier onset of damage in wider areas then younger rats. This study shows, along with many others, that the effects of TBI on the elderly are often more significant than an equivalent injury in a middle aged person.

MOOD DISORDERS AND THE HIPPOCAMPUS

It was found that patients who developed mood disorder following traumatic brain injury has significantly lower hippocampal volume than patients without mood disturbance. Reduced hippocampus volumes were associated with poor vocational outcome in one year follow-up. The findings are consistent with the "double-hit" mechanism by which neural and glial elements affected by trauma are further damaged by the neuro-toxic effects of increased cortisol found in association with mood disorders. The need for volumetric studies of the hippocampus following moderate to severe brain injuries becoming more and more important.

SELECTIVE BRAIN COOLING PROTECTS AGAINST TBI

Therapeutic hypothermia is a promising treatment for patients with severe TBI. Using a head cap and neck band filled with cooling material, patients who underwent such cooling after admission, had a far higher rate of good neurological outcome than those who did not. The non-evasive procedure is a safe method of improving the prognosis in severe TBI patients and hopefully this treatment will begin to be offered in the United States soon.

MILD TBI CELL DEATH

The presence of apoptotic cell death after mild traumatic brain injury in rats has been established. Selective neuronal cell loss was evident in several regions of the brain and the data suggest a biological basis for the permanent symptoms found in some mild TBI patients. (Raghupathi, R et al. 2002).

LONG TERM OUTCOME FOLLOWING MILD TBI

Following patients who reported mild TBI for an average of eight (8) years post injury, revealed that "MTBI can have adverse long term neuropsychological outcomes on subtle aspects of complex attention and working memory." (Danderploeg, RD 2005).

MILD TRAUMATIC BRAIN INJURY, LONG TERM SYMPTOMS

A European study from 2006 followed the progression of victims of MTBI and the results of follow-up neuropsychological testing showed "the idea that MTBI can have sustained consequences, and that the subjectively experienced symptoms and difficulties in every day situations are related to objectively measurable parameters in neuro-cognitive function." (Sterr A, et al. 2006).

VISUOSPATIAL ATTENTION DEFICIT AND EXECUTIVE FUNCTIONS PROBLEMS AND MTBI

A group of patients who had suffered mild traumatic brain injury were given a battery of test to determine the nature and rate of their recovery. The researchers noted "these findings indicate that the regions of the brain associated with orientating and executive components of visuospatial attention may be the most susceptible to neuro damage resulting from MTBI. Moreover, the lack of recovery in the executive component indicates that the degree and time course for recovery may be regionally specific." The findings show the deficits in executive functioning existed one month after trauma.

MILD TRAUMATIC BRAIN INJURY EQUALS PERMANENT DEFICITS IN MICE

Researches tested mice following mild traumatic brain injury for up to 90 days post injury. There findings showed "these results demonstrate that persistent deficits in these tests of cognitive learning abilities and emergence of depression-like behavior in injured mice are similar to those reported in human post-concussion syndrome." (Milman A, et al. 2005).

DIFFUSION TENSOR IMAGING (DTI) ADVANCES

The type of MRI now being utilized is know as Diffusion Tensor Imaging, promises to be more sensitive than normal MRI, especially in detection of white matter brain injury. It has the ability to see and is more sensitive to diffuse axonal injury and the effects of stretched neurons. Persons with ongoing TBI symptoms in the face of normal MRI should consider DTI to rule out more subtle damage. (Wilde EA et al. 2006).

INCREASED AGE MEANS POORER OUTCOME

A Japanese study (Tokutomi, T., et al. 2008) has shown again what has been known for years. All other factors being equal, victims of TBI who were elderly have a worse outcome. One hypothesis is that ?cognitive reserve? in older patients is lower and thus their recovery from brain trauma is diminished compared to younger persons who have not suffered brain atrophy through aging.

UNEXPECTED PROTECTION FROM TBI

A study in Hawaii (O'Phelan, K., et al. 2008) found, unexpectedly, that the survival rate of TBI victims who tested positive for alcohol and methamphetamine was higher than those who tested negative for any drugs in their system. It is speculated that these substances, as well as cannabis, may provide some neuro-protective mechanism to the brain after trauma.

CONTINUED DEBATE OVER CEREBRAL PERFUSION

It has long been understood that low cerebral blood flow (also cerebral perfusion pressure - CPP, the rate at which oxygenated blood is flowing through the brain) is associated with poor outcome after TBI.. This has lead to studies trying to present with an agreed target to achieve in patients with brain trauma. An attempt to regulate at 70mmHg showed complications and a goal of 60mmHg is now recommended, although the debate continues.

APOE4 AND OUTCOME OF TBI:

For the past ten years research has shown, then not shown, an association between comparatively worse outcome in patients with TBI who harbor the APOE4 gene. A meta-analysis (Zhou, W., et al. 2008) showed that the APOE4 gene was significantly associated with poor outcome of TBI six-months after injury, but was not associated with the initial severity of brain injury following TBI. There are many difficulties in showing this in the litigation context, since genetic testing for this purpose is not well received by treating physicians and many facilities are unwilling to do this type of genetic testing. However, brain injury litigators need to keep trying to screen for this, especially in cases where the patient has a comparatively bad outcome which is being contested by the insurance company.

BRAIN INJURY AND CHRONIC PAIN

The Journal of the American Medical Association in 2008 explored the association between TBI and chronic pain syndromes. After ruling out other factors, such as PTSD and depression, it was found that "chronic pain is a common complication of TBI. It is independent of psychologic disorders such as PTSD and depression and is common even among patients with apparently minor injuries to the brain." Thus, complaints of pain which complicate recovery from TBI need to be taken seriously and addressed in the proper methods.

EXCITING NEW DRUG

Researchers has shown that a single dose of COG1410, a small molecule derived from the APOE receptor region of the brain, improves outcome following TBI. In these early animal tests, significant improvement was found after administration of this drug, speculating that the drug appears to block the development of significant behavioral deficits and reduces tissue loss associated with TBI.

TBI AND CEREBRAL ATROPHY

It is well known that one of the consequences of a moderate to severe TBI is atrophy or shrinking of the brain due to the injury to millions of cells. High speed velocity change injuries (motor vehicle accident or fall from a height) can give rise to acute Diffuse Axonal Injury (DAI), which is widespread damage to the axons of the brain. This study (Ding, K. et al. 2008) showed the relationship between imaging studies which showed DAI in the acute phase and whether or not at the chronic phase (more than six-months later) there was correlation to brain atrophy. They noted that ?acute axonal lesions measured by flare (MRI) imaging are strongly predictive of post traumatic cerebral atrophy. ? In other words, the more white matter damage found early by MRI flare or DTI, the more likely there would be pathological brain shrinkage with the passage of time.

SUCCESSFUL NEW TBI TREATMENT

Studies are starting to mount which indicate a high beneficial course of treatment for those suffering from TBI. A combination of therapy of simvastatin and bone marrow stromal cells (MSCs) showed improve functional outcome in rats after traumatic brain injury. The improvement was long lasting and showed that the stromal cells had permanently attached themselves in the injured brain of the rats, leading to increased healing. These two treatments used together will hopefully be available to human patients within two or three years and should improve the functional outcome of all patients after TBI.

COMMON PILL AIDS TBI RECOVERY

Progesterone, a component of birth control pills, has been shown to improve the neurological outcome for patients with severe head injuries according to The Journal of Critical Care. A Chinese study treated similarly injured patients for three to six months after severe brain injury and significantly more patients given Progesterone had favorable outcomes. Exactly how the compound works is not yet fully understood, but its wide adoption in emergency rooms across the United States should occur quickly.

NEW IMAGING STUDY SHOWS MILD TRAUMATIC BRAIN INJURY

Diffusion tensor imaging (DTI), which can be done on an MRI scanner with special software, has been shown to show structural changes in the white matter of the brain even in patients with mild traumatic brain injury. Dr. Marilyn Kraus noted "even in patients with mild TBI - those identified as having minimal or no loss of consciousness - there were structural deficits." Thirty-seven TBI patients underwent the imaging study as well as neuropsychological testing to evaluate memory, attention and executive functioning. Researches found that the structural changes in the white matter correlated to the observable cognitive deficits related to thinking, memory and attention.

STEM CELLS REPAIR TBI

Scientist in many parts of the world are looking towards stem cells to help repair brain damage from TBI. The limited capacity of self repair for the brain following TBI requires cellular transplantation of stem cells to replace those lost in trauma. Cellular transplantation has begun to be evaluated in several models with animals with promising results.

Because this treatment has not yet been approved in the United States for humans, several doctors and companies have been set up in other countries, in which the patients with TBI can receive stem cells through intravenous transfusion. (The company Medra working out of the Soviet Union, Germany and the Dominican Republic has significant anecdotal success with patients but they are still fighting a battle to be accepted by the medical community).

There appears to be some basis for this treatment in The Journal of Neurosurgery (Mahmood A. 2004), it was shown that marrow cell transplantation after traumatic injury showed increased cellular growth in rats. In another study in the Henry Ford Health Center in Detroit, intravenous bone marrow stromal self therapy reduced "apoptosis" and promoted cell growth in rat brains. "Apoptosis" is a method by which brain cells die after trauma. These and other studies give great hope that bone marrow or fetal stem cell transfusion holds great promise.

PROOF OF MILD TRAUMATIC BRAIN INJURY IN MICE

Because it is unethical to produce traumatic brain injury in humans, many of the most cutting edge experiments are done on mice. Although this is unfortunate, studies show that mild traumatic brain injury, when induced in mice, shows signs of apoptotic cell death in the brain. "Apoptotic cell death" is a fancy word for programed cell death. All of the cells in our body have the ability to regulate their population, if needed. In addition to this internal balance in the body, it has been discovered that traumatic brain injury can give rise to disregulation of brain chemicals, and can thus lead to apoptotic cell death in brain cells. This study at the University of Pennsylvania found objective signs of apoptotic cell death following mild traumatic brain injury to rats. Findings of this occur as a result of mild traumatic brain injury helps explain why in some cases mild traumatic brain injury has long standing and profound effects.

A second study on mice published in the Journal of Neurotrauma showed mice with induced mild traumatic brain injury suffered long lasting cognitive defects, emotional difficulties and behavioral disturbances. Again, the prejudice against those who complain of ongoing symptoms after mild traumatic brain injury is increasingly misplaced. These studies show not only objective signs of brain injury after a mild trauma but show that long term symptomology is shown in mice similar to those reported in humans with post concussive syndrome.

BRAIN REPAIR AFTER ALCOHOL DAMAGE

MRI scans used to measure the volume of the brains of alcoholics has shown hopeful evidence that brain volume showed an increase of 2% in size, 38 days after stopping the intake of alcohol. The study also showed better performance on tests. Thus, the long known symptom of chronic alcohol abuse, namely a reduction in brain volume (mild to moderate brain atrophy) can be somewhat reduced in a recovering alcoholic.

FOOTBALL STUDY CONSISTENT WITH CAR ACCIDENTS

Researchers outfitted college football players helmets with devices to measure the speed, direction and force at which their heads were struck during a game. Surprisingly, the data failed to predict which hit would or did cause a concussion or brain injury.

This is consistent with the real world, wherein it is difficult to determine who might walk away from a trauma without a brain injury and who might suffer an injury. Factors such as the positioning of the head, the exact line of force, heredity and other unknown variables all must come into play. Some individuals can simply have an increased susceptibility to traumatic brain injury, for reasons we do not fully understand.

DEPRESSION IN NFL PLAYERS TIED TO CONCUSSION

A study by the University of North Carolina, in a health survey of over 2500 retired NFL players, showed that 20% of those who reported sustaining three or more concussions on the football field suffered from depression. That was three times the rate of players who did not sustain concussions. While the findings are consistent with previous research on elevated depression rates on those having suffered a TBI, the NFL and some experts have attacked the study as being inconclusive. Further studies are upcoming.

CENTER FOR DISEASE CONTROL DEFINITION OF MILD TRAUMATIC BRAIN INJURY

The Center for Disease Control (CDC) in 2003 published the following:

Recommended definitions for mild traumatic brain injury.

Incident cases of MTBI

The conceptual definition of MTBI is an injury to the head as a result of blunt trauma or acceleration or deceleration forces that result in one or more of the following conditions:

Any period of observed or self reported:

  • transient confusion, disorientation, or impaired consciousness;
  • dysfunction of memory around the time of injury;
  • loss of consciousness lasting less than 30 minutes.

Observed signs of neurological or neuropsychological dysfunction, such as:

  • seizures acutely following injury to the head;
  • symptoms among older children and adults such as headache, dizziness, irritability, fatigue or poor concentration, when identified soon after injury, can be used to support he diagnosis of mild TBI, but cannot be used to make the diagnosis in the absence of loss of consciousness or altered consciousness. Research may provide additional guidance in this area.

MEMORY/PROBLEM SOLVING CONTINUE TO IMPROVE AFTER TBI

In a study (Hammond FM et al., 2004) patients who had suffered TBI were tested between the years one and five post injury. The greatest amount of improvement noted was observed in memory and problem solving (34%) which was higher than previous studies had indicated.

The greatest amount of decline was observed for social interaction, which was consistent with previous studies.

These results are more hopeful for victims of TBI that the previous idea that little, if any, cognitive recovery occurs after one or two years post injury.

AMBIEN WAKES COMA PATIENTS

Several instances of partial or significant recovery from coma or vegetative state have been published in the last year, which were caused by the administration of Ambien. The commonly prescribed sleeping pill (Zolpiden) was featured in a BBC documentary aired in October 2007, entitled "The Waking Pill."

It is thought that Ambien may activate receptions in the brain which are usually reserved for the neuro-transmitter gamma aminobutyric acid (GABA). Researchers believe that brain injury may alter GABA receptors, causing regions of the brain to remain dormant. They speculate that Ambien could possibly temporarily reverse this change.

Several patients have undergone PET scans to show the increase level of activity in the brain following the administration of Ambien, and such activity was indeed shown.

MILD BRAIN INJURY AND SLEEP PROBLEMS

It has long been established that brain injury can cause profound disruptions in sleep which have a significant negative impact on patients. Half the patients in this study were found to have a delayed sleep phase syndrome.?Problems included falling asleep, waking up and irregular sleep patterns.

This study, along with previous studies, points to sleep difficulties as one of the under appreciated and understudied aspects of traumatic brain injury.

PROGESTERONE: Treatment for Severe TBI.

The female sex hormone progesterone has been successfully used to treat severe traumatic brain injury, as recorded in the Annals of Emergency Medicine. A hundred patients with blunt traumatic brain injury showed a higher survival rate in those patients who were treated with intravenous progesterone within the first thirty (30) days after injury.

EXTRAORDINARY HOPE FOR SEVERE BRAIN INJURY
In a landmark study published in the Journal, Nature, doctors described reviving a patient in a minimally aware coma by implanting tiny electrodes in the brain. Scientist believe that the process, which is now used in Parkinson's patients amplifies the electrical activity of the diminished injured brain resulting in increased awareness and function. The man could only say yes or no, however; after therapy, with the new system, was able to repeat the Pledge of Allegiance and is much more fully aware. This provides possible hope to the 100,000 to 300,000 minimally conscious patients now in the U. S., most of whom are in nursing homes. The doctors caution that those with more severe brain damage may not see such dramatic results. People interested in this procedure should search for facilities that advertise "deep brain stimulation for Parkinson's rehabilitation."

WARNINGS ABOUT OBESITY SURGERY

Doctors warn that Bariatric surgery (shortening of the intestines to prevent obesity) can result in Wernicke's Encephalopathy, which is caused by a thiamine's deficiency or lack of Vitamin B1. Patients were urged that if they showed symptoms of confusion or poor coordination to seek immediate help and get injections of thiamine as early as possible.

COCOA COULD IMPROVE BRAIN FUNCTION

Several recent studies suggest that some types of cocoa contain substances that could enhance blood flow in the brain and improve brain function. Although it is a little distressing that the conference at which this breakthrough was discussed was sponsored by Mars Incorporated, the candy maker, it did point to compounds known as Flavanois as to their ability to keep the brain healthy and prevent cognitive decline and dementia. Scientist in England believe that drinks containing this compound could be used to treat vascular impairments in the brain. After consumption of the liquid, it was noted that there was increased blood flow to the gray matter for two to three hours.

FEMALE HORMONE SAVES TBI LIVES

Promising new treatment for severe brain injury has emerged in a recent Atlanta study. 77 patients were given the female hormone, Progestin (which is a steroid and also protects brain cells but has no effects on males from hormone stand point). The percentage of patients who died which were not given the Progestin was 30% and only 13% of those given a Progestin died from a head injury. Follow-up studies are underway and they hold great promise.

MIGRAINE UPDATE

Studies linking the onset of migraines to certain food such as chocolate, red wine, and aged cheese have not proved to be related. In a recent study, 90 of 100 people were self-diagnosed sinus headaches were found to have migraines. They feel most "sinus" headaches are really migraines. Things that actually caused or aggravated migraines included positive or negative stress, weather changes, estrogen withdrawal, fatigue and sleep disturbances, as well as overuse of over the counter pain medication.

DEPRESSION IS A COMMON LONG-TERM OR EVEN LIFETIME PROBLEM THAT OFTEN FOLLOWS TRAUMATIC BRAIN INJURY

Earlier studies have shown that persons with traumatic brain injury induced depression are more difficult to treat than those with other types of depression. A couple of studies published in the archives of general psychiatry show promise in treating 18 chronically depressed men and women with a drug Ketamine is not yet approved for depression and is commonly used as an animal tranquilizer. It is doubtful Ketamine will be able to be prescribed for depression for at least a year or two but please consult you treating physician.

OUTCOME 3 TO 5 YEARS AFTER MODERATE TO SEVERE TBI

Investigators (Dikmen, SS 2003) followed persons with moderate to severe TBI for three to five years noting the degree of recovery. Unfortunately, significant functional limitations were observed in all areas. In 65% of cases, there was recovery to pre-injury levels in personal care, 40% recovered in regard to cognitive competency, major activity, leisure and recreation. How long the patient was unconscious appeared to contribute to the outcome more than damage seen on MRI.

EFFECTS OF AGING ON TBI RECOVERY

Researches at the Mayo Clinic (Testa JA et al. 2005) confirmed again what was previously known - that age adversely affects recovery from TBI. Findings show that older patients with TBI have a greater likelihood of becoming physically and financially dependent on others. Older TBI patients were more likely to have changes in employment status compared with younger patients. An earlier study had compared TBI patients over 60 ,and limited to patients with only mild TBI, they showed the same improvement and functional status as the patients under 60. Therefore, the age difference appears to be more significant as the injury goes from mild into the moderate and severe categories.

LONG TERM OUTCOME FOLLOWING MILD TBI

Patients, on an average of 8 years post TBI, most in the mild range, were given follow-up neuropsychological testing and compared with normals than those who were in motor vehicle accident without TBI. Those who suffered the mild TBI continued, an average of 8 years later, to have problems with aspects of attention and working memory. The study's conclusion was that it showed "that MTBI can have adverse long-term neuropsychological outcomes on subtle aspects of complex attention and working memory."

FATIGUE AND MILD TRAUMATIC BRAIN INJURY

Although fatigue is one of the most reported symptoms after TBI, there have not been many studies on its effects. A group in the Netherlands (Stuleneijer, M et al. 2006), studies approximately 300 patients with MTBI found that one-third of the patients experienced severe fatigue six months after injury and that the type of fatigue is associated with limitations in daily functioning. Severe fatigue was highly associated with the experience of other symptoms and limitation and did not stand alone.

LONGER AMNESIA PREDICTS MORE BRAIN ATROPHY

Post-traumatic amnesia (PTA) has long been used as a predictor of outcome in those with TBI. A recent study (Wilde, EA, Bigler, ED et al. 2006) showed that a correlation between the duration of PTA in the existence of atrophy of brain tissue following an accident exists. The longer the period of PTA the higher the rate of brain tissue atrophy following an injury.

RELIEF FROM CHRONIC PAIN?

Persons suffering from intractable chronic pain have found relief in monitoring their own brain waves on a functional MRI scanner. After some training, the volunteers were able to make changes in the way their brains processed the pain signals and reported feeling less pain. The Stanford University study physicians caution that much is yet to be done but a company called Omneuron is trying to develop the equipment for commercial use.

CURE FOR COCAINE HABIT?

Because many who suffer traumatic brain injury can develop addiction problems, a recent finding could provide some help. Cocaine addicts, who were hospitalized, were given a supplement known as NAC (N-acetylcysteine), which appear to lessen the desire for the drug. MRI's taken of the patient's brain saw a difference associated with the supplement.

MOLECULAR DAMAGE FROM TBI ONGOING FOR YEARS

In a recent paper further evidence of secondary or delayed cell death following TBI was shown. The diffuse and wide spread damage is progressive and prolonged for months or years after the initial insult. Areas continued to be vulnerable to such ongoing destruction are the cortex, hippocampus, thalamus, striatum and subcortical nuclei.

DEPRESSION AND TBI

Several recent studies continue to solidify the relationship between depression and traumatic brain injury. A multicenter study (Seel RT 2003) showed that patients with TBI are at "great" risk for developing depressive symptoms. Unemployment and poverty may be substantial risk factors in the development of depressive symptoms. A study tracking the psychiatric illnesses following TBI (Fann JR 2004) found that 34% of those with mild TBI had a high initial and ongoing risk of persistent psychiatric illnesses.

PEDIATRIC TBI EQUALS WORSE OUTCOME

An experiment, with one-week old rats who sustained TBI, has clearly shown that the trauma triggered cell death (apoptosis) in the brains of the very young rats was far greater than those in older rats. These results help explain the unfavorable outcomes of very young pediatric head trauma patients and outlines again the importance of trying to prevent secondary cell death following head trauma.

SPECT SCAN VALIDATED IN TBI

SPECT scanning of the brain, which has received increasing recognition in the past five years, has again shown to be sensitive to TBI. In a variation known as Proton Magnetic Residence Spectroscopy (1 H-MRS) the relationship of brain chemicals in the brain following trauma, which are now seen to be markers for diffuse axonal injury. The levels of chemicals have a significant correlation with the functional status of the patient. Thus, localized 1H-MRS has the potential to be used for detecting diffuse axonal injury (DAI) in TBI patients and can be useful as a guide to future rehabilitation.

EARLY SYMPTOMS OF TBI LINKED TO OUTCOME

Mild traumatic brain injury patient's symptoms were used to predict severity of post traumatic complaints six-months after injury. It was found that the patients complaining of headache, dizziness, or nausea at the emergency room after mild traumatic brain injury strongly associate with the severity of symptoms six-months after. Patients at the emergency room without headache, dizziness, nausea did much better at six-months following injury than those who had these complaints (R deKra 2002)

WATCH YOUR PITUITARY

Pituitary gland function and levels of growth hormone can be adversely affected by TBI. A recent study (Aimaretti, G. 2004) suggest that careful screening of the pituitary function should occur following TBI. Keeping these systems in chemical balance will speed TBI recovery.

MAGNETIC FIELDS MAY REDUCE DEPRESSION FOLLOWING TBI

Many patients have depression following brain injury which does not respond to antidepressant drugs. The authors of the study contend that there may be subclinical, partial complex seizure activity which continues for months or years after "recovery." Four patients who had such an injury showed significant improvement of depression after having burst-firing magnetic fields across their temporal lobe once a week for five weeks. (Baker-Price L.A. 1996).

NEW WAY OF DETECTING HEARING LOSS

Because many persons with traumatic brain injury are in a coma or otherwise unable to communicate their problems, it is often a bit difficult to determine if hearing loss is part of the injury. A recent study (Lew H. L. 2004) showed encouraging results by having the individual undergo brain stem auditory evoked potential. They follow this test up with CT scan of the bilateral temporal bones. Use of these two test may prove valuable in ruling out hearing loss in those with severe TBI.

EXERCISE HELPS

It has been found that treadmill activity, forced limb movement, and other physical activities help promote brain plasticity (ability to repair). A pattern of exercise before an injury promotes a defense against cell death. It is thought that in the chronic stages after brain injury, an exercise program might reactivate mechanism of healing and thus it is recommended to keep victims as physically active as possible. In a related study, recreational therapy was found to improve rehabilitation.

NEW VACCINE

Trauma induced brain injury can possibly be reduced, post-accident, by giving the patient a vaccination of Cop-1, a synthetic co-polymer used to treat MS. Such a vaccine may be available soon, and would be ideal for use at trauma centers and emergency room facilities. Do not expect this vaccination until, at least, 2005.

NEW WONDER DRUG?

Mifepristone, also known as the abortion pill, may have a wonderful side effect in that it protects brain cells. Experiments in mice have shown that the drug extends the life of neurons and protects against the cellular destruction which occurs in traumatic brain injury and for other reasons in a process called apoptosis.

BETTER NEUROLOGICAL OUTCOME

Trial studies of the drug, dexanabinol, briefly conducted in cases of severe head injury. Patients treated with the drug had increased positive blood flow after injury without dangerously low blood pressure. Overall the patients treated with the drug had faster and better neurologic outcome.

MAGNETIZATION TRANSFER RATIO (MTR)

Research into new MRIs have shown promise into showing, more sensitively, brain damage due to trauma. The type of MRI known as Magnetization Transfer Ratio (MTR) has shown to be effective in detecting abnormalities in the white matter of the brain following trauma. These abnormalities were looked at in the splenium of the corpus callosum in the brain stem. (Sinson, G. 2002).

PROMISING NEW DRUG

Researchers at the University of Florida are working toward a treatment to curtail the secondary cell death which follows severe brain trauma. Early signs show that administration of the common chemotherapy drug Cyclosporin A, within 12 hours of injury interrupts the chain of events that can lead to the worsening of brain injury in the first day or two following trauma. Tests on animals show great promise in reducing swelling and regulation of calcium induced damage.

SAY NO TO HERBAL REMEDIES

The use of herbal supplements is common in the U.S. However, following a brain injury, remedies such as St. Johns Wort and Ginko Giloba, SHOULD BE AVOIDED. Studies show that they may induce mania in TBI patients. If you feel that you must take supplements, make sure you clear them with your doctor, especially if taken in conjunction with prescription medication. (Spinella M., 2002)

MRI USED FOR DIAGNOSIS OF MENTAL ILLNESS

Several hospital centers across the U.S. are beginning to use MRI (MRS) to diagnose mental illness such as depression and panic disorder. Changes in metabolic activity can clearly correlate with certain disorders. For example, evidence of bipolar disorder in the frontal lobes can be seen and changes associated with ADD in children, can be gleaned through changes in brain volume.

DRUG FOR SEVERE BRAIN INJURY

A recent study confirmed the safety and usefulness of intravenous dexanabinol (HU-211), in cases of severe head injury. Patients experienced excellent control of intra-cranial pressure, a common deadly side effect of brain injury. Patients on HU-211, also experienced faster and better neurologic outcome. (Knoller N., 2002)

Long Term Depression with TBI

A long term follow-up study on head injured veterans reported in the archives of general psychiatry showed that concussions and other head injuries in early adulthood may significantly raise the risk of depression decades later. This is consistent with earlier studies that show that head injured patients may be prone to depression shortly after the head injury. The study suggest that the risk of depression persists even fifty years after the injury. (Keep in mind that the study by McCallister and Flashman in 1999 concluded that 20% to 30% of mild TBI patients show major depression in the first year post injury) (T. Holsinger 2002).

QUANTITATIVE MAGNETIC RESONANCE

Dr. Erin Bigler of Brigham Young University and others are examining ways in which MRI studies can show demonstrable reductions in the volume or surface area of the brain after traumatic injury. The "atrophy" for shrinking of the brain after traumatic injury has been shown to be consistent with the aftermath of diffuse axonal injury (DAI) and focal brain injury. Following the early stages, this method of imaging the brain holds great promise in proving injury. (Bigler E. 2001)

BRAIN FOOD

The Annals of Neurology has found that creatine, a common food supplement administered to rats after traumatic brain injury, increased the repair of cortical tissue by 30% to 50%. (Sullivan P.G. 2000)

TREATMENT FOUND NOT EFFECTIVE

The New England Journal of Medicine in February 2001, reported that a hopeful therapy for brain injury, hypothermia, was not shown to be effective in reducing residual brain injury symptoms, as previously thought.

REHABILITATION HOPE

The Journal of Brain Injury recently reported that patients in the slow-to-recover subset of severe TBI, may benefit from longer trials of rehabilitation, with functional recovery continuing to improve months or years after injury. (Grey D.S. 2000)

CHILDREN AT GREATER RISK

The French study further confirmed that the "Kennard Principal" (that recovery from injury is greater in children that adults) appears to be false, especially in diffuse injuries. They recommended that final assessment of childhood outcome for TBI should be done only after several years. (Laurent-Bannier A. 2000)

DRIVING PROBLEMS

A study in Norway found that post injury TBI patients, had a highly increased percentage of involvement in driving accidents and recommended special assessment for driving post injury. (Mosberg A. 2000)

REHABILITATION

In a study of paid attendant care to victims of TBI, the main benefit was found to be that of friendship to the victim, and the study recommended further training to stress this important component of care. (McCluskey A. 2000)

PTSD

A study from this year in the Journal of Nervous and Mental Disorders found the rate of Post Traumatic Stress Syndrome in cases of severe traumatic brain injury to be 27% and recommended rehabilitation efforts to take this into account.

LOSS OF CONSCIOUSNESS

The study of brain injured athletes showed no relevant distinction in the outcome between athletes who loss consciousness and those who did not at the time of injury. (Lovell M.R. 1999)

CHILDREN MORE AT RISK

A study in rats showed that neuro-degeneration after trauma was worse in immature verses mature individuals, and cited as the cause Apoptotic Degeneration.

CELLULAR DAMAGE

In the studies that support the findings supporting the use of MRS, protein markers consistent with traumatic brain injury were found in injured patients and was consistent with the follow-up outcome of neuropsychological testing. (Ingebrigtsen T. 1999)

CELLULAR DAMAGE

Secondary damage after traumatic brain injury via lipid peroxidation (LPO) was found in patients within twenty-fours hours post injury. Treatment with natural or synthetic antioxidants was recommended. (Sutkovoi 1999)

HOPE FOR EPILEPSY

Wide spread use of nerve stimulators in patients with severe epilepsy have shown in 66% of patients a good to moderate reduction in reducing seizures. Patients undergo a one to two hour surgery to implant a stop-watch size device in the chest. The procedure, covered by most insurance, costs approximately $20,000.00.

LEAD POISONING FINDINGS

The recent study showed that blood lead concentrations much lower than previously thought, were associated with declines in cognitive and academic skills. Decreases in performance occurred in children having a blood level less than 5 micrograms per deciliter (ug/dL). These finding would indicate that the current blood level concentration cut off of 10 ug/dL is incorrect and would have to be lowered. (Lanphear 2000)

TINNITUS IMAGING

Ringing in the ears (Tinnitus) is a common and often terrible symptom of brain injury. Previously, there was no test to objectively determine the existence or non existence of this complaint. However, a recent study indicates that changes in the inner ear leading to Tinnitus may be detectable on MRI imaging of the ear. (Meriot 2001)

IMAGING IMPROVED

MRI imaging technology continues to be refined and improved. Adding magnetization transfer imaging (MTI) and contour plot analysis to MRI studies greatly adds to the sensitivity of the imaging in detecting signs of traumatic brain injury (McCowan J.C. 2000)

SURPRISING STATISTIC

There are apparently far more visits to the emergency room in the United States for traumatic brain injury than previously thought. A re-analysis of data from the calender year 1995 to 1996, showed one million visits, much higher than previously thought. (Guerrero 2000)

CHILDHOOD INJURY

A long term follow-up of victims of childhood brain injury showed continuing vocational problems at age 21. Again showing that children are not more immune to brain injury than adults. (Nybo 1999)

SLEEP DISORDERS

This study, among others, has confirmed that there is a direct relationship between traumatic brain injury and the emergents of sleep disorders. The severity and impact of chronic sleep disorder is just now beginning to be understood, and is far more of a problem than previously thought. (Beetar 1999)

INVISIBLE INJURIES

In this older study, reconfirmed by more recent studies, 686 victims of mild traumatic brain injury were examined and found to have completely normal neurological exams. The patients then underwent imaging studies and 18% of the patients were found to have lesions in the brain. (Stein 1993)

HYPERTENSION

Contrary to what was previously thought, cognitive decline in patients suffering from diabetes and hypertension starts at middle age rather than old age. (Knopman 2001)

MAGNETIC RESONANCE SPECTROCOPY (MRS)

Yet another study confirms the exciting possibilities of this new diagnostic tool, which measures the relationship of brain chemicals utilizing MRI. The finding of certain relationships is consistent with the diagnosis of brain injury. (Brooks W.M. 2001)