Late mortality after head injury.

OBJECTIVES: To investigate mortality trends in a cohort of people admitted to a regional head injury unit with all severities of injury in the calendar year 1981. METHODS: A computerised database with details of 1919 admissions was compared with deaths registered by the NHS Central Register, Scotland for the years 1981 to mid-2002. Death certificate information for matches was analysed. RESULTS: The 1919 admissions referred to 1871 individuals, comprising 93 severe, 205 moderate, and 1573 minor injuries according to Glasgow coma scale criteria. There were 57 deaths (42 severe head injuries, eight moderate, seven minor) during the initial admission, and 340 (six severe, 33 moderate, 301 minor) in the subsequent years. Substance abuse, principally alcohol, was a factor in 37 deaths, suicide accounted for 20, and accidents for 25. The great majority of these latter deaths were in people under the age of 70 years. CONCLUSION: Premature deaths after predominantly minor head injury are commonly alcohol related or the result of suicide or accidents.

Peduncular hallucinations following subarachnoid haemorrhage.

We describe the case of a 56-year-old woman who suffered vivid visual hallucination following subarachnoid haemorrhage (SAH). These occurred from day 9 to day 28 after the haemorrhage. An association with sleep disturbance, clinical findings, and the nature of the hallucinations suggested peduncular hallucinosis. Putative mechanisms in this case are discussed.

A prospective study of thalamic deep brain stimulation for the treatment of movement disorders in multiple sclerosis.

The place for neurosurgical management of movement disorders in multiple sclerosis is unclear. To evaluate the potential benefits of unilateral thalamic deep brain stimulation (DBS) a prospective study was performed. Fifteen patients with confirmed MS and chronic, severe, drug-resistant movement disorders underwent stereotactic surgery to implant a thalamic DBS electrode using CT image guidance and intra-operative neurophysiological testing. The primary outcome measures were reduction in tremor severity and improvement in tests of hand function when the DBS electrode was turned on, 12 months after surgery. Secondary outcome measures included indices of disability, handicap, neuropsychological function and independence. Thirty-seven patients were assessed for treatment, but only 15 underwent surgery. In the 10 patients in whom implantation of the complete DBS system was carried out there was a significant reduction in the severity of tremor (p = 0.02) and improvement in hand function (p = 0.02). There were no benefits in any of the secondary outcome measures. Two patients had thalamocapsular haemorrhages at the site of electrode implantation and two had seizures in the follow-up period. Thalamic stimulation significantly reduced the tremor associated with MS and improved hand function in the targeted upper limb. However, there can be difficulties with identifying an optimal implantation site during operation, significant procedural morbidity and difficulty in predicting immediate outcome. It is also likely that the insignificant benefits of DBS on disability and handicap reflect persisting cerebeller dysmetria, and both the severity and diffuse nature of the disease process in this patient cohort.

Relatives' reports of long term problems following traumatic brain injury or subarachnoid haemorrhage.

PURPOSE: To describe and compare the late outcome of traumatic brain injury (TBI) and subarachnoid haemorrhage (SAH) in terms of the carers' perspectives, and their symptoms' profiles. METHOD: Postal survey to surviving patients who had been discharged from a Regional Neurosurgical Unit five to seven years previously. There were 288 patients identified retrospectively from hospital records, of whom 209 (126 TBI and 83 SAH) were alive and traced at follow-up. The Glasgow Outcome Scale (GOS) and the Relative's Questionnaire (RQ) were used. RESULTS: Relative's questionnaires were returned by 128 patients; 70 TBI and 58 SAH, giving response rates of 56% and 70% respectively. In terms of outcome, there was a high degree of similarity between groups. On the GOS, approximately half of each group were classified as moderately disabled (49% and 48% of the TBI and SAH groups respectively); a quarter remained severely disabled (27% and 22%); and the remaining quarter were adjudged to have made a good recovery (24% and 29%). There was a considerable overlap in terms of the most commonly reported symptoms. Cognitive and physical problems tended to be more commonly reported by relatives of the TBI patients, whilst emotional and subjective symptoms were reported equally in both patient groups. CONCLUSIONS: The effects of TBI and SAH persist for many years post-injury, leading to considerable disability and increased dependency. Although the demographic details and mechanisms of injury in these two patient groups differ, there is a high degree of similarity in the pattern of sequelae reported by carers.

A case of cerebral haemorrhage-can Ginkgo biloba be implicated?

The case of a 56 year old man who suffered a spontaneous intracerebral haemorrhage after regular self medication with the herbal preparation, Ginkgo biloba leaf extract is described, and the possible association is discussed.

Brain injury - the perceived health of carers.

PURPOSE: This paper explores the perceived health and reported level of strain in the primary carers of severely brain injured individuals, 15 - 18 months after discharge from inpatient rehabilitation. METHOD: Seventy carers took part in a prospective descriptive study utilizing a semistructured interview and standardized measures including the SF36, The Carer Strain Index and the Relative Questionnaire. Functional consequences for the injured person were also assessed. RESULTS: The SF36 demonstrated a trend towards lower perceived health for carers than that reported in the general population. Neither perceived health status nor level of strain differed significantly according to the type of injury sustained (haemorrhagic or traumatic) nor initial severity of injury. Factors that contributed to carers having worse health status included the injured person's level of disability and interpersonal factors such as the nature of the relationship, with spouses having lower perceived health status than parents. CONCLUSIONS: Irrespective of cause of injury, generalised health consequences result for the carers of those with disabling consequences of brain injury. Factors independent of the injured individual themselves (such as the nature of the relationship to the carer) need to be taken into consideration when exploring wellbeing of carers and planning services.

Reliability of the relative's questionnaire for assessment of outcome after brain injury.

PURPOSE: The relative's questionnaire (RQ) was developed to assess outcome after brain injury. The present study investigated its test-retest reliability when used in a postal survey. METHOD: Hospital records were used to identify and contact 288 surviving patients treated for brain injury five to seven years earlier. Patients were sent a copy of the RQ (RQ1) and one month later a second copy (RQ2) was sent to those who returned RQ1. RESULT: Two hundred and eleven patients were successfully contacted, of whom 128 (61%) returned RQ1, and 94 of these (73%) returned RQ2. The reliability of items was variable, with most having a kappa value of > 0.6 suggesting 'substantial agreement' or better. CONCLUSION: The data presented suggest that the RQ is a reliable instrument in collecting outcome information in brain-injured patients by postal survey. Further research is recommended to test the suitability of the RQ for the use as a telephone interview.

Simple assessment of outcome after acute brain injury using the Glasgow Outcome Scale.

To evaluate alternative methods of determining Glasgow Outcome Scale scores, a postal survey was made of 288 general practitioners and 128 relatives of patients who had sustained acute brain injuries 5-7 years previously. The Glasgow Outcome Scale score from the general practitioner and relative were compared with that calculated from questionnaire information by an experienced rater. There was poor agreement between general practitioner and rater (K = 0.17) and relative and rater (K = 0.35) scores. Both general practitioners and relatives indicated more favourable outcomes than the rater, with a higher level of agreement (K = 0.61) between them. When Glasgow Outcome Scale scores are used, the methods employed should be valid and reliable; failure to ensure this may be responsible for a considerable proportion of variability in reported studies of brain injury outcome.

Information needs of families when one member has a severe brain injury.

Despite calls for health and social services to respond to the needs of informal carers, there is little evidence to guide practioners in the best way to provide support and/or information in situations of complex need such as brain injury. This study addressed such an intervention in a prospective descriptive study, using both qualitative and quantitative methodology. Eighty-nine patients who had been admitted to a regional neurorehabilitation unit for management of traumatic or haemorrhagic brain injuries were consecutively discharged to the community over a period of 12 months. Eighty-two of these people identified a carer who agreed to be interviewed at approximately six weeks after discharge regarding their concerns. The study identified that even soon after discharge from inpatient rehabilitation, carers wanted more information. In many cases the need for information was unrelated to either the severity of injury or level of functional deficit. In addition, requests for information were in many cases not sought spontaneously, but required prompting. Such findings have implications if interventions in this field are to have the optimum chance of succeeding in providing support and assistance.

Survey of the late consequences of polio in Edinburgh and the Lothians.

OBJECTIVE: This study aimed to identify the nature and frequency of new symptoms and associated disabilities experienced by people who suffered poliomyelitis many years ago, and their access to hospital services. DESIGN: Postal survey regarding symptoms, disability (Office of Population Censuses & Surveys (OPCS) disability questionnaire), and experience of services. SUBJECTS & SETTING: People known to the British Polio Fellowship and the regional rehabilitation service who had previously had polio and were resident in Edinburgh and the Lothians. RESULTS: The study population of 125 people had a median age of 59 years, and 60% were female. The most common symptoms, present in over 60%, were: cold intolerance, fatigue, increased and new muscle weakness, muscle and joint pain, and sleep disturbance. Motor disabilities, particularly of lower limbs, were prominent. Patient contact with hospital services in the preceding five years was: clinic (62%); physiotherapy (46%); occupational therapy (29%); speech therapy (2%); wheelchair service (42%); orthotics (40%). CONCLUSIONS: New problems are sufficiently frequent and severe to warrant a more detailed study to quantify the health care requirements of the post-polio population.

Wernicke-Korsakoff syndrome in head injury: a missed insult.

A survey of the use of thiamine in patients at risk from Wernicke-Korsakoff syndrome (WKS) in Scottish specialist neurosurgical units, and a 2-year retrospective study of 218 at-risk patients admitted to a regional neurosurgical unit with a head injury were undertaken. Although responses to the survey indicated otherwise, the study revealed that there was no consistent practice regarding thiamine administration. Overall, 20.6% of patients received thiamine, with an alcohol history being the only factor correlating with thiamine administration. Of known alcoholics and heavy drinkers, 56.1% and 26.2% respectively received thiamine as in-patients; 44.5% of patients received additional carbohydrate loads in the form of i.v. dextrose or parenteral nutrition, but only 28.9% of these received thiamine as well. Although the actual thiamine status of these patients was not known, given the difficulties of diagnosing WKS in the presence of a head injury, the conclusion is that written protocols are needed in units to ensure that head injury patients at risk of WKS receive appropriate thiamine treatment or prophylaxis.

The Functional Assessment Measure (FIM + FAM) as part of the hospital discharge summary after brain injury rehabilitation.

OBJECTIVE: To assess the value of providing Functional Assessment Measure (FIM + FAM) data as part of the hospital discharge information after brain injury rehabilitation. DESIGN: Postal survey of general practitioners (GPs) and consultants. SUBJECTS: Consecutive discharges (n = 117) from an early brain injury rehabilitation unit over one year. RESULTS: Response rates were 81% from GPs and 54% from consultants. Eighty-four (89%) of GPs and 57 (82%) of consultants rated the information as useful; 87 (92%) and 51 (84%) respectively described the accompanying notes as easy to understand. CONCLUSIONS: The incorporation of FIM + FAM data in discharge summaries is worthwhile but the utility of this practice is still to be established.

Use of the functional assessment measure (FIM+FAM) in head injury rehabilitation: a psychometric analysis.

OBJECTIVES: The drive to measure outcome during rehabilitation after brain injury has led to the increased use of the functional assessment measure (FIM+FAM), a 30 item, seven level ordinal scale. The objectives of the study were to determine the psychometric structure, internal consistency, and other characteristics of the measure. METHODS: Psychometric analyses including both traditional principal components analysis and Rasch analysis were carried out on FIM+FAM data from 2268 assessments in 965 patients from 11 brain injury rehabilitation programmes. RESULTS: Two emergent principal components were characterised as representing physical and cognitive functioning respectively. Subscales based on these components were shown to have high internal consistency and reliability. These subscales and the full scale conformed only partially to a Rasch model. Use of raw item ratings, as opposed to transformed ratings, to produce summary scores for the two subscales and the full scale did not introduce serious distortion. CONCLUSION: The full FIM+FAM scale and two derived subscales have high internal reliability and the use of untransformed ratings should be adequate for most clinical and research purposes in comparable samples of patients with head injury.

Cognitive and psychosocial outcome following moderate or severe traumatic brain injury.

The outcome of 96 consecutive adult patients with moderate to severe head injury was sequentially measured at 6, 12 and 24 months post-injury. In addition to global outcome using the Glasgow Outcome Scale (GOS) and a battery of neuropsychological tests of cognitive function, the Head Injury Symptom Checklist (HISC) and Relative's Questionnaire (RQ) were used. Although poorer GOS scores and severe cognitive impairments were typically associated with greater severity of initial injury, relatives reported similar functional problems irrespective of injury severity. This illustrates the legacy of moderate head injury in influencing many aspects of everyday life, supporting the argument that the needs of this group should not be overlooked.

Persisting symptoms and carers' views of outcome after subarachnoid haemorrhage.

OBJECTIVE: To report the outcome of aneurysmal subarachnoid haemorrhage (SAH) in terms of subjective symptoms and carers' perspective over a period of two years. DESIGN: Forty-four consecutive patients admitted to a Regional Neurosurgical Unit and who survived aneurysmal SAH were invited for outpatient assessment at 6, 12 and 24 months post haemorrhage. MEASURES: The Glasgow Outcome Scale (GOS) was used to measure global outcome; the Hospital Anxiety and Depression Scale (HAD) to screen for affective symptoms; the Head Injury Symptom Checklist (HISC) to detect symptoms commonly reported after head trauma; and information was collected from a close friend or relative of the patient using the Relative's Questionnaire (RQ). RESULTS: GOS outcome was significantly related to the severity of the original haemorrhage, as classified by the World Federation of Neurological Surgeons (WFNS) Grading Scale, on admission to hospital. However, even in cases where patients had made a good recovery according to the GOS, a variety of problems were frequently reported by patients and relatives, and many of these persisted for the duration of the study. The three most common and persistent symptoms were tiredness (63%, 59% and 59% at 6, 12 and 24 months respectively), memory disturbance (50%, 52% and 56%) and passivity (61%, 47% and 46%). In contrast, the prevalence of disturbed mood, as reported using the HAD, was similar to that of the general population. CONCLUSIONS: Studies of outcome following SAH should address these subtle disturbances, and information pertaining to potential long-term problems should be provided to patients and relevant others.

Rater reliability of Fahn's tremor rating scale in patients with multiple sclerosis.

OBJECTIVE: Assessment of movement disorders in patients with multiple sclerosis (MS) is difficult because of the complex nature of the movement disorders. The aim of this study was to determine the reliability of Fahn's Tremor Rating Scale (FTRS) in assessing movement disorders in patients with MS. METHOD: Videos were made of 10 patients with MS showing their rest, postural, action/intention, and goal-related movement disorders as well as their performance of spirometry, a volumetric task, and timed functional tasks. Ratings of tremor were carried out by one rater on two occasions 3 months apart and by 8 raters on one occasion using FTRS. RESULTS: Intrarater reliability was generally very good, with no significant "drift" in ratings over time. Interrater reliability was generally good, with some variation in interpretation of scoring criteria that may reflect raters' backgrounds. CONCLUSION: The FTRS is a reliable and potentially useful tool with which to assess movement disorders in patients with MS.

Virtual reality: a new prosthesis for brain injury rehabilitation.

Virtual Reality (VR) technology is a relatively new application to rehabilitation medicine, yet it offers considerable potential to achieve significant successes in assessment, treatment and improved outcome, thereby increasing our knowledge of neuroplasticity. The capabilities of VR are especially evident in neurological rehabilitation, where cognitive and behavioural problems often interact with physical impairments to reduce the overall level of functioning and interaction. The need for effective interventions in neurological rehabilitation demands communication and collaboration between disciplines. This paper presents some of the current areas of the clinical applications of VR, emphasising the link between experimental evidence on recovery after brain damage and the clinical problems encountered in a ward setting.