Day-of-Injury Computed Tomography and Longitudinal Rehabilitation Outcomes: A Comparison of the Marshall and Rotterdam Computed Tomography Scoring Methods.

OBJECTIVE: The aim of the study was to compare the relative predictive value of Marshall Classification System and Rotterdam scores on long-term rehabilitation outcomes. This study hypothesized that Rotterdam would outperform Marshall Classification System. DESIGN: The study used an observational cohort design with a consecutive sample of 88 participants (25 females, mean age = 42.0 [SD = 21.3]) with moderate to severe traumatic brain injury who were admitted to trauma service with subsequent transfer to the rehabilitation unit between February 2009 and July 2011 and who had clearly readable computed tomography scans. Twenty-three participants did not return for the 9-mo postdischarge follow-up. Day-of-injury computed tomography images were scored using both Marshall Classification System and Rotterdam criteria by two independent raters, blind to outcomes. Functional outcomes were measured by length of stay in rehabilitation and the cognitive and motor subscales of the Functional Independence Measure at rehabilitation discharge and 9-mo postdischarge follow-up. RESULTS: Neither Marshall Classification System nor Rotterdam scales as a whole significantly predicted Functional Independence Measure motor or cognitive outcomes at discharge or 9-mo follow-up. Both scales, however, predicted length of stay in rehabilitation. Specific Marshall scores (3 and 6) and Rotterdam scores (5 and 6) significantly predicted subacute outcomes such as Functional Independence Measure cognitive at discharge from rehabilitation and length of stay. CONCLUSIONS: Marshall Classification System and Rotterdam scales may have limited utility in predicting long-term functional outcome, but specific Marshall and Rotterdam scores, primarily linked to increased severity and intracranial pressure, may predict subacute outcomes.

Volumetric analysis of day of injury computed tomography is associated with rehabilitation outcomes after traumatic brain injury.

BACKGROUND: Day-of-injury (DOI) brain lesion volumes in traumatic brain injury (TBI) patients are rarely used to predict long-term outcomes in the acute setting. The purpose of this study was to investigate the relationship between acute brain injury lesion volume and rehabilitation outcomes in patients with TBI at a level one trauma center. METHODS: Patients with TBI who were admitted to our rehabilitation unit after the acute care trauma service from February 2009-July 2011 were eligible for the study. Demographic data and outcome variables including cognitive and motor Functional Independence Measure (FIM) scores, length of stay (LOS) in the rehabilitation unit, and ability to return to home were obtained. The DOI quantitative injury lesion volumes and degree of midline shift were obtained from DOI brain computed tomography scans. A multiple stepwise regression model including 13 independent variables was created. This model was used to predict postrehabilitation outcomes, including FIM scores and ability to return to home. A p value less than 0.05 was considered significant. RESULTS: Ninety-six patients were enrolled in the study. Mean age was 43 ± 21 years, admission Glasgow Coma Score was 8.4 ± 4.8, Injury Severity Score was 24.7 ± 9.9, and head Abbreviated Injury Scale score was 3.73 ± 0.97. Acute hospital LOS was 12.3 ± 8.9 days, and rehabilitation LOS was 15.9 ± 9.3 days. Day-of-injury TBI lesion volumes were inversely associated with cognitive FIM scores at rehabilitation admission (p = 0.004) and discharge (p = 0.004) and inversely associated with ability to be discharged to home after rehabilitation (p = 0.006). CONCLUSION: In a cohort of patients with moderate to severe TBI requiring a rehabilitation unit stay after the acute care hospital stay, DOI brain injury lesion volumes are associated with worse cognitive FIM scores at the time of rehabilitation admission and discharge. Smaller-injury volumes were associated with eventual discharge to home. Volumetric neuroimaging in the acute injury phase may improve surgeons' ultimate outcome predictions in TBI patients. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level V.

Institutional Variation in Traumatic Brain Injury Acute Rehabilitation Practice.

OBJECTIVE: To describe institutional variation in traumatic brain injury (TBI) inpatient rehabilitation program characteristics and evaluate to what extent patient factors and center effects explain how TBI inpatient rehabilitation services are delivered. DESIGN: Secondary analysis of a prospective, multicenter, cohort database. SETTING: TBI inpatient rehabilitation programs. PARTICIPANTS: Patients with complicated mild, moderate, or severe TBI (N=2130). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Mean minutes; number of treatment activities; use of groups in occupational therapy, physical therapy, speech therapy, therapeutic recreation, and psychology inpatient rehabilitation sessions; and weekly hours of treatment. RESULTS: A wide variation was observed between the 10 TBI programs, including census size, referral flow, payer mix, number of dedicated beds, clinician experience, and patient characteristics. At the centers with the longest weekday therapy sessions, the average session durations were 41.5 to 52.2 minutes. At centers with the shortest weekday sessions, the average session durations were approximately 30 minutes. The centers with the highest mean total weekday hours of occupational, physical, and speech therapies delivered twice as much therapy as the lowest center. Ordinary least-squares regression modeling found that center effects explained substantially more variance than patient factors for duration of therapy sessions, number of activities administered per session, use of group therapy, and amount of psychological services provided. CONCLUSIONS: This study provides preliminary evidence that there is significant institutional variation in rehabilitation practice and that center effects play a stronger role than patient factors in determining how TBI inpatient rehabilitation is delivered.

Psychotropic Medication Use During Inpatient Rehabilitation for Traumatic Brain Injury.

OBJECTIVE: To describe psychotropic medication administration patterns during inpatient rehabilitation for traumatic brain injury (TBI) and their relation to patient preinjury and injury characteristics. DESIGN: Prospective observational cohort. SETTING: Multiple acute inpatient rehabilitation units or hospitals. PARTICIPANTS: Individuals with TBI (N=2130; complicated mild, moderate, or severe) admitted for inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Not applicable. RESULTS: Most frequently administered were narcotic analgesics (72% of sample), followed by antidepressants (67%), anticonvulsants (47%), anxiolytics (33%), hypnotics (30%), stimulants (28%), antipsychotics (25%), antiparkinson agents (25%), and miscellaneous psychotropics (18%). The psychotropic agents studied were administered to 95% of the sample, with 8.5% receiving only 1 and 31.8% receiving ≥6. Degree of psychotropic medication administration varied widely between sites. Univariate analyses indicated younger patients were more likely to receive anxiolytics, antidepressants, antiparkinson agents, stimulants, antipsychotics, and narcotic analgesics, whereas those older were more likely to receive anticonvulsants and miscellaneous psychotropics. Men were more likely to receive antipsychotics. All medication classes were less likely administered to Asians and more likely administered to those with more severe functional impairment. Use of anticonvulsants was associated with having seizures at some point during acute care or rehabilitation stays. Narcotic analgesics were more likely for those with history of drug abuse, history of anxiety and depression (premorbid or during acute care), and severe pain during rehabilitation. Psychotropic medication administration increased rather than decreased during the course of inpatient rehabilitation in each of the medication categories except for narcotics. This observation was also true for medication administration within admission functional levels (defined by cognitive FIM scores), except for those with higher admission FIM cognitive scores. CONCLUSIONS: Many psychotropic medications are used during inpatient rehabilitation. In general, lower admission FIM cognitive score groups were administered more of the medications under investigation compared with those with higher cognitive function at admission. Considerable site variation existed regarding medications administered. The current investigation provides baseline data for future studies of effectiveness.

Traumatic Brain Injury Patient, Injury, Therapy, and Ancillary Treatments Associated With Outcomes at Discharge and 9 Months Postdischarge.

OBJECTIVE: To examine associations of patient and injury characteristics, inpatient rehabilitation therapy activities, and neurotropic medications with outcomes at discharge and 9 months postdischarge for patients with traumatic brain injury (TBI). DESIGN: Prospective, longitudinal observational study. SETTING: Inpatient rehabilitation centers. PARTICIPANTS: Consecutive patients (N=2130) enrolled between 2008 and 2011, admitted for inpatient rehabilitation after an index TBI injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Rehabilitation length of stay, discharge to home, and FIM at discharge and 9 months postdischarge. RESULTS: The admission FIM cognitive score was used to create 5 relatively homogeneous subgroups for subsequent analysis of treatment outcomes. Within each subgroup, significant associations were found between outcomes and patient and injury characteristics, time spent in therapy activities, and medications used. Patient and injury characteristics explained on average 35.7% of the variation in discharge outcomes and 22.3% in 9-month outcomes. Adding time spent and level of effort in therapy activities and percentage of stay using specific medications explained approximately 20% more variation for discharge outcomes and 12.9% for 9-month outcomes. After patient, injury, and treatment characteristics were used to predict outcomes, center differences added only approximately 1.9% additional variance explained. CONCLUSIONS: At discharge, greater effort during therapy sessions, time spent in more complex therapy activities, and use of specific medications were associated with better outcomes for patients in all admission FIM cognitive subgroups. At 9 months postdischarge, similar but less pervasive associations were observed for therapy activities, but not classes of medications. Further research is warranted to examine more specific combinations of therapy activities and medications that are associated with better outcomes.

Readmission to an Acute Care Hospital During Inpatient Rehabilitation for Traumatic Brain Injury.

OBJECTIVE: To assess the incidence of, causes for, and factors associated with readmission to an acute care hospital (RTAC) during inpatient rehabilitation for traumatic brain injury (TBI). DESIGN: Prospective observational cohort. SETTING: Inpatient rehabilitation. PARTICIPANTS: Individuals with TBI admitted consecutively for inpatient rehabilitation (N=2130). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: RTAC incidence, RTAC causes, rehabilitation length of stay (RLOS), and rehabilitation discharge location. RESULTS: A total of 183 participants (9%) experienced RTAC for a total of 210 episodes. Of 183 participants, 161 patients experienced 1 RTAC episode, 17 had 2, and 5 had 3. The mean time from rehabilitation admission to first RTAC was 22±22 days. The mean duration in acute care during RTAC was 7±8 days. Eighty-four participants (46%) had ≥1 RTAC episodes for medical reasons, 102 (56%) had ≥1 RTAC episodes for surgical reasons, and 6 (3%) participants had RTAC episodes for unknown reasons. Most common surgical RTAC reasons were neurosurgical (65%), pulmonary (9%), infection (5%), and orthopedic (5%); most common medical reasons were infection (26%), neurological (23%), and cardiac (12%). Any RTAC was predicted as more likely for patients with older age, history of coronary artery disease, history of congestive heart failure, acute care diagnosis of depression, craniotomy or craniectomy during acute care, and presence of dysphagia at rehabilitation admission. RTAC was less likely for patients with higher admission FIM motor scores and education less than high school diploma. RTAC occurrence during rehabilitation was significantly associated with longer RLOS and smaller likelihood of discharge home. CONCLUSIONS: Approximately 9% of patients with TBI experienced RTAC episodes during inpatient rehabilitation for various medical and surgical reasons. This information may help inform interventions aimed at reducing interruptions in rehabilitation for RTAC. RTACs were associated with longer RLOS and discharge to an institutional setting.

Inpatient rehabilitation for traumatic brain injury: the influence of age on treatments and outcomes.

BACKGROUND: Elderly persons with traumatic brain injury (TBI) are increasingly admitted to inpatient rehabilitation, but we have limited knowledge of their characteristics, the treatments they receive, and their short-term and medium-term outcomes. This study explored these issues by means of comparisons between age groups. METHODS: Data on 1419 patients admitted to 9 inpatient rehabilitation facilities for initial rehabilitation after TBI were collected by means of (1) abstraction from medical records; (2) point-of care forms completed by therapists after each treatment session; and (3) interviews at 3 months and 9 months after discharge, conducted with the patient or a proxy. RESULTS: Elderly persons (65 or older) had a lower brain injury severity, and a shorter length of stay (LOS) in acute care. During rehabilitation, they received fewer hours of therapy, due to a shorter LOS and fewer hours of treatment per day, especially from psychology and therapeutic recreation. They regained less functional ability during and after inpatient rehabilitation, and had a very high mortality rate. CONCLUSIONS: Elderly people can be rehabilitated successfully, and discharged back to the community. The treatment therapists deliver, and issues surrounding high mortality need further research.

Cerebral volume loss, cognitive deficit, and neuropsychological performance: comparative measures of brain atrophy: II. Traumatic brain injury.

Traumatic brain injury (TBI) results in a variable degree of cerebral atrophy that is not always related to cognitive measures across studies. However, the use of different methods for examining atrophy may be a reason why differences exist. The purpose of this manuscript was to examine the predictive utility of seven magnetic resonance imaging (MRI)-derived brain volume or indices of atrophy for a large cohort of TBI patients (n = 65). The seven quantitative MRI (qMRI) measures included uncorrected whole brain volume, brain volume corrected by total intracranial volume, brain volume corrected by the ratio of the individual TICV by group TICV, a ventricle to brain ratio, total ventricular volume, ventricular volume corrected by TICV, and a direct measure of parenchymal volume loss. Results demonstrated that the various qMRI measures were highly interrelated and that corrected measures proved to be the most robust measures related to neuropsychological performance. Similar to an earlier study that examined cerebral atrophy in aging and dementia, these results suggest that a single corrected brain volume measure is all that is necessary in studies examining global MRI indicators of cerebral atrophy in relationship to cognitive function making additional measures of global atrophy redundant and unnecessary.

Day-of-injury computerized tomography, rehabilitation status, and development of cerebral atrophy in persons with traumatic brain injury.

OBJECTIVE: To compare day-of-injury (DOI) computerized tomography (CT) findings with acute injury severity markers, disability at acute hospital admission and discharge from inpatient rehabilitation, injury severity markers, and degree of postacute cerebral atrophy on magnetic resonance imaging (MRI). DESIGN: Retrospective chart review of 240 consecutive traumatic brain injury (TBI) admissions (mean age 31.7 +/- 15.8 yrs) with moderate-to-severe initial brain injury. All DOI CT abnormalities were qualitatively rated. Disability was assessed using the Disability Rating Scale (DRS) and the FIM measure. In a representative subset, cerebral atrophy was determined by the ventricle-to-brain ratio (VBR) method and quantified from MRI scans 25 or more days postinjury. RESULTS: CT classification resulted in nonsignificant differences in DRS and FIM ratings at the time of discharge from the rehabilitation unit, except in brainstem injury subjects who had significantly higher DRS and lower FIM scores at rehabilitation discharge. At 25 or more days postinjury, presence of any DOI CT abnormality was associated with larger VBR. Increased VBR, as an index of cerebral atrophy, was associated with worse rehabilitation discharge DRS and FIM ratings. CONCLUSIONS: Other than brainstem injury, DOI CT findings relate poorly to rehabilitation outcome. Presence of DOI CT abnormalities were associated with the development of cerebral atrophy, which was associated with poorer rehabilitation discharge DRS and FIM scores.

Post-traumatic amnesia predicts long-term cerebral atrophy in traumatic brain injury.

PRIMARY OBJECTIVE: To examine post-traumatic amnesia (PTA) and its relation to long-term cerebral atrophy in persons with traumatic brain injury (TBI) using objective indicators of PTA duration and Quantitative Magnetic Resonance Imaging (QMRI). It was hypothesized that longer PTA would predict later generalized atrophy (increased ventricle-to-brain ratio (VBR)). As a guide in assessing patients with TBI, this study determined the probability of developing chronic cerebral atrophy based on PTA duration. RESEARCH DESIGN: Probability model using 60 adult patients with mild-to-severe TBI. MAIN OUTCOMES AND RESULTS: A logistic regression model with a cut-off determined by normative QMRI data confirmed that longer PTA duration predicts increased VBR. A probability model demonstrated a 6% increase in the odds of developing later atrophy on neuroimaging with each additional day of PTA. CONCLUSIONS: PTA has previously proven to be a good indicator of later cognitive recovery and functional outcome and also predicts long-term parenchymal change.

Another look at observational studies in rehabilitation research: going beyond the holy grail of the randomized controlled trial.

Horn SD, DeJong G, Ryser DK, Veazie PJ, Teraoka J. Another look at observational studies in rehabilitation research: going beyond the holy grail of the randomized controlled trial. This commentary compares randomized controlled trials (RCTs) and clinical practice improvement (CPI) approaches to study design, evaluates their relative advantages and disadvantages, and discusses their implications for rehabilitation research and evidence-based practice. Many argue that observational cohort studies are not sufficient as scientific evidence for practice change. We challenge this assertion by introducing the concept of a CPI study: a comprehensive observational paradigm structured to decrease biases generally associated with observational research. One strength of CPI studies is their attention to defining and characterizing the "black box" of clinical practice. CPI studies require demanding data collection, but by using bivariate and multivariate associations among patient characteristics, process steps, and outcomes, they can uncover best practices more quickly while achieving many of the presumed advantages of RCTs.

An exploration of central nervous system medication use and outcomes in stroke rehabilitation.

UNLABELLED: Conroy B, Zorowitz R, Horn SD, Ryser DK, Teraoka J, Smout RJ. An exploration of central nervous system medication use and outcomes in stroke rehabilitation. OBJECTIVE: To study associations between neurobehavioral impairments, use of neurotropic medications, and outcomes for inpatient stroke rehabilitation, controlling for a variety of confounding variables. DESIGN: Observational cohort study of post-stroke rehabilitation. SETTING: Six inpatient rehabilitation hospitals in the United States. PARTICIPANTS: Patients with moderate or severe strokes (N=919). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Discharge disposition, FIM score change, and rehabilitation length of stay (LOS). RESULTS: Neurobehavioral impairments and use of many medications, including first-generation selective serotonin reuptake inhibitors, older traditional antipsychotic medications, and anti-Parkinsonian neuro-stimulants, have a statistical association with poorer outcomes, whereas use of the atypical antipsychotic medications has a positive association with improvement in motor FIM scores. Counter-intuitively, use of opioid analgesics is associated with a larger motor FIM score change but not an increase in LOS or reduced percentage of discharge to community. There was significant variation in use of neurotropic medications among the 6 study sites during inpatient stroke rehabilitation. CONCLUSIONS: There are many opportunities to enhance a stroke survivor's ability to benefit from acute inpatient stroke rehabilitation through improved understanding of associations of neurotropic medications with outcomes for different patient groups.

The early impact of the inpatient rehabilitation facility prospective payment system on stroke rehabilitation case mix, practice patterns, and outcomes.

UNLABELLED: DeJong G, Horn SD, Smout RJ, Ryser DK. The early impact of the inpatient rehabilitation facility prospective payment system on stroke rehabilitation case mix, practice patterns, and outcomes. OBJECTIVE: To determine the early effects of the inpatient rehabilitation facility (IRF) prospective payment system (PPS) on stroke rehabilitation case mix, practice patterns, and outcomes. DESIGN: Prospective observational cohort study. SETTING: Three IRFs in the United States. PARTICIPANTS: Consecutively enrolled convenience sample of 539 stroke rehabilitation patients treated between 2001 and 2003 in 3 IRFs. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Length of stay (LOS), therapy utilization, FIM instrument gain, and discharge destination. RESULTS: The IRF-PPS had no material short-term effect on stroke rehabilitation case mix and LOS for the study facilities. Facilities shifted physical and occupational therapy resources from those in the most severe case-mix groups (CMGs) to those in the moderate CMGs. Those in the more severe CMGs also experienced a noticeable decline in FIM score gain over the course of the rehabilitation stay. Using multivariate analyses, the authors discerned no major role for the IRF-PPS in explaining pre- and post-PPS differences in utilization and outcome among study facilities. CONCLUSIONS: For the 3 study facilities, IRF-PPS did not materially reshape stroke rehabilitation case mix, utilization, and outcome in the early stages of PPS implementation, apart from the shift in therapy resources from more severely involved stroke patients to moderately involved patients. The study's findings are limited to 3 facilities, and a longer time horizon is needed to more fully determine the effects of the IRF-PPS.

Measuring medical complexity during inpatient rehabilitation after traumatic brain injury.

OBJECTIVE: To compare the performance of 3 severity of illness (SOI) indices--the Comprehensive Severity Index (CSI), All Patient Refined Diagnosis Related Groups Severity of Illness, case-mix group (CMG)--and 5 well-known neurologic parameters, as measures of medical complexity. DESIGN: Retrospective chart review. SETTING: Inpatient rehabilitation center within a level I trauma center. PARTICIPANTS: Consecutive traumatic brain injury (TBI) admissions (N=212). INTERVENTION: Acute inpatient TBI rehabilitation. CSI and neurologic parameters were scored by chart extraction. SOI was based on diagnosis codes by using 3M PC Grouper software, version 15. MAIN OUTCOME MEASURES: Adjusted R 2 was used to predict rehabilitation charges as a proxy of medical complexity. RESULTS: The highest adjusted R 2 values for single variables predicting charges were: CMG .349, CSI .293, duration of posttraumatic amnesia .260. Adjusted R 2 values for the CMG combined with the CSI, 5 neurologic parameters, and SOI to predict charges were .446, .431, and .365, respectively. CONCLUSIONS: The CMG was the best single predictor of rehabilitation charges for TBI. Predictive ability was better when the CMG was combined with the CSI or a combination of the 5 neurologic parameters. A severity index based on objective clinical findings rather than diagnostic codes may have distinct advantages for rehabilitation outcome studies and reimbursement methodology.

Surgical drainage of choroidal effusions following glaucoma surgery.

PURPOSE: To determine the efficacy and safety of surgical drainage of choroidal effusions that occurs following glaucoma surgical procedures. PATIENTS AND METHODS: Ninety-four choroidal drainage procedures performed at a single institution from 1986 to 2001 were reviewed retrospectively. Sixty-three eyes of 63 persons who underwent one or more drainage procedures for choroidal effusions that developed following glaucoma surgical procedures were identified. Eyes diagnosed with suprachoroidal hemorrhage prior to intervention were excluded. The cases were evaluated for resolution of choroidal detachment, post-drainage complications, visual acuity, and intraocular pressure before and after drainage. RESULTS: Indications for choroidal drainage included flat anterior chamber (25 eyes), decreased vision (22 eyes), and persistent choroidal detachment (16 eyes). Complete resolution of choroidal effusions was achieved in 37 (59%) eyes by 1 month, 51 (81%) eyes by 2 months, and in 57 (90%) eyes by 4 months following the initial drainage procedure. Overall success rate per procedure at 12 months was 77% (60/78). Compared with pre-drainage, intraocular pressure was higher at 6 and 12 months post-drainage (P < 0.0001) and visual acuity was better at 6 and 12 months post-drainage (logMAR, P < 0.0001). Twenty-seven (77%) of 35 phakic eyes developed cataracts during the 12 months post-drainage. CONCLUSIONS: Choroidal effusions that develop after glaucoma surgery can usually be drained with minimal complications. Surgical drainage is associated with improved vision and resolution of hypotony. Cataracts may progress following choroidal drainage but this may be due to the pre-drainage hypotony conditions.

Alcohol abuse and traumatic brain injury: quantitative magnetic resonance imaging and neuropsychological outcome.

Prior or concurrent alcohol use at the time of traumatic brain injury (TBI) was examined in terms of post-injury atrophic changes measured by quantitative analysis of magnetic resonance imaging (MRI) and neuropsychological outcome. Two groups of TBI subjects were examined: those with a clinically significant blood alcohol level (BAL) present at the time of injury (TBI + BAL) and those without a significant BAL (TBI-only). To explore the potential impact of both acute and chronic alcohol use, subjects in both groups were further clustered into one of four subgroups (NONE, MILD, MODERATE or HEAVY) based upon available information regarding their pre-injury alcohol use. One-way analysis of covariance (ANCOVA) and multiple analysis of covariance (MANCOVA) were used with subject grouping as the main factor. Age, injury severity as measured by Glasgow Coma Scale (GCS) score, years of education, total intracranial volume (TICV), and the number of days post-injury were included as covariates where appropriate. Increased general atrophy was observed in patients with (a) a positive BAL and/or (b) a history of moderate to heavy pre-injury alcohol use. In addition, performance on neuropsychological outcome variables (WAIS-R and WMS-R Index scores) was generally worse in the subgroups of patients with positive BAL and a history of preinjury alcohol use, as compared to the other TBI groups though not statistically significant. Implications of alcohol use, at the time of brain injury, are discussed.

Traumatic brain injury and atrophy of the cingulate gyrus.

The medial surface areas of the cingulate gyrus (CG) and other midline structures (corpus callosum, thalamus, lateral ventricle) were examined in 27 traumatically brain injured (TBI) and 12 age- and gender-matched control subjects from an established TBI data base. Significant atrophy, primarily in the posterior CG, was found in TBI patients. Degree of atrophy was related to severity of injury. TBI subjects also had significantly reduced corpus callosum and thalamic cross-sectional surface areas with associated increased lateral ventricular volume, as well as reduced brain volume and increased ventricle-to-brain ratio. Despite significant atrophy of the posterior CG, neuropsychological performance was not related to changes in CG cross-sectional surface area in the TBI subjects. This apparent discrepancy is discussed.