Quality of life in patients with traumatic brain injury-basic issues, assessment and recommendations.

INTRODUCTION: Traumatic brain injuries (TBI) are one of the most common consequences of traffic accidents. Patients with mild, moderate or severe brain injuries suffer from physical, cognitive, behavioral, emotional and social problems. Most of these problems have been a long standing focus amongst practitioners and researchers. Only recently a development has started that took interest in the quality of life outcome of TBI patients. The international members of this consensus meeting reviewed the literature on Quality of Life assessment after TBI and discussed the applicability of different measurements to this specific patient group. TIME POINTS: During the acute phase (T1; < 3 month after trauma) QoL it is difficult to assess due to the reduced consciousness of TBI patients. In the phase of rehabilitation (T2; < one year after trauma) and in the post-rehabilitation phase (T3) repeated assessment of QoL is recommended. INSTRUMENTS: Several generic and disease-specific instruments possibly relevant to TBI patients or specifically developed for this group were assessed according to the existing evidence in the literature. Criteria for the evaluation of these instruments were: feasibility, specificity, validity, comprehensiveness, international availability, existence of norms, and psychometric quality. The cognitive impairment and the existential dimension were not sufficiently considered in most of the reviewed instruments. GROUP CONSENSUS: The family's and relatives' view of the patient's QoL should not be used as a proxy but provides an additional source of information in the acute phase. At T2 and T3, assessment of the patient's quality of life should include a generic as well as a disease specific instrument. Among the generic instruments the SF-36, the EuroQol and the WHO-QoL should be considered. The literature about specific instruments for patients with TBI like the EBIC is scarce. Therefore, the group could hardly give an empirically based recommendation. The need for further investigation on QoL instruments in TBI patients is strongly emphasized.

Long term results after multiple injuries including severe head injury.

OBJECTIVE: To describe the long term results in patients with multiple injuries including severe head injury. DESIGN: Retrospective and prospective clinical study. SETTING: Level I trauma centre, Germany. PATIENTS: Patients aged 16-60 years who had been injured more than 2 years before, whose Injury Severity Score was over 20 and whose cranial Abbreviated Injury Score (AIS) was over 3. MAIN OUTCOME MEASURES: Glasgow Outcome Scale (GOS), functional, neuropsychological, vocational and social outcomes. RESULTS: 58 patients, median age 24 (range 16-53, interquartile range (IQR) 21-32) years were investigated 5 (3-9; IQR 4-7) years after their injury. Median ISS was 34 (21-57; IQR 26-41) and GCS 6 (3-8; IQR 4-7). Duration of coma was 10 (2-51; IQR 7-22) days and neurological rehabilitation lasted 169 (10-830; IQR 80-300) days. Movements of the elbow and ankle was most impaired by injury. All psychometric tests showed deficits, particularly in speed of processing, concentration, recent memory, and learning performance. The social environment had been changed in half and vocational rehabilitation was dependent on age. 24 (42%) returned to their former profession, 18 (31%) were retrained to another profession, 16 (27%) were unemployed or retired on a pension. 31 (53%) made a good recovery with moderate disability, 19 (33%) had severe disability, and 8 (14%) remained in a persistent vegetative state assessed by the GOS. CONCLUSION: Early and concentrated rehabilitation facilitates functional, social, and neuropsychological reintegration.

[Functional, neuropsychological and social outcome of polytrauma patients with severe craniocerebral trauma]. / Funktionelles, neuropsychologisches und soziales Outcome polytraumatisierter Patienten mit schwerem Schädel-Hirn-Trauma.

The aim of this study was to identify, in (pre-) clinically obtained data, parameters predicting the outcome of patients with multiple trauma and severe head injury. Fifty-eight patients aged 27 +/- 10 years were investigated an average of 5.8 years after the accident. The Hanover Polytrauma Score was 34 +/- 11 points, the initially assessed Glasgow Coma Scale (GCS) was 6.2 +/- 3.2 points; and the duration of coma was 15.4 +/- 14.4 days. The primary length of stay in hospital averaged 33.4 days, including 22.9 days in the intensive care unit and 20.2 days of ventilation. For a further 223 days the patients were treated at the Neurologic Clinic of Hessisch Oldendorf. Besides different neurologic deficiency symptoms, the psychometric tests showed deficits in all areas. In particular, information processing speed, concentration, recent memory and learning performance were impaired. There was free mobility of all joints in 33% of the patients. Due to injury the elbow and ankle joint developed the worst restriction. Central paralysis and heterotopic ossification also caused a restriction in joint mobility. Half of the patients were confronted with different social changes. The rate of return to work was dependent on age. Some 42% of all patients had taken up their former profession, 5% were still in training or at college, 32% were retrained to other professions, 16% were unemployed and 5% were completely retired on pension. Age, injury severity, GCS, duration of coma and duration of weaning were suitable predictors in correlation- and regression analysis. The Glasgow Outcome Scale showed good recovery and moderate disability in 53%, severe disability in 33% and persistent vegetative state in 14% of the patients.

[Not Available]. / Funktionelles, neuropsychologisches und soziales Outcome polytraumatisierter Patienten mit schwerem Schädel-Hirn-Trauma.

The aim of this study was to identify, in (pre-) clinically obtained data, parameters predicting the outcome of patients with multiple trauma and severe head injury. Fifty-eight patients aged 27±10 years were investigated an average of 5.8 years after the accident. The Hanover Polytrauma Score was 34±11 points, the initially assessed Glasgow Coma Scale (GCS) was 6.2±3.2 points; and the duration of coma was 15.4±14.4 days. The primary length of stay in hospital averaged 33.4 days, including 22.9 days in the intensive care unit and 20.2 days of ventilation. For a further 223 days the patients were treated at the Neurologic Clinic of Hessisch Oldendorf. Besides different neurologic deficiency symptoms, the psychometric tests showed deficits in all areas. In particular, information processing speed, concentration, recent memory and learning performance were impaired. There was free mobility of all joints in 33% of the patients. Due to injury the elbow and ankle joint developed the worst restriction. Central paralysis and heterotopic ossification also caused a restriction in joint mobility. Half of the patients were confronted with different social changes. The rate of return to work was dependent on age. Some 42% of all patients had taken up their former profession, 5% were still in training or at college, 32% were retrained to other professions, 16% were unemployed and 5% were completely retired on pension. Age, injury severity, GCS, duration of coma and duration of weaning were suitable predictors in correlation- and regression analysis. The Glasgow Outcome Scale showed good recovery and moderate disability in 53%, severe disability in 33% and persistent vegetative state in 14% of the patients.

[Prognosis of polytrauma patients with severe craniocerebral trauma during the critical care phase]. / Prognose des polytraumatisierten Patienten mit schwerem Schädel-Hirn-Trauma während der Intensivphase.

In this study multiple trauma patients with severe head injury showed a different functional, neuropsychological and social outcome depending on several clinical parameters. In a stepwise regression analysis age, injury severity, Glasgow Coma Scale, length of coma and weaning time were proved to be suitable predictors. During the intensive care stay an early prognosis on severe head injury patients is possible.

[Effect of multiple trauma on rehabilitation of patients with craniocerebral injuries]. / Einfluss der Polytraumatisierung auf die Rehabilitation schädelhirnverletzter Patienten.

The aim of this investigation was to proof, wether there is a direct influence of polytrauma on rehabilitation and outcome in patients with severe head injury (SHI). 558 patients were investigated 3 years after the accident. 82% (447) had combined SHI and polytrauma. Patients with polytrauma and similar degrees of SHI showed significantly poorer outcome than those with isolated SHI. The healing process in the rehabilitation hospital was complicated especially by tracheo-pulmonary factors and wrong bedding factors (atrophi, calcification, decubital ulcers). It can be concluded, that diagnostics and operative treatment must be done under continuous intensive and neuromonitoring. Only life-saving operations should be done in the acute stage. All patients with moderate and severe head injury need early rehabilitation parallel to the intensive care treatment.

Parallel and serial visual search after closed head injury: electrophysiological evidence for perceptual dysfunctions.

Event-related potentials (ERPs) were recorded from closed head injury (CHI) patients at least 2 years postinjury and from controls in order to assess their parallel and serial processing abilities during visual search. In Experiment 1, stimuli consisted of arrays of eight triangles; half of the arrays contained a target item. In the "feature-present" condition, the target item was a triangle with an additional horizontal line that could be detected automatically and in parallel, while in the "feature-absent" condition all items except for the target triangle had an additional horizontal line, thus requiring a serial search. In Experiment 2, stimuli consisted of eight solid bars (50%), seven solid bars and a vertical open bar (25%), and seven solid bars and a horizontal open bar (25%): the array containing the horizontal bar served as a target. By recording ERPs to the arrays containing vertical open bars, which were similar to the target items, parallel processing of "pop-out" stimuli could be studied in the absence of any overt response. ERP data were compared with the results of neuropsychological and neuroimaging (MRI, CAT) examination. Patient exhibited a decreased behavioral performance both in the parallel and in the serial processing mode. Furthermore, abnormalities of early and intermediate ERP components (P1, N1, P2, N2) were found, whereas the late component (P3) was less affected by CHI. The results were interpreted as an index of CHI-induced dysfunctions in perceptual processes such as simple feature registration and early target discrimination. It was suggested that these dysfunctions contribute to impairments of parallel as well as serial processes in visual search.

[Progresses in the treatment of skull-brain injuries in childhood]. / Fortschritte in der Behandlung des Schädel-Hirntraumas im Kindesalter.

In a group of children with severe head injury it was possible to lower the rate of mortality in a comparable group of injured children. Besides consistent neuroradiologic diagnosis and the possibility of immediate neurosurgical intervention, improvement of intensive therapy by monitoring of intracranial pressure and rehabilitation at an early stage brought about significant progress.

[Results of monitoring intracranial pressure in patients with severe head injury]. / Ergebnisse intrakranieller Druckmessungen im akuten posttraumatischen Stadium

Intracranial pressure (ICP) was monitored in 100 patients with severe head injury. In comparison to intraventricular pressure epidural measurement gives reliable values with less risk for the patients. There are no firm values for the onset and development of post traumatic brain oedema. In most cases clinical findings allowed no conclusions as to the height of ICP. On the other hand the effects of diuretic agents varied so much that exact oedema therapy is only possible after observation of the values of ICP monitoring. Combined use of ICP monitoring and high doses of dexamethasone reduced mortality significantly.

Advances in management of severe head injuries in childhood.

An analysis of the clinical courses of 205 children with severe head injuries is given. In addition to the use of modern intensive care methods, advances are due to monitoring intracranial pressure directly, steroid therapy in very high doses, and early activation in the subacute stage after injury. By this it is possible to lower mortality and to achieve better clinical results.

The relation between intracrainal pressure, mean arterial pressure and cerebral blood flow in patients with severe head injury.

UNLABELLED: In patients with severe head injuries ICP, MAP and CBF were measured continuously. In most patients there was a positive vasopressor response to increasing ICP, but the ICP/MAP ratio varied considerably in individual cases. CBF was diminished either by increasing ICP or by decreasing MAP. This effect was more marked with ICP above 40 mm Hg or MAP below 110 mm Hg. In terminal stages there was often a negative MAP/ICP ratio accompanied by massive cerebral hyperaemia. Key words: Severe head injury--intracranial pressure--mean arterial pressure--cerebral blood flow--cerebral perfusion pressure--critical limit of ICP and CBF. ABBREVIATIONS: ICP equals intracranial pressure (mm Hg); CBF, Flow equals cerebral blood flow (ml/min); MAP equals mean arterial pressure (mm Hg); CPP equals cerebral perfusion pressure (mm Hg) (difference between MAP and ICP); BP equals blood pressure.