Brazilian version of the Rivermead Post-Concussion Symptoms Questionnaire / Versão Brasileira do Questionário Rivermead de Sintomas Pós-Concussionais

ABSTRACT Background: After a traumatic brain injury, post-concussion symptoms are commonly reported by patients. Although common, these symptoms are difficult to diagnose and recognize. To date, no instruments evaluating post-concussion symptoms have been culturally translated or adapted to the Brazilian context. Objective: To culturally adapt the Rivermead Post-Concussion Symptoms Questionnaire for use in Brazilian Portuguese. Methods: Cross-cultural adaptation was done in five steps: translation, synthesis of translations, back-translation, evaluation by two expert committees and two pretests among adults in a target population. Results: The semantic, idiomatic, cultural and experimental aspects of the adaptation were considered adequate. The content validity coefficient of the items regarding language clarity, pratical pertinence, relevance and dimensionality were considered adequate for evaluating the desired latent variable. Both pretests demonstrated that the instrument had satisfactory acceptability. Conclusion: The Brazilian version, named Questionário Rivermead de Sintomas pós Concussionais (RPQ-Br), has been adapted, and is ready for use in the Brazilian context.

RESUMO Introdução: Após um traumatismo cranioencefálico, os sintomas pós-concussionais são comumente relatados pelos pacientes e, embora comuns, são difíceis de serem reconhecidos. Até o momento, não existem instrumentos que tenham sido traduzidos ou adaptados culturalmente para o contexto brasileiro. Objetivo: Adaptação transcultural do Rivermead Post Concussion Symptoms Questionnaire para o português do Brasil. Métodos: O processo de adaptação transcultural foi realizado em cinco etapas: tradução, síntese das traduções, retrotradução, avaliação por dois comitês de especialistas e dois pré-testes com adultos da população-alvo. Resultados: Os aspectos semânticos, idiomáticos, culturais e experimentais foram considerados adequados. Os coeficientes de validade de conteúdo dos itens quanto à clareza da linguagem, pertinência teórica, relevância prática e dimensionalidade foram considerados adequados para avaliar a variável latente desejada. Ambos os pré-testes demonstraram aceitabilidade satisfatória do instrumento. Conclusão: A versão brasileira do Questionário Rivermead de Sintomas pós Concussionais (RPQ-Br) foi traduzida e adaptada com sucesso e está pronta para ser utilizada no contexto brasileiro.

Post-concussive mTBI in Student Athletes: MRI Features and Machine Learning.

Purpose: To determine and characterize the radiomics features from structural MRI (MPRAGE) and Diffusion Tensor Imaging (DTI) associated with the presence of mild traumatic brain injuries on student athletes with post-concussive syndrome (PCS). Material and Methods: 122 student athletes (65 M, 57 F), median (IQR) age 18.8 (15-20) years, with a mixed level of play and sports activities, with a known history of concussion and clinical PCS, and 27 (15 M, 12 F), median (IQR) age 20 (19, 21) years, concussion free athlete subjects were MRI imaged in a clinical MR machine. MPRAGE and DTI-FA and DTI-ADC images were used to extract radiomic features from white and gray matter regions within the entire brain (2 ROI) and the eight main lobes of the brain (16 ROI) for a total of 18 analyzed regions. Radiomic features were divided into five different data sets used to train and cross-validate five different filter-based Support Vector Machines. The top selected features of the top model were described. Furthermore, the test predictions of the top four models were ensembled into a single average prediction. The average prediction was evaluated for the association to the number of concussions and time from injury. Results: Ninety-one PCS subjects passed inclusion criteria (91 Cases, 27 controls). The average prediction of the top four models had a sensitivity of 0.80, 95% CI: [0.71, 0.88] and specificity of 0.74 95%CI [0.54, 0.89] for distinguishing subjects from controls. The white matter features were strongly associated with mTBI, while the whole-brain analysis of gray matter showed the worst association. The predictive index was significantly associated with the number of concussions (p < 0.0001) and associated with the time from injury (p < 0.01). Conclusion: MRI Radiomic features are associated with a history of mTBI and they were successfully used to build a predictive machine learning model for mTBI for subjects with PCS associated with a history of one or more concussions.

Hipopituitarismo postraumatismo encefalocraneano: revisión de la literatura y algoritmo de estudio y abordaje terapéutico

Hypopituitarism after moderate or severe traumatic brain injury (TBI) is usually underdiagnosed and therefore undertreated. Its course can be divided in an acute phase during the first 14 days after TBI with 50 to 80% risk of hypopituitarism, and a chronic phase, beginning three months after the event, with a prevalence of hypopituitarism that ranges from 2 to 70%. Its pathophysiology has been addressed in several studies, suggesting that a vascular injury to the pituitary tissue is the most important mechanism during the acute phase, and an autoimmune one during chronic stages. In the acute phase, there are difficulties to correctly interpret pituitary axes. Hence, we propose a simple and cost-effective algorithm to detect and treat a potential hypothalamic-pituitary-adrenal axis impairment and alterations of sodium homeostasis, both of which can be life-threatening. In the chronic phase, post-concussion syndrome is the most important differential diagnosis. Given the high prevalence of hypopituitarism, we suggest that all pituitary axes should be assessed in all patients with moderate to severe TBI, between 3 to 6 months after the event, and then repeated at 12 months after trauma by a specialized team in pituitary disease.

Factor structure models for the Post-Concussion Syndrome Scale with monolingual Spanish-speaking adults from Colombia.

PRIMARY OBJECTIVE: The Post-Concussion Syndrome Scale (PCSS) is a self-report questionnaire that measures post-concussive symptom severity and has been primarily normed on young Caucasian samples. This study aims to explore the factor structure models of a Spanish translation of the PCSS at a chronic post-traumatic brain injury (TBI) time point. RESEARCH DESIGN: Descriptive and exploratory research designs were utilized. METHODS AND PROCEDURES: The study consisted of a monolingual sample of Spanish-speaking adults from Colombia, with 100 subjects in the control group and 70 subjects in the TBI group. A t-test, chi-square, and MANOVA were calculated to compare group differences. Cronbach's alpha was calculated to investigate reliability. Confirmatory factor analysis compared item loadings onto an existing four-factor model. Exploratory factor analysis sought to identify a new factor model if the loadings did not fit. MAIN OUTCOMES AND RESULTS: There were no group differences in demographic variables. Internal consistency was acceptable. Model fit indices revealed a poor fit with the original four factors. Item loadings revealed a novel six-structure model. CONCLUSIONS: While the PCSS appears to capture general post-TBI sequelae, the underlying factors may differ due to cultural and linguistic differences in Spanish-speaking individuals. Clinical implications and future directions are further discussed.

Transcranial light-emitting diode therapy for neuropsychological improvement after traumatic brain injury: a new perspective for diffuse axonal lesion management.

The cost of traumatic brain injury (TBI) for public health policies is undeniable today. Even patients who suffer from mild TBI may persist with cognitive symptoms weeks after the accident. Most of them show no lesion in computed tomography or conventional magnetic resonance imaging, but microstructural white matter abnormalities (diffuse axonal lesion) can be found in diffusion tensor imaging. Different brain networks work together to form an important part of the cognition process, and they can be affected by TBI. The default mode network (DMN) plays an important central role in normal brain activities, presenting greater relative deactivation during more cognitively demanding tasks. After deactivation, it allows a distinct network to activate. This network (the central executive network) acts mainly during tasks involving executive functions. The salience network is another network necessary for normal executive function, and its activation leads to deactivation of the DMN. The use of red or near-infrared (NIR) light to stimulate or regenerate tissue is known as photobiomodulation. It was discovered that NIR (wavelength 800-900 nm) and red (wavelength 600 nm) light-emitting diodes (LEDs) are able to penetrate through scalp and skull and have the potential to improve the subnormal, cellular activity of compromised brain tissue. Based on this, different experimental and clinical studies were done to test LED therapy for TBI, and promising results were found. It leads us to consider developing different approaches to maximize the positive effects of this therapy and improve the quality of life of TBI patients.

Transcranial Direct Current Stimulation for Post-Concussion Syndrome: Study Protocol for a Randomized Crossover Trial.

BACKGROUND: Mild traumatic brain injury (MTBI) represents 70-80% of all treated brain injuries. A considerable proportion of MTBI patients experience post-concussion symptoms for a prolonged period after MTBI, and these symptoms are diagnosed as persistent post-concussion syndrome (PPCS). PPCS is defined as a range of physical, cognitive, and emotional symptoms. However, memory and executive dysfunction seems to be one of the most debilitating symptoms. Recently, non-invasive brain stimulation has been studied as a potential treatment method for traumatic brain injury (TBI) patients. Therefore, our primary goal is to verify the effects of transcranial direct current stimulation (tDCS) in patients with PPCS who demonstrate cognitive deficits in long-term episodic memory, working memory, and executive function following MTBI. METHODS/DESIGN: This is a randomized crossover trial of patients with a history of MTBI with cognitive deficits in memory and executive function. Thirty adult patients will be randomized in a crossover manner to receive three weekly sessions of anodal tDCS (2 mA) at left dorsolateral prefrontal cortex, left temporal cortex, and sham stimulation that will be performed at 7-day intervals (washout period). The clinical diagnosis of PPCS will be determined using the Rivermead Post-Concussion Symptoms Questionnaire. Patients who meet the inclusion criteria will be assessed with a neuropsychological evaluation. A new battery of computerized neuropsychological tests will be performed before and immediately after each stimulation. Statistical analysis will be performed to determine trends of cognitive improvement. DISCUSSION: There is paucity of studies regarding the use of tDCS in TBI patients, and although recent results showed controversial data regarding the effects of tDCS in such patients, we will address specifically patients with PPCS and MTBI and no brain abnormalities on CT scan other than subarachnoid hemorrhage. Moreover, due to the missing information on literature regarding the best brain region to be studied, we will evaluate two different regions to find immediate effects of tDCS on memory and executive dysfunction. CLINICAL TRIAL REGISTRATION: www.ClinicalTrials.gov, identifier NCT02292589 (https://register.clinicaltrials.gov).

Dementia resulting from traumatic brain injury / Demência resultante de traumatismo crânio-encefálico

ABSTRACT Traumatic brain injury (TBI) represents a significant public health problem in modern societies. It is primarily a consequence of traffic-related accidents and falls. Other recently recognized causes include sports injuries and indirect forces such as shock waves from battlefield explosions. TBI is an important cause of death and lifelong disability and represents the most well-established environmental risk factor for dementia. With the growing recognition that even mild head injury can lead to neurocognitive deficits, imaging of brain injury has assumed greater importance. However, there is no single imaging modality capable of characterizing TBI. Current advances, particularly in MR imaging, enable visualization and quantification of structural and functional brain changes not hitherto possible. In this review, we summarize data linking TBI with dementia, emphasizing the imaging techniques currently available in clinical practice along with some advances in medical knowledge.

RESUMO O traumatismo cranioencefálico (TCE) representa um importante problema de saúde pública nas sociedades modernas. As suas principais causas são: os acidentes de trânsito e as quedas. O traumatismo leve e repetido relacionado com os esportes de contato ou o traumatismo relacionado com as ondas de choque provenientes de explosões em cenário de guerra são hoje reconhecidas como importantes causas de TCE. A mortalidade e morbilidade associada ao TCE é considerável. TCE representa o fator de risco ambiental melhor reconhecido para o desenvolvimento de demência. Com o reconhecimento recente de que até o TCE leve pode determinar déficts cognitivos, os estudos de imagem adquiriram grande importância neste contexto. Contudo, não está definido qual o melhor estudo de imagem para caracterizar o TCE. Avanços tecnológicos, como a ressonância magnética, permitem atualmente identificar e quantificar alterações intra-parenquimatosas estruturais e funcionais, não detectáveis nos estudos convencionais. Neste artigo os autores resumem os estudos que relacionam TCE e demência, dando particular ênfase às técnicas de imagem atualmente disponíveis na prática clínica, bem como alguns avanços nos métodos de imagem ainda limitados ao plano da investigação.

Dementia resulting from traumatic brain injury.

Traumatic brain injury (TBI) represents a significant public health problem in modern societies. It is primarily a consequence of traffic-related accidents and falls. Other recently recognized causes include sports injuries and indirect forces such as shock waves from battlefield explosions. TBI is an important cause of death and lifelong disability and represents the most well-established environmental risk factor for dementia. With the growing recognition that even mild head injury can lead to neurocognitive deficits, imaging of brain injury has assumed greater importance. However, there is no single imaging modality capable of characterizing TBI. Current advances, particularly in MR imaging, enable visualization and quantification of structural and functional brain changes not hitherto possible. In this review, we summarize data linking TBI with dementia, emphasizing the imaging techniques currently available in clinical practice along with some advances in medical knowledge.

O traumatismo cranioencefálico (TCE) representa um importante problema de saúde pública nas sociedades modernas. As suas principais causas são: os acidentes de trânsito e as quedas. O traumatismo leve e repetido relacionado com os esportes de contato ou o traumatismo relacionado com as ondas de choque provenientes de explosões em cenário de guerra são hoje reconhecidas como importantes causas de TCE. A mortalidade e morbilidade associada ao TCE é considerável. TCE representa o fator de risco ambiental melhor reconhecido para o desenvolvimento de demência. Com o reconhecimento recente de que até o TCE leve pode determinar déficts cognitivos, os estudos de imagem adquiriram grande importância neste contexto. Contudo, não está definido qual o melhor estudo de imagem para caracterizar o TCE. Avanços tecnológicos, como a ressonância magnética, permitem atualmente identificar e quantificar alterações intra-parenquimatosas estruturais e funcionais, não detectáveis nos estudos convencionais. Neste artigo os autores resumem os estudos que relacionam TCE e demência, dando particular ênfase às técnicas de imagem atualmente disponíveis na prática clínica, bem como alguns avanços nos métodos de imagem ainda limitados ao plano da investigação.

Trastornos neuropsiquiátricos por trauma craneoencefálico / Neuropsychiatric Disorders Due to Traumatic Brain Injuries

Introducción: el traumatismo craneoencefálico representa un grave problema de salud pública, ya que cada vez es mayor el número de personas que por diversas razones se ven afectadas (accidentes de tránsito, caídas, violencia, deportes), más en países como Colombia, donde las tasas de mortalidad y morbilidad son verdaderamente alarmantes. Una de las consecuencias más serias a las que se ven enfrentados tanto el paciente como sus cuidadores son las alteraciones neuropsiquiátricas, ya que impactan de gran manera el tratamiento, el proceso de rehabilitación y a sus cuidadores. Objetivo: intentar dar una visión resumida y práctica de los principales trastornos psiquiátricos después de un traumatismo craneoencefálico (pos-TEC), mencionando algunos elementos fi siopatológicos y de enfoque del tratamiento. Método: se revisan los principales trastornos neuropsiquiátricos pos-TEC, usando textos importantes, conocidos y recientes sobre el tema. Conclusiones: se ha identifi cado que los pacientes pos-TEC presentan anomalías neuropsicológicas y de neuroimágenes sutiles, pero signifi cativas que parecen estar en relación con los síntomas que se refi eren. Las terapias de orientación cognitiva han dado resultados favorables y, de hecho la educación temprana acerca de cómo afrontar las molestias posteriores al TEC disminuye de manera importante el desarrollo de este síndrome.

Introduction: Traumatic brain injury (TBI) is a serious public health problem, affecting more people everyday for various reasons (car accidents, falls, violence, sports), specially in countries like Colombia where morbimortality rates are truly alarming. The patient and caregivers are confronted with serious consequences such as neuropsychiatric disorders that impact heavily on the treatment, the rehabilitation process and the caregivers lives. Objective: To give a practical description of the main psychiatric disorders present after traumatic brain injuries together with available treatments, including also some of the physiopathological elements involved. Method: Review of current, well-known literature on the subject. Conclusions: Post-TBI patients exhibit subtle, although signifi cant, neuropsychological and neuroimaging anomalies, since they appear to be related to the symptoms patients describe. Cognitive oriented therapies have shown good results, and in fact, early education on how to manage discomfort following TBI diminishes the risk of presenting post-concussion syndrome.

Tratamiento farmacológico de alteraciones neuropsiquiátricas del daño cerebral traumático / Pharmacological Treatment of Neuropsychiatric Disorders in Traumatic Brain Injury

Introducción: el manejo farmacológico de alteraciones neuropsiquiátricas del paciente con daño cerebral traumático (DCT) parte del supuesto de una cuidadosa valoración clínica. Previo a toda intervención farmacológica debe ser observada la psicopatología particular del paciente, su entorno, los antecedentes y los factores relacionados con su vida diaria que puedan ser susceptibles de manejo no farmacológico, ya que este conocimiento permite la adecuación de la terapia a la individualidad del paciente. Objetivo: señalar cuáles son algunas de las alteraciones directamente relacionadas con el DTC, así como las posibles ganancias secundarias voluntarias o involuntarias generadas por éste. Método: se presentan los aspectos generales del uso de psicofármacos en pacientes con DCT. Conclusiones: alteraciones como cuadros afectivos secundarios al daño cerebral, apatía, trastornos ansiosos, etc., requieren ser identifi cados y seguidos de manera periódica luego de que una intervención es instaurada. Además, los pacientes con DCT deben ser tratados por grupos interdisciplinarios con experiencia en este campo, ya que de esta manera la respuesta farmacológica es evaluada con herramientas clínicas de la neurociencia cognitiva y a la luz de un enfoque neuropsiquiátrico.

Introduction: Pharmacological treatment of neuropsychiatric disorders in the patient with traumatic brain injury (TBI) stems from a careful clinical assessment. The patient’s psychopathology, history, environment and factors related to daily living susceptible of being treated non-pharmacologically should be assessed, prior to any pharmacological intervention. Objective: To point out which disorders are directly caused by TBI and which could be possible voluntary or involuntary secondary gains. Method: General aspects of the use of psychopharmacological agents in patients with TBI are described. Conclusions: Symptoms such as mood disorders due to brain damage, apathy, anxiety disorders, etc., need to be identifi ed, treated and followed up periodically. Patients with TBI should be treated by experienced interdisciplinary teams allowing the response to pharmacotherapy to be assessed using clinical tools from cognitive neuroscience from a neuropsychiatric perspective.