scholarly journals Agitation Following Severe Traumatic Brain Injury Is a Clinical Sign of Recovery of Consciousness

2021 ◽  
Vol 8 ◽  
Author(s):  
Zhe Wang ◽  
Nathan J. Winans ◽  
Zirun Zhao ◽  
Megan E. Cosgrove ◽  
Theresa Gammel ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Severe Traumatic Brain Injury ◽  
Retrospective Chart Review ◽  
University Hospital ◽  
Clinical Notes ◽  
Violent Behaviors ◽  
Neurological Functioning ◽  
Command Following ◽  
Recovery Of Consciousness

Objective: Severe traumatic brain injury (sTBI) often results in disorders of consciousness. Patients emerging from coma frequently exhibit aberrant behaviors such as agitation. These non-purposeful combative behaviors can interfere with medical care. Interestingly, agitation is associated with arousal and is often among the first signs of neurological recovery. A better understanding of these behaviors may shed light on the mechanisms driving the return of consciousness in sTBI patients. This study aims to investigate the association between posttraumatic agitation and the recovery of consciousness.Methods: A retrospective chart review was conducted in 530 adult patients (29.1% female) admitted to Stony Brook University Hospital between January 2011 and December 2019 with a diagnosis of sTBI and Glasgow Coma Scale (GCS) ≤8. Agitation was defined as a Richmond Agitation Sedation Scale (RASS) > +1, or any documentation of equivalently combative and violent behaviors in daily clinical notes. The ability to follow verbal commands was used to define the recovery of consciousness and was assessed daily.Results: Of 530 total sTBI patients, 308 (58.1%) survived. Agitation was present in 169 of all patients and 162 (52.6%) of surviving patients. A total of 273 patients followed commands, and 159 of them developed agitation. Forty patients developed agitation on hospital arrival whereas 119 developed agitation later during their hospital course. Presence of in-hospital agitation positively correlated with command-following (r = 0.315, p < 0.001). The time to develop agitation and time to follow commands showed positive correlation (r = 0.485, p < 0.001). These two events occurred within 3 days in 54 (44.6%) patients, within 7 days in 81 (67.8%) patients, and within 14 days in 96 (80.2%) patients. In 71 (59.7%) patients, agitation developed before command-following; in 36 (30.2%) patients, agitation developed after command-following; in 12 (10.1%) patients, agitation developed on the same day as command-following.Conclusion: Posttraumatic agitation in comatose patients following sTBI is temporally associated with the recovery of consciousness. This behavior indicates the potential for recovery of higher neurological functioning. Further studies are required to identify neural correlates of posttraumatic agitation and recovery of consciousness after sTBI.

scholarly journals Cortical Function in Acute Severe Traumatic Brain Injury and at Recovery: A Longitudinal fMRI Case Study

2020 ◽  
Vol 10 (9) ◽  
pp. 604
Author(s):  
Karnig Kazazian ◽  
Loretta Norton ◽  
Teneille E. Gofton ◽  
Derek Debicki ◽  
Adrian M. Owen
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Speech Perception ◽  
Severe Traumatic Brain Injury ◽  
Resting State ◽  
Cortical Function ◽  
Sound Perception ◽  
Command Following ◽  
Resting State Connectivity ◽  
Recovery Of Consciousness

Differences in the functional integrity of the brain from acute severe brain injury to subsequent recovery of consciousness have not been well documented. Functional magnetic resonance imaging (fMRI) may elucidate this issue as it allows for the objective measurement of brain function both at rest and in response to stimuli. Here, we report the cortical function of a patient with a severe traumatic brain injury (TBI) in a critically ill state and at subsequent functional recovery 9-months post injury. A series of fMRI paradigms were employed to assess sound and speech perception, command following, and resting state connectivity. The patient retained sound perception and speech perception acutely, as indexed by his fMRI responses. Command following was absent acutely, but was present at recovery. Increases in functional connectivity across multiple resting state networks were observed at recovery. We demonstrate the clinical utility of fMRI in assessing cortical function in a patient with severe TBI. We suggest that hallmarks of the recovery of consciousness are associated with neural activity to higher-order cognitive tasks and increased resting state connectivity.

Modeling the return to consciousness after severe traumatic brain injury at a large academic level 1 trauma center

2020 ◽  
Vol 133 (2) ◽  
pp. 477-485
Author(s):  
Nathan J. Winans ◽  
Justine J. Liang ◽  
Bradley Ashcroft ◽  
Stephen Doyle ◽  
Adam Fry ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Hospital Mortality ◽  
Regression Model ◽  
Severe Traumatic Brain Injury ◽  
Cox Regression ◽  
University Hospital ◽  
Cox Regression Model ◽  
Head Ct ◽  
Command Following

OBJECTIVESevere traumatic brain injury (sTBI) carries significant morbidity and mortality. It remains difficult to counsel families on functional prognosis and plan research initiatives aimed at treating traumatic coma. In order to better address these problems, the authors set out to develop statistical models using retrospective data to identify admission characteristics that correlate with time until the return of consciousness, defined as the time to follow commands (TFC). These results were then used to create a TFC score, allowing for rapid identification of patients with predicted prolonged TFC.METHODSData were reviewed and collected from medical records of sTBI patients with Glasgow Coma Scale (GCS) motor subscores ≤ 5 who were admitted to Stony Brook University Hospital from January 2011 to July 2018. Data were used to calculate descriptive statistics and build binary logistic regression models to identify admission characteristics that correlated with in-hospital mortality and in-hospital command-following. A Cox proportional hazards model was used to identify admission characteristics that correlated with the length of TFC. A TFC score was developed using the significant variables identified in the Cox regression model.RESULTSThere were 402 adult patients who met the inclusion criteria for this study. The average age was 50.5 years, and 122 (30.3%) patients were women. In-hospital mortality was associated with older age, higher Injury Severity Score (ISS), higher Rotterdam score (head CT grading system), and the presence of bilateral fixed and dilated pupils (p < 0.01). In-hospital command-following was anticorrelated with age, ISS, Rotterdam score, and the presence of a single fixed and dilated pupil (p < 0.05). TFC was anticorrelated with age, ISS, Rotterdam score, and the presence of a single fixed and dilated pupil. Additionally, patients who sustained injuries from falls from standing height had a shorter average TFC. The 3 significant variables from the Cox regression model that explained the most variance were used to create a 4-point TFC score. The most significant of these characteristics were Rotterdam head CT scores, high impact traumas, and the presence of a single fixed and dilated pupil. Importantly, the presence of a single fixed and dilated pupil was correlated with longer TFC but no increase in likelihood of in-hospital mortality.CONCLUSIONSThe creation of the 4-point TFC score will allow clinicians to quickly identify patients with predicted prolonged TFC and estimate the likelihood of command-following at different times after injury. Discussions with family members should take into account the likelihood that patients will return to consciousness and survive after TBI.

Location of Subcortical Microbleeds and Recovery of Consciousness After Severe Traumatic Brain Injury

Neurology ◽  
2021 ◽  
pp. 10.1212/WNL.0000000000012192
Author(s):  
Marta Bianciardi ◽  
Saef Izzy ◽  
Bruce Rosen ◽  
Lawrence L. Wald ◽  
Brian L. Edlow
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Severe Traumatic Brain Injury ◽  
Basal Forebrain ◽  
Mesencephalic Reticular Formation ◽  
Brainstem Nucleus ◽  
Severe Tbi ◽  
Mesopontine Tegmentum ◽  
Recovery Of Consciousness ◽  
Nucleus Volume

Background:In patients with severe traumatic brain injury (TBI), coma is associated with impaired subcortical arousal mechanisms. However, it is unknown which nuclei involved in arousal (“arousal nuclei”) are implicated in coma pathogenesis and are compatible with coma recovery.Methods:We mapped an atlas of arousal nuclei in the brainstem, thalamus, hypothalamus, and basal forebrain onto 3 Tesla susceptibility-weighted images (SWI) in twelve patients with acute severe TBI who presented in coma and recovered consciousness within six months. We assessed the spatial distribution and volume of SWI microbleeds and evaluated the association of microbleed volume with the duration of unresponsiveness and functional recovery at six months.Results:There was no single arousal nucleus affected by microbleeds in all patients. Rather, multiple combinations of microbleeds in brainstem, thalamic, and hypothalamic arousal nuclei were associated with coma and were compatible with recovery of consciousness. Microbleeds were frequently detected in the midbrain (100%), thalamus (83%) and pons (75%). Within the brainstem, the microbleed incidence was largest within the mesopontine tegmentum (e.g., pedunculotegmental nucleus, mesencephalic reticular formation) and ventral midbrain (e.g., substantia nigra, ventral tegmental area). Brainstem arousal nuclei were partially affected by microbleeds, with microbleed volume not exceeding 35% of brainstem nucleus volume on average. Compared to microbleed volume within non-arousal brainstem regions, the microbleed volume within arousal brainstem nuclei accounted for a larger proportion of variance in the duration of unresponsiveness and 6-month Glasgow Outcome Scale-Extended scores.Conclusions:These results suggest resilience of arousal mechanisms in the human brain after severe TBI.

scholarly journals Functional networks reemerge during recovery of consciousness after acute severe traumatic brain injury

Cortex ◽  
2018 ◽  
Vol 106 ◽  
pp. 299-308 ◽  
Author(s):  
Zachary D. Threlkeld ◽  
Yelena G. Bodien ◽  
Eric S. Rosenthal ◽  
Joseph T. Giacino ◽  
Alfonso Nieto-Castanon ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Severe Traumatic Brain Injury ◽  
Functional Networks ◽  
Recovery Of Consciousness

Detection of Covert Command-Following and Communication in a Patient with Severe Traumatic Brain Injury

2014 ◽  
Vol 95 (10) ◽  
pp. e78
Author(s):  
Yelena Guller ◽  
Hong Pan ◽  
Swathi Iyer ◽  
Lorene Leung ◽  
Rachel Cohn ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Severe Traumatic Brain Injury ◽  
Command Following

scholarly journals The Prevalence of Pituitary Dysfunction in Children Following Severe Traumatic Brain Injury in the Acute Phase

2020 ◽  
pp. 89-94
Author(s):  
Adil Rabi ◽  
Abdelali Tali ◽  
Said Younous ◽  
Laila Chabaa
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Head Trauma ◽  
Acute Phase ◽  
Severe Traumatic Brain Injury ◽  
Clinical Signs ◽  
University Hospital ◽  
Endocrine Disorders ◽  
Pituitary Dysfunction ◽  
Cortisol Levels

Neuro-endocrine disorders are a frequent complication of head trauma. The exploration of these disturbances is important because it can contribute to the understanding of some symptoms presented by the patients for better management in the acute phase or during the evolution. Aim: The objective of this study was to identify the anterior pituitary dysfunction of severe traumatic brain injury and to analyze the correlations between these disorders, brain lesions and clinical signs. Materials and Methods: This is a prospective and descriptive study, conducted in collaboration between the pediatric intensive care unit and the clinical biochemistry laboratory of the Mohammed VI University Hospital of Marrakech. This study was spread over 9 months. It Included children admitted for severe head trauma and with a clinical, hormonal and CT scan. And the interest was in 28 severely traumatized skulls in the acute phase. All patients received TSH, T3, T4, Prolactin and cortisol levels 8 hours after admission. Results: There were twenty eight patients included in the study. Sex ratio m / f of 1.54, whose age varies between 9 months and 14 years, with an average age of 6.5 years. Half of the patients had an initial Glasgow score of 8/15. This was cerebral oedema in (46.42%) cases. In this study, the rate of endocrine disorders was 85.71%, the exploration of the thyrotropic axis proved normal in all of these patients. Low cortisol levels were observed in 11% of cases, 67.84% of children had hyperprolactinemia. One-third of the patient included in the study had 2-axis involvement, namely cortisol and prolactin. Half, on the other hand, showed only one axis. Conclusion: In the aftermath of head trauma, pituitary disturbances are frequent and should be included in their management.

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