Gulf War and Health Volume 7: Long-Term Consequences of Traumatic Brain Injury (2009) / Chapter Skim
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6 NEUROCOGNITIVE OUTCOMES
6 NEUROCOGNITIVE OUTCOMES
Pages 173-196
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From page 173... ...
The term neurocognitive outcome as used in this chapter refers to cognitive impairment while the word neuropsychologic refers to the kinds of measurements most studies utilized to determine the level of impairment. With regard to penetrating brain injury, it has been determined that the location of a brain injury and the volume of brain tissue lost affect the type and extent of neurocognitive deficits.
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From page 174... ...
studied 35 World War II veterans selected from 185 veterans who had penetrating missile injuries and loss of brain tissue and 12 controls from 101 veterans who had missile injuries of peripheral nerves but no brain injury. All veterans had sustained their injuries 5–8 years before the study.
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From page 175... ...
The cohort consisted of 263 men who had penetrating brain injuries -- 96 with lesions in the right hemisphere, 78 in the left hemisphere, and 89 in both -- and 64 uninjured controls who met the inclusion criteria: they served in Vietnam during the same years as the brain-injured, and they were stratified according to preinjury Armed Forces Qualification Test (AFQT) to be matched with the brain-injured.
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From page 176... ...
provided evidence of the detrimental effects of penetrating head injuries on facial discrimination (1986) and examined neurocognitive performance on the Wisconsin Card Sorting Test, noting that brain-damaged Vietnam veterans made more errors than controls (1990)
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From page 177... ...
(1989) demonstrated poorer performance on cognitive tests in veterans who had penetrating head injury than in controls and continued decline over 30 years in the brain-injured veterans on every cognitive measure except vocabulary, which remained constant.
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From page 178... ...
178 TABLE 6.1 Penetrating Head Injury and Neurocognitive Outcomes Type of TBI: Mild, Health Moderate, Severe; Outcomes or Blunt, Penetrating, Outcome Comments or Reference Study Design Population Blast Measures Results Adjustments Limitations Teuber and Cohort 35 men with brain Penetrating missile Form Board Test Brain-injured Subjects, controls Weinstein, injury selected injuries of head or subjects took more sustained injuries 5– 1954 from 185 with peripheral nerves time, made more 8 years before testing missile wounds of errors, recalled head, 12 controls fewer forms than Subjects grouped on with peripheral controls basis of location of nerve injury lesions wounds of head controls chosen from 101 with missile wounds of peripheral nerves Weinstein and Cohort 62 men with loss Penetrating head AGCT Controls had mean Eliminated Preinjury AGCT Teuber, 1957b of cerebral tissue trauma or peripheral administered 13– increase of 13.0 men with score available for 53 due to penetrating nerve trauma 15 years before AGCT points from aphasic subjects head trauma, 50 injury (on preinjury to difficulties that controls with induction into postinjury testing prevented them Preinjury educational peripheral nerve Army) from reading level determined by injury Brain-injured practice-test interview and from AGCT group, excluding questions case records administered aphasics, had again 10–12 years average increase of after injury 5.2 points; total brain-injured group had increase of 1.6 points Education before injury did not influence extent to which performance on intelligence test was affected after injury
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From page 179... ...
every cognitive World War II; measure except subsamples selected vocabulary, which from 314 studied by was constant Teuber and Weinstein (1956, 1957) ; age, performance correlated only in brain-injured subjects, so age related factors might have contributed to exacerbated decline Grafman et al., Prospective, long- 263 brain-injured Penetrating head Cognitive- Preinjury AFQT ANOVAs, 1988 term followup of veterans, 64 injury outcome, AFQT score was most multiple Vietnam War uninjured controls predictive factor regression veterans (Part of matched on for postinjury analysis VHIS)
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180 Type of TBI: Mild, Health Moderate, Severe; Outcomes or Blunt, Penetrating, Outcome Comments or Reference Study Design Population Blast Measures Results Adjustments Limitations education level not brain lesions associated with predicted cognitive decline cognitive function after injury Raymont et Prospective, long- Subjects drawn Penetrating head Cognitive- At phase 3, no ANOVAs, Those with al., 2008 term followup of from VHIS injury outcome, AFQT significant linear logistic penetrating head Vietnam War registry; 92% had differences and stepwise injury had lower Veterans penetrating head between head- multiple AFQT scores at (part of VHIS injury; of 520 from injured and regressionphase 3 than phase 3) phase 2, 484 are controls in age, procedurescontrols, still alive, and 182 education, preformed to significantly greater 2,000 patients attended phase 3 intelligence assess impact decrease in AFQT entered in registry of demographic score than controls in 1967–1970 The more global factors, from phase 2 to the cognitive test, preinjury phase 3 and from the greater the intelligence, preinjury to phase 3; effect of brain- brain-volume when impact of volume loss loss, lesion education, preinjury location, intelligence, brain genetic volume loss, lesion markers onlocation on cognitive postinjury ability 36–39 intelligence was years after examined, most injury important determinant of postinjury intelligence was preinjury performance as measured by AFQT NOTE: AFQT = Armed Forces Qualification Test, AGCT = Army General Classification Test, ANOVA = analysis of variance, TBI = traumatic brain injury, VHIS = Vietnam Head Injury Study.
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From page 181... ...
with information abstracted from the primary studies. Primary Studies The committee selected six primary studies of closed head injury.
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(1998) examined neurocognitive outcomes in 85 consecutive patients who had moderate to severe head injury and were admitted into the intensive care unit (ICU)
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From page 183... ...
Neurocognitive assessments included tests of attention, working memory, episodic memory, and speed of information processing and used the Paced Auditory Serial Addition Test, the California Verbal Learning Test-I (CVLT-I) , the Symbol Digit Modalities Test, and the Trail Making Test.
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(1998, 1999, 2001) have conducted a series of studies to determine the effects of heading on neurocognitive outcomes in soccer players.
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From page 185... ...
Boxers who had taken part in many bouts had slightly lower scores on a motor measure (finger-tapping) than soccer players and track and field athletes, but overall the boxers did not have significant cognitive impairment.
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Mild Traumatic Brain Injury Vanderploeg et al.
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Primary and secondary studies are consistent in demonstrating sufficient evidence of an association between severe brain injury and neurocognitive deficit. Neurocognitive impairments result in a host of difficulties in people who sustain severe TBI, ranging from attention, memory, informationprocessing speed, and executive functions to even more robust functions, such as language and visuospatial constructional skills.
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From page 188... ...
There is inadequate and insufficient evidence of association between mild TBI and neurocognitive deficits more than 6 months after injury. Although there are known to be subjective neurocognitive complaints in some persons with mild TBI after 6 months, the studies show inconsistent results with regard to objective measures of neurocognitive performance in this group.
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From page 189... ...
TABLE 6.2 Closed Head Injury and Neurocognitive Outcomes Type of TBI: Health Mild, Moderate, Outcomes or Severe; Blunt, Outcome Comments or Reference Study Design Population Penetrating, Blast Measures Results Adjustments Limitations Dikmen et al., Prospective 436 adults, Minimal severity Subjects assessed At 1 year after injury: Controls Study subjects 1995 cohort head-injured patients criteria: any period 1 mo, 1 year afterhead-injured matched on age, included 85% of recruited at time of of LOC, PTA for injury significantly worse sex, education 514 subjects injury in one of three at least 1 h, or than controls (p < recruited from prospective other objective Neuropsychologic 0.01) on Results represent three longitudinal longitudinal studies: evidence of head tests included neuropsychologic tests weighted studies behavioral outcome trauma Halstead Reitan except difference on averages that of head injury, Neuropsycho- Category Test adjust for patient characteristics Head-injury logical Test (p < 0.05)
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; 15–60 years old memory and learning (WMS, Healthy friend SR) ; reasoning controls may not (Category Test)
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From page 191... ...
; at 1 year 1 h or evidence of after TBI, most 15–60 years old 97 of 102 head- cerebral trauma subscales still show injured, 88 of 102 significant impairment controls evaluated at 30% GCS 3–8, 1 year after injury 12% GCS 9–11, Memory performance 59% GCS > 12 a function of head injury severity, length 23% PTA < 24 h, of coma at 1 mo; 25% PTA 1–6 weaker relationship at days, 20% PTA 7– 1 year after TBI 13 days, 32% PTA > 14 days 77% moving vehicle accidents, 10% falls, 8% fights or assaults, 5% other Tate et al., 1991 Cohort Consecutive series of Severe, blunt TBI: Subjects 70% of head-injured Controls Australian first 100 admissions sustained open examined by showed impairments: matched on age, rehabilitation into adult head-injury head injury, initial trained clinical 56.5% of head-injured sex, education, population 191
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From page 192... ...
; univariate disease or mental February 1996 information analyses showed retardation processing; visual significant differences 32 TCs (traumatic reaction time; (p < 0.05) on almost injuries of parts of memory, all tests, with TBI body other than learning; verbal group performing head)
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From page 193... ...
Type of TBI: Health Mild, Moderate, Outcomes or Severe; Blunt, Outcome Comments or Reference Study Design Population Penetrating, Blast Measures Results Adjustments Limitations study period Heitger et al., Prospective 37 patients with mild Mild Neurocognitive At 12 mo, no Controls Exclusion criteria 2006 cohort head injury, 37 testing: PASAT, neurocognitive matched on age, included alcohol controls; patients TMT A and TMT deficits remained sex, education or drug use; CNS recruited from ED of B, WASI disorder; Christchurch Marginal group psychiatric Hospital, New differences on CVLT conditions; Zealand; controls total standard score structural brain recruited from damage or database of interested hematoma on CT students scan; oculomotor or somatomotor deficits; strabismus, poor visual acuity, skull fracture, or history of prior TBI NOTE: AM = Austin Maze, BCT = Booklet Category Test, CNS = central nervous system, CT = computed tomography, CVLT = California Verbal Learning Test, DF = Design Fluency Test, ED = emergency department, GCS = Glasgow Coma Scale, ICU = intensive care unit, LOC = loss of consciousness, MANOVA = multivariate analysis of variance, MMS = Mini Mental Status, OR = odds ratio, PASAT = Paced Auditory Serial Addition Test, PIQ = performance intelligence quotient, PTA = posttraumatic amnesia, ROCF = Rey-Osterrieth Complex Figure Test, SES = socioeconomic status, SR = Selective Reminding Test, SRP = Selective Reminding Procedure, TBI = traumatic brain injury, TC = trauma control, TFC = time to follow commands, TMT A and TMT B = Trail Making Test A and B, TT = Tower of London Test, VIQ = Verbal Intelligence Quotient, WAIS = Wechsler Adult Intelligence Scale, WAIS-R = Wechsler Adult Intelligence Scale -- Revised, WASI = Wechsler Abbreviated Scale of Intelligence, WCST = Wisconsin Card Sorting Test, WMS = Wechsler Memory Scale, WMS-LM = Wechsler Memory Scale, Logical Memory, WMS-VR = Wechsler Memory Scale-Visual Reproduction.
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1990. Wisconsin card sorting test performance based on location and size of neuroanatomical lesion in Vietnam veterans with penetrating head injury.
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1998. Chronic traumatic brain injury in professional soccer players.
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From page 196... ...
2005. Long-term neuropsychological outcomes following mild traumatic brain injury.
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