Citations
Citations
Kernohan-Woltman notch phenomenon (KWP) is an ipsilateral motor weakness due to compression of the contralateral cerebral peduncle. We report two cases of KWP following traumatic brain injury. In case 1, ipsilateral hemiplegia was noted after right subdural hemorrhage. Although magnetic resonance imaging showed no abnormal signal changes on cerebral peduncle, diffusion tensor tractography (DTT) revealed interruption of corticospinal tract (CST) at lower level of the midbrain level. In case 2, there was abnormal signal change of the right cerebral peduncle contralateral to the primary lesion and we could not reconstruct right CST. Case 1 showed unsatisfactory motor recovery even after 15 months, and follow-up DTT showed no change. In case 2, follow-up DTT was not performed, but her ipsilateral hemiparesis had almost disappeared during the 15 months. DTT would be useful in detecting ipsilateral hemiparesis due to KWP and the clinical course may differ according to the lesion characteristics.
Citations
To evaluate the effects of electric cortical stimulation in the experimentally induced focal traumatic brain injury (TBI) rat model on motor recovery and plasticity of the injured brain.
Twenty male Sprague-Dawley rats were pre-trained on a single pellet reaching task (SPRT) and on a Rotarod task (RRT) for 14 days. Then, the TBI model was induced by a weight drop device (40 g in weight, 25 cm in height) on the dominant motor cortex, and the electrode was implanted over the perilesional cortical surface. All rats were divided into two groups as follows: Electrical stimulation (ES) group with anodal continuous stimulation (50 Hz and 194 µs duration) or Sham-operated control (SOC) group with no electrical stimulation. The rats were trained SPRT and RRT for 14 days for rehabilitation and measured Garcia's neurologic examination. Histopathological and immunostaining evaluations were performed after the experiment.
There were no differences in the slice number in the histological analysis. Garcia's neurologic scores & SPRT were significantly increased in the ES group (p<0.05), yet, there was no difference in RRT in both groups. The ES group showed more expression of c-Fos around the brain injured area than the SOC group.
Electric cortical stimulation with rehabilitation is considered to be one of the trial methods for motor recovery in TBI. However, more studies should be conducted for the TBI model in order to establish better stimulation methods.
Citations
To evaluate the motor innervation of trunk muscles in traumatic brain injury patients.
Twenty patients (12 men and 8 women) with traumatic brain injury were enrolled in this study. Their mean age was 41 years. Motor evoked potentials (MEPs) were performed on the motor cortex. Electromyographic activities were recorded from the bilateral rectus abdominis muscles, the external oblique abdominal muscles, and the 4th and 9th thoracic erector spinae muscles. The onset latency and amplitude of contralateral and ipsilateral MEPs were measured. All patients were assessed by the Korean version of the Berg Balance Scale (K-BBS) to investigate the relationship between the frequency of MEPs in trunk muscles and gait ability.
The mean frequency of ipsilateral MEPs was 23.8% with more damaged hemisphere stimulation, while the contralateral MEPs showed a mean frequency of 47.5% with more damaged hemisphere stimulation in traumatic brain injury patients. The latencies and amplitudes of MEPs obtained from the more damaged hemisphere were not significantly different from those of the less damaged hemisphere. There was no correlation between the manifestation of MEPs in trunk muscles and gait ability.
The ipsilateral and contralateral corticospinal pathways to trunk muscles are less likely to be activated in traumatic brain injury patients because of direct injury of the descending corticospinal motor tract or decreased excitability of the corticospinal tract from prefrontal contusion.
Citations
MethodSprague-Dawley rats were randomized to sham ischemia procedures followed by TBI, IPC followed by TBI, and IPC followed by sham TBI. IPC was induced by 20 min of right common carotid artery occlusion 24 hour prior to TBI, and experimental injury was induced using lateral fluid percussion model of moderate severity. We measured metabolic changes with 1H-MRS and conducted motor function and 4 arm maze tests to identify neurobehavioral deficits and cognitive deficits, respectively, at 1 day to 4 weeks post-injury.
ResultsThe NAA/Cr ratios in the affected hemisphere were significantly lower in TBI than in IPC-TBI group at 2 (p=0.006) and 4 (p=0.012) weeks and in the unaffected hemisphere at 4 weeks (p=0.030). TBI group also showed a trend towards reduction in NAA/Cho ratio in the affected hemisphere at 4 weeks (p=0.054).
ConclusionBrief IPC 24 hours before moderate lateral fluid percussion brain injury increases the resistance to brain damage and that is associated with changes in brain metabolites. These findings indicate that IPC induces neuroprotection against TBI in rat brains.
Objective: Traumatic brain injury is related to the acute stress response, and this can be accompanied by an elevated serum glucose level. So we estimated the influence of hyperglycemia on neurologic, functional status and outcome.
Method: We studied the 139 traumatic brain injured patients who had been admitted to the department of neurosurgery from 1996 to 2000, retrospectively. We reviewed initial serum glucose level, postoperative glucose level, and Glasgow Coma Scale (GCS), Glasgow Outcome Scale (GOS). We compared these values with functional independence measure (FIM) scores. Patients were divided into two groups according to the initial serum glucose level, then we analyzed the correlation between glucose level and GCS, GOS, FIM.
Results: The correlations of early hyperglycemia with GCS, GOS, initial FIM scores were significant (p＜0.01). But serum glucose levels were not correlated with plateau FIM scores (p＞0.05). Patients with unfavorable neurologic outcome after 10 days from head injury had significantly high serum initial and postoperative glucose levels than those with favorable neurologic outcome (p＜0.01).
Conclusion: In patients who had received rehabilitation therapy with moderate or severe head injury, early hyperglycemia were significantly correlated with initial FIM scores, GCS, GOS, but not with the plateau FIM scores.
Objective: To present one case of dysphagia associated with jugular foramen syndrome (Vernet syndrome) by trauma. The jugular foramen syndrome refers to paralysis of the IX, X and XI cranial nerves. Dysphagia due to jugular foramen syndorme without pseudobular palsy is rare in traumatic brain injury.
Case Summary: A 16-year-old boy with the left occipital skull fracture and skull base fracture was not able to take any food by mouth. There was no other significant symptom without dysphagia. Physical examination, laryngoscopic examination and electromyography revealed paralysis of the left IX, X and XI cranial nerves. Videofluoroscopic examination demonstrated atonic ballooned pyriformis sinus and closed upper esophageal sphincter. Brain CT and MRI showed fracture line in the left jugular foramen without brain stem or diffuse cortical lesion. Feeding gastrostomy was performed.
Conclusion: We report an unusual case of dysphagia due to jugular foramen syndrome in traumatic brain injury patient.
Objective: The purpose of this study was to determine whether 1H magnetic resonance spectroscopy (MRS) is a potential tool for the detection of microscopic diffuse axonal injury (DAI) and for the evaluation of functional status of patients with traumatic brain injury (TBI).
Method: Seven patients with severe TBI and fourteen normal control volunteers were examined. Image guided spectra of localized in vivo 1H MRS were obtained from parietal white matter (PWM) and occipital gray matter (OGM) in which definite abnormality was not detected in MR imaging. The severity of TBI was evaluated by the initial Glasgow Coma Scale (GCS), and the functional status was evaluated by Functional Independence Measure (FIM) at the time of the MRS examination, approximately 2 months after onset.
Results: In PWM, the [N-acetylaspartate(NAA)/Creatine(Cr)] ratio was significantly lower, and the [Choline(Cho)/Cr] and [myo-Inositol(mI)/Cr] ratios were significantly higher in the patients with TBI than those of normal volunteers. There was no significant correlation between the ratios of metabolites and GCS scores. However, interestingly, a significant correlation between the [NAA/Cr] ratio in PWM and the FIM scores was observed.
Conclusion: We could conclude that decreased [NAA/Cr], increased [Cho/Cr], and increased [mI/Cr] ratios in PWM can be considered as markers for DAI. Localized 1H MRS has a potential to be used for the detection of DAI in vivo and evaluation of functional status of the patients with TBI.
Objective: To evaluate the effect of methylphenidate on cognitive function especially on working memory and visuospatial attention in the patients with traumatic brain injury (TBI).
Method: Eighteen subjects, 16 males and 2 females, with TBI were enrolled. Their mean age was 34.2 years old. A double-blind placebo-controlled study was designed. The baseline cognitive assessment was performed before the administration of drug. Two days after the baseline study, 20 mg of methylphenidate or placebo was administered. The second cognitive assessment was performed 2 hours after the treatment. The follow-up assessment conducted two days after the second test. Cognitive assessments consisted of 'one-back working memory task' and 'endogenous visuospatial attention task', designed using SuperLab Pro 2.0Ⱂ software.
Results: In one-back working memory test, there was significant improvement of response accuracy in methylphenidate group in comparison with placebo group (p＜0.01). Significant shortening of reaction time was also seen after the administration of drug in methylphenidate group (p＜0.05). In endogenous visuospatial attention test, significant improvement of response accuracy was noticed after the administration of drug in methylphenidate group (p＜0.05).
Conclusion: These results demonstrated that the administration of methylphenidate was beneficial in improving cognitive function following TBI. The effect was prominent in the accuracy of working memory.
Objective: To identify the clinical characteristics of the patients with hypoxic-hypotensive brain injury (HBI) and to compare the prognosis of HBI with patients with traumatic brain injury (TBI).
Method: Six patients with HBI and sixteen patients with TBI, who had been comatose for more than 8 hours, were enrolled. The functional status was evaluated by the Functional Independence Measure (FIM) score.
Results: The causes of HBI were: two respiratory arrest, three cardiac arrest, and one hypotensive shock. Most patients had memory disturbance, confusion, spasticity, contracture of joints, and weakness after the HBI. Other problems included dysphagia, ataxia or tremor, dementia, and concomitant medical problems. Among these clinical features, confusion and spasticity were serious obstacles in rehabilitation. The HBI patients had lower initial and discharge total FIM score, total FIM gain, total FIM efficacy, cognitive FIM efficacy, and motor FIM efficacy than the TBI patients. The HBI patients had a poor outcome due to more widespread brain damage, medical complications, and delayed rehabilitation treatments as compared with TBI patients.
Conclusion: We concluded that HBI patients had more diffuse and severe deficit than TBI patients.
Objective: To identify the incidence and characteristics of language disorders in patients with traumatic brain injury (TBI), and to understand the differences of language disorder according to the degree and lesion of brain damage and the outcomes after proper language training programs.
Method: The subjects were 24 adult TBI patients. Seventeen patients with language disorder were examined with language disorder screening test. The characteristics of the language disorders were evaluated according to the degree and lesion site of the brain injury. Prognosis of the language disorders was studied. The tests were performed at the initiation and termination of the language treatment program.
Results: The incidence of language disorders was 91.7%. At the initial evaluation, all items showed a low rate of correct response, but at the final evaluation, the statistically significant improvement was noted in all items. There was no difference between moderate and severe brain damages at final evaluation. Focal lesion group revealed higher rate of correct response than diffuse lesion group on comprehension, expression, reading, and calculation at final evaluation.
Conclusion: The TBI patients showed diffuse language dysfunction on fluency, comprehension, expression, reading, writing, and calculation. But the majority of these patients showed satisfactory recovery, especially the focal brain lesion showed the better outcome. These patients with focal lesion were needed precise language evaluation and more intensive language treatment program.
Mirror writing is script that runs in the direction opposite to normal, with individual letters also reversed. A Right handed woman suddenly developed mirror-writing. After traumatic brain injury without definitive lesions on MRI, she could not discriminate between right and left by herself. Several theories, including motor, visual dominance, spatial disorientation and supplementary motor hypotheses, have been proposed to explain such. We believe that availability of mirror engrams induce reversal of normal left-to-right writing pattern including mirror-writings.
Objective: Lower extremity orthoses are important in the rehabilitation of the patients with stroke and traumatic brain injury. But it is unknown how much they are used in the social activity after the discharge from the hospital. This study was carried out to investigate the status of using orthosis in social activity and complaints about orthosis.
Method: The questionnaires were given to 42 cases with stroke and 17 cases with traumatic brain injury.
Results: The user of lower extremity orthosis in social activity were 55.9%, and the causes of disuse were patient's poor condition, improved gait pattern, inappropriate design and defect of orthosis, and patient's refusal. The degree of satisfaction with orthosis for comfort, external appearance and weight were 79.3%, 86.2%, and 72.4%, respectively.
Conclusion: Physiatrists should give more attention in orthosis at follow-up of patients with stroke and traumatic brain injury and make efforts to improve function and external appearance of orthosis.
Objective: To investigate the frequency and nature of dysphagia of traumatic brain injured (TBI) patients, and to examine the relationship of clinical parameters with the dysphagia.
Method: Forty-two TBI patients were included in this study. We examined clinical parameters such as Glasgow coma scale (GCS), duration of coma, and posttraumatic amnesia (PTA), hospital stay, rehabilitation stay, functional independence measure (FIM) gain, and efficiency as functional outcomes. We classified the brain lesions into two categories: focal and nonfocal lesion according to the findings of the brain CT imaging. We performed videofluoroscopic swallowing study (VSS) for patients with dysphagia.
Results: Eighteen (42.8%) out of total 42 TBI patients had dysphagia. The presence of dysphagia had significant relationship with GCS, duration of PTA, hospital and rehabilitation stay, and FIM gain. Duration of dysphagia was positively correlated with duration of coma, and hospital and rehabilitation stay, but negatively correlated with FIM gain and efficiency. Duration of dysphagia was longer in patients with nonfocal brain lesion than those with focal brain lesion. On VSS findings, common problems were impairment of tongue control and prolonged pharyngeal transit time. Majority of patients had combined problems in oral and pharyngeal phases.
Conclusion: Dysphagia was common problem in TBI patients, and occurrence and duration were correlated with several clinical parameters and with prognosis of TBI patients.
Objective: To identify the neurobehavioral impairment in the traumatic brain injured (TBI) patients and to determine the relationship between the neurobehavioral impairment and functional recovery.
Method: We analyzed and compared Functional Independence Measure (FIM) scores and neurobehavioral psychometry results in 16 patients with severe TBI. The neurobehavioral psychometry tests included Minimental Status Examination (MMSE), Galvestone Orientation and Amnesia Test (GOAT) as screening tools, Korean Wechsler Intelligence Scale (KWIS) for intelligence, Wechsler Memory Scale-Revised (WMS-R) test for memory function, Color Trail test (CTT) 1 and 2 for attention and concentration, Grooved Pegboard Test (GPT) and Finger Tapping Test (FTT) for motor function, Wisconsin Card Sorting Test (WCST) for executive function, and Symptom Checklist-90-Revision (SCL-90-R) for personality.
Results: At discharge, neurobehavioral psychometry of the TBI patients showed impairment of the attention and concentration as demonstrated by severe and moderate impairment in CTT 1 and CTT 2, repectively. Memory disturbance was also noted by the result of mental retardation in WMS-R. But GOAT and MMSE showed normal, KWIS was below average. Motor dysfunction was seen in GPT and FTT and mild executive dysfunction in WCST. Functional recuperation was influenced by attention and concentration, as the FIM score has significant correlation with CTT 1 and FTT.
Conclusion: The TBI patients have the pervasive neurobehavioral impairment, especially severe dysfunction in the memory, attention and concentration. And functional recovery was significantly correlated with attention. The neurobehavioral psychometry will be useful in neurobehavioral evaluation in TBI patients. A further prospective study using Neurobehavioral psychometry would bring a more precise and valuable information.
We report a 47-year old traumatic brain injury male patient who was treated for the rigidity and tremor with sinemet (carbidopalevodopa) and artane (trihexyphenidyl). He came to the emergency room ten days after the stopping of sinemet. Acute onset of increased obtunded, immobile, rigid, deep coma, and minimal response to a deep pain was presented. There was no evidence of the focal neurological signs. Over the next two days, he awoke with a normal mental status. His muscle tone become normal and he returned to home without residual medical problems or complications.
We report a serotonin syndrome in a traumatic brain injury patient who was treated with sinemet and artane, which resulted in a dysregulation of serotonin activity.
Objectives: To investigate the correlation of the initial Computerized Tomography(CT) findings of the brain and the functional outcome, and to suggest the initial CT findings as a functional outcome predictor in the traumatic brain injured(TBI) patients.
Methods: Thirty-nine TBI patients were included in this study. Subjects were divided into groups of non-focal or focal TBI, and with or without a depressed skull fracture according to their initial brain CT findings.
Results: The non-focal TBI patients were not significantly different from focal TBI patients in the days from onset to rehabilitation, rehabilitation stay, and initial FIM score. However their outcome in FIM gain and FIM efficiency significantly worse than focal TBI patients. The TBI patients with a depressed skull fracture were not significantly different from the patients without a depressed skull fracture in the days from onset to rehabilitation, rehabilitation stay, and intial FIM score. However their outcomes were significantly worse than patients without a depressed skull fractrue in FIM efficiency.
Conclusion: The initial brain CT findings were generally useful for the prediction of functional outcomes in TBI patients.
Objective: The purposes of this study were to estimate the incidence and complications of the tracheostomy and after decannulation, and to compare the functional outcomes between tracheostomy and non-tracheostomy groups in the severe traumatic brain injury (TBI) patients.
Method: One hundred and fifteen severe TBI patients were included in this study and the functional outcomes were measured by the Functional Independence Measure (FIM) scores retrospectively.
Results: The incidence of tracheostomy was 45.2% and the average duration of tracheostmy was 69.7 days. Twenty seven complications associated with the tracheostomy (51.9%) were reported and a pneumonia was the most common complication. Fourteen complications (26.9%) were reported after the decannulation and a tracheal granuloma was the most common complication. Complications mostly occurred during the first two weeks of tracheostomy. The duration of rehabilitation treatment for the patients with tracheostomy was longer than the patients without tracheostomy. TBI patients with tracheostomy had significantly lower initial and discharge FIM scores, FIM gain, and FIM efficiency than the patients without tracheostomy.
Conclusion: The complications of tracheostomy were mostly occurred early in the acute stage. Functional outcomes were lower in severe TBI patients with tracheostomy, thus early comprehensive and aggressive rehabilitation treatments would be necessary.
The incidence of traumatic brain injury (TBI) has increased with the advanced technology of society. A careful evaluation of associated problems, initial severity, and complications is important for the acute management and rehabilitation of patients with TBI. To predict the rehabilitation potentials of patients with TBI, we have retrospectively investigated the causes, types of injury, associated problems, and complications in 186 patients and also assessed the rehabilitation outcomes by measuring the functional gains according to the types of brain injury and the initial severities evaluated by the Glasgow coma scale in 82 patients. The functional gains were measured by differences of the Mini-mental status examination, PULSES profile, and Barthel index of pre- and post-rehabilitation states. The incidence of TBI was highest in the 3rd decade men and the most common cause was a traffic accident (120 cases, 64.5%). The types of brain injury were a diffuse axonal injury, 87 cases (46.8%); epidural hematoma, 21 cases (11.3 %); subarachnoid hemorrhage, 25 cases (13.4%); subdural hematoma, 28 cases (15.1%); and intracerebral hematoma, 25 cases (12.9%). Common associated problems were fractures and injuries of nervous system. The 7th cranial nerve and the peroneal nerve were the most common injuries for cranial and peripheral nerves, respectively. Common complications were pulmonary and skin disorders. Total hospital stay and the duration for rehabilitation were not significantly different by the types of injury. Functional gain tended to be higher in the intracerebral hematoma compared to the other types of brain injury. The functional gain was statistically higher in patients with initial severity of moderate degree according to the Glasgow coma scale. In conclusion the moderate traumatic brain injured patients seem to have a higher potential for the good functional outcome.
The sympathetic skin response(SSR) is a simple test to assess sympathetic nerve function through sudomotor activity after electric stimulation. However the electrophysiologic characteristics of sympathetic skin response have not been fully documented regardless of the impending necessities. To understand the characteristics of central conduction of SSR by taking SSRs in various central nervous system diseases, 336 SSRs were measured in 14 stroke patients, 6 spinal cord injury patients and 2 traumatic brain injury patients and analysed by classifying into no response(NR), slight and normal groups.
In stroke patients, normal SSRs were obtained more in hemiplegic side than non-hemiplegic side after both limb stimulations. And normal SSR were obtained more in left hemiplegic patients than right hemiplegic patients even though number of subject was limited. The patterns of SSR in traumatic brain injured and spinal cord injured patients were not so closely correlated with severity of clinical symptoms and abnormal somatosensory evoked potentials.
The sympathetic skin response seems to be exclusively under the control of central nervous system of which the subcortex would be regarded as the sudomotor reflex center.
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