Neurosurgery & Trauma

Recent developments regarding the nature of transmissible pathologic proteins in a variety of common neurodegenerative diseases have started to cause clinicians and public health experts to wonder if there is cause for concern.

A group from the National Hospital for Neurology & Neurosurgery at Queen Square, London, recently published a study presenting evidence that Alzheimer’s disease may have transmissible properties similar to traditionally regarded prion diseases such as Creutzfeldt-Jakob disease (Nature. 2015 Sep 10;525:247-50. doi:10.1038/nature15369). This conclusion was based upon the observation of cerebral and vascular amyloid-beta deposition in several patients who had received cadaveric growth hormone extracts ranging from 19 to 39 years earlier and who developed iatrogenic Creutzfeldt-Jakob disease (CJD). Amyloid deposition was also identified in the pituitary glands of patients with amyloid-beta pathology also felt to be iatrogenically transmitted.

This is not the first time, however, that analogies have been drawn between neurodegenerative diseases and prion-related diseases. Perhaps inspired by the evident connectivity of affected upper and lower motor neuronal populations in amyotrophic lateral sclerosis, previous investigators have sought cell-to-cell transmission of neurodegenerative pathology and have demonstrated this for amyloid as well as tau species in Alzheimer’s disease, and for synuclein species in Parkinson’s disease.

A recent article by Dr. Stanley Prusiner of the University of California, San Francisco, and his colleagues presented evidence that brain extracts from patients with multiple system atrophy (MSA) transmitted the characteristic MSA alpha-synuclein aggregates in the brains of transgenic mice as well as in cultured human embryonic kidney cells (Proc Natl Acad Sci U S A. 2015 Aug 31. doi:10.1073/pnas.1514475112).

An emerging theme from these recent and prior studies is that neurodegenerative diseases behave a lot like prion diseases, and although they follow a much slower time course, may spread through synaptic pathways as well as between people through prion-like mechanisms. CJD, while transmissible, is not “contagious,” and public messaging should draw this distinction in regard to neurodegenerative diseases. Nonetheless, further research is urgently needed given the implications of this work. Dr. Prusiner and his associates concluded, for example, that deep brain stimulation electrodes and related equipment should not be reused from Parkinson’s disease patients for fear of spreading the synucleinopathy from one person to another. Should there be restrictions with regard to any form of tissue transplantation or blood transfusion from patients with Parkinson’s disease or Alzheimer’s disease? Questions such as these need further clarification, and given the prevalence of these procedures, such research should be highly prioritized.

Dr. Caselli is professor of neurology at the Mayo Clinic, Scottsdale, Ariz. He also serves there as associate director and clinical core director of the Alzheimer’s Disease Center.

Recent developments regarding the nature of transmissible pathologic proteins in a variety of common neurodegenerative diseases have started to cause clinicians and public health experts to wonder if there is cause for concern.

A group from the National Hospital for Neurology & Neurosurgery at Queen Square, London, recently published a study presenting evidence that Alzheimer’s disease may have transmissible properties similar to traditionally regarded prion diseases such as Creutzfeldt-Jakob disease (Nature. 2015 Sep 10;525:247-50. doi:10.1038/nature15369). This conclusion was based upon the observation of cerebral and vascular amyloid-beta deposition in several patients who had received cadaveric growth hormone extracts ranging from 19 to 39 years earlier and who developed iatrogenic Creutzfeldt-Jakob disease (CJD). Amyloid deposition was also identified in the pituitary glands of patients with amyloid-beta pathology also felt to be iatrogenically transmitted.

This is not the first time, however, that analogies have been drawn between neurodegenerative diseases and prion-related diseases. Perhaps inspired by the evident connectivity of affected upper and lower motor neuronal populations in amyotrophic lateral sclerosis, previous investigators have sought cell-to-cell transmission of neurodegenerative pathology and have demonstrated this for amyloid as well as tau species in Alzheimer’s disease, and for synuclein species in Parkinson’s disease.

A recent article by Dr. Stanley Prusiner of the University of California, San Francisco, and his colleagues presented evidence that brain extracts from patients with multiple system atrophy (MSA) transmitted the characteristic MSA alpha-synuclein aggregates in the brains of transgenic mice as well as in cultured human embryonic kidney cells (Proc Natl Acad Sci U S A. 2015 Aug 31. doi:10.1073/pnas.1514475112).

An emerging theme from these recent and prior studies is that neurodegenerative diseases behave a lot like prion diseases, and although they follow a much slower time course, may spread through synaptic pathways as well as between people through prion-like mechanisms. CJD, while transmissible, is not “contagious,” and public messaging should draw this distinction in regard to neurodegenerative diseases. Nonetheless, further research is urgently needed given the implications of this work. Dr. Prusiner and his associates concluded, for example, that deep brain stimulation electrodes and related equipment should not be reused from Parkinson’s disease patients for fear of spreading the synucleinopathy from one person to another. Should there be restrictions with regard to any form of tissue transplantation or blood transfusion from patients with Parkinson’s disease or Alzheimer’s disease? Questions such as these need further clarification, and given the prevalence of these procedures, such research should be highly prioritized.

Dr. Caselli is professor of neurology at the Mayo Clinic, Scottsdale, Ariz. He also serves there as associate director and clinical core director of the Alzheimer’s Disease Center.

Recent developments regarding the nature of transmissible pathologic proteins in a variety of common neurodegenerative diseases have started to cause clinicians and public health experts to wonder if there is cause for concern.

A group from the National Hospital for Neurology & Neurosurgery at Queen Square, London, recently published a study presenting evidence that Alzheimer’s disease may have transmissible properties similar to traditionally regarded prion diseases such as Creutzfeldt-Jakob disease (Nature. 2015 Sep 10;525:247-50. doi:10.1038/nature15369). This conclusion was based upon the observation of cerebral and vascular amyloid-beta deposition in several patients who had received cadaveric growth hormone extracts ranging from 19 to 39 years earlier and who developed iatrogenic Creutzfeldt-Jakob disease (CJD). Amyloid deposition was also identified in the pituitary glands of patients with amyloid-beta pathology also felt to be iatrogenically transmitted.

This is not the first time, however, that analogies have been drawn between neurodegenerative diseases and prion-related diseases. Perhaps inspired by the evident connectivity of affected upper and lower motor neuronal populations in amyotrophic lateral sclerosis, previous investigators have sought cell-to-cell transmission of neurodegenerative pathology and have demonstrated this for amyloid as well as tau species in Alzheimer’s disease, and for synuclein species in Parkinson’s disease.

A recent article by Dr. Stanley Prusiner of the University of California, San Francisco, and his colleagues presented evidence that brain extracts from patients with multiple system atrophy (MSA) transmitted the characteristic MSA alpha-synuclein aggregates in the brains of transgenic mice as well as in cultured human embryonic kidney cells (Proc Natl Acad Sci U S A. 2015 Aug 31. doi:10.1073/pnas.1514475112).

An emerging theme from these recent and prior studies is that neurodegenerative diseases behave a lot like prion diseases, and although they follow a much slower time course, may spread through synaptic pathways as well as between people through prion-like mechanisms. CJD, while transmissible, is not “contagious,” and public messaging should draw this distinction in regard to neurodegenerative diseases. Nonetheless, further research is urgently needed given the implications of this work. Dr. Prusiner and his associates concluded, for example, that deep brain stimulation electrodes and related equipment should not be reused from Parkinson’s disease patients for fear of spreading the synucleinopathy from one person to another. Should there be restrictions with regard to any form of tissue transplantation or blood transfusion from patients with Parkinson’s disease or Alzheimer’s disease? Questions such as these need further clarification, and given the prevalence of these procedures, such research should be highly prioritized.

Dr. Caselli is professor of neurology at the Mayo Clinic, Scottsdale, Ariz. He also serves there as associate director and clinical core director of the Alzheimer’s Disease Center.

Peripheral plasma levels of the CNS protein tau are chronically elevated after traumatic brain injury and appear to correlate with the severity of postconcussive symptoms, according to a report published Aug. 3 in JAMA Neurology.

If these findings are confirmed, this will be the first biomarker that is sensitive and specific to persistent traumatic brain injury–related symptoms. The results also suggest that “months to years after the primary brain injury, there may be a continuation of secondary injuries with residual axonal degeneration and blood-brain barrier disruptions in this population that may contribute to the maintenance of postconcussive disorder symptoms and affect symptom severity,” wrote Anlys Olivera, Ph.D., of the National Institute of Nursing Research, Bethesda, Md., and her associates.

Tau is a protein that stabilizes the structure of the axonal cytoskeleton. It is elevated in the cerebrospinal fluid and the peripheral blood (albeit in extremely low concentrations) of patients with severe traumatic brain injury (TBI), professional boxers, and athletes who sustain concussions. The extremely low levels of tau in the peripheral blood have been very difficult to measure until the recent development of an ultrahigh-sensitivity immunoassay technology. Using this innovation, the researchers were able to examine for the first time the associations between plasma tau levels and the frequency and severity of deployment-related TBIs.

Over a 2-year period, Dr. Olivera and her associates assessed tau levels in 70 members of the military who self-reported one or more TBIs and 28 control subjects without TBI who were matched for age, sex, race, time since deployment, and number of deployments. Almost all of those in the TBI group had been injured at least 18 months previously. The most common sources of TBI were blows to the head, exposure to blasts, vehicular crashes, and sports-related concussions.

Total tau was significantly increased in the TBI group (mean level, 1.13 pg/mL), compared with the control group (0.63 pg/mL). Total tau also increased with increasing severity of the initial brain injury, with increasing numbers of TBIs, and increasing severity of present-day postconcussive symptoms. These associations, moreover, were independent of symptoms of posttraumatic brain disorder (PTSD) and depression, which were prevalent in the TBI group, the investigators said (JAMA Neurol. 2015 Aug 3 doi: 10.1001/jamaneurol.2015.1383).

Tau is not only a marker of brain injury; it also can contribute to secondary injury processes such as inflammation, which makes it a potential target for therapy. If the findings of this study are confirmed and extended to demonstrate a direct mechanistic relationship between TBI and tau aggregation, treatments such as the direct delivery of proteasomes “would be invaluable, considering the dearth of treatments for TBIs and chronic [postconcussive disorder] symptoms,” Dr. Olivera and her associates said.

Among the limitations cited by the investigators are lack of neuroimaging and neuropsychological data.

This study was supported by the National Institutes of Health’s National Institute of Nursing Research and the Center for Neuroscience and Regenerative Medicine, which is a collaborative program between the Department of Defense and the NIH. Dr. Olivera reported having no relevant financial disclosures. One of her associates reported ties to Quanterix, developer of the ultrahigh-sensitivity Simoa technology used in this study, which allows measurement of extremely low levels of tau and other CNS-derived biomarkers in the plasma or serum.

Peripheral plasma levels of the CNS protein tau are chronically elevated after traumatic brain injury and appear to correlate with the severity of postconcussive symptoms, according to a report published Aug. 3 in JAMA Neurology.

If these findings are confirmed, this will be the first biomarker that is sensitive and specific to persistent traumatic brain injury–related symptoms. The results also suggest that “months to years after the primary brain injury, there may be a continuation of secondary injuries with residual axonal degeneration and blood-brain barrier disruptions in this population that may contribute to the maintenance of postconcussive disorder symptoms and affect symptom severity,” wrote Anlys Olivera, Ph.D., of the National Institute of Nursing Research, Bethesda, Md., and her associates.

Tau is a protein that stabilizes the structure of the axonal cytoskeleton. It is elevated in the cerebrospinal fluid and the peripheral blood (albeit in extremely low concentrations) of patients with severe traumatic brain injury (TBI), professional boxers, and athletes who sustain concussions. The extremely low levels of tau in the peripheral blood have been very difficult to measure until the recent development of an ultrahigh-sensitivity immunoassay technology. Using this innovation, the researchers were able to examine for the first time the associations between plasma tau levels and the frequency and severity of deployment-related TBIs.

Over a 2-year period, Dr. Olivera and her associates assessed tau levels in 70 members of the military who self-reported one or more TBIs and 28 control subjects without TBI who were matched for age, sex, race, time since deployment, and number of deployments. Almost all of those in the TBI group had been injured at least 18 months previously. The most common sources of TBI were blows to the head, exposure to blasts, vehicular crashes, and sports-related concussions.

Total tau was significantly increased in the TBI group (mean level, 1.13 pg/mL), compared with the control group (0.63 pg/mL). Total tau also increased with increasing severity of the initial brain injury, with increasing numbers of TBIs, and increasing severity of present-day postconcussive symptoms. These associations, moreover, were independent of symptoms of posttraumatic brain disorder (PTSD) and depression, which were prevalent in the TBI group, the investigators said (JAMA Neurol. 2015 Aug 3 doi: 10.1001/jamaneurol.2015.1383).

Tau is not only a marker of brain injury; it also can contribute to secondary injury processes such as inflammation, which makes it a potential target for therapy. If the findings of this study are confirmed and extended to demonstrate a direct mechanistic relationship between TBI and tau aggregation, treatments such as the direct delivery of proteasomes “would be invaluable, considering the dearth of treatments for TBIs and chronic [postconcussive disorder] symptoms,” Dr. Olivera and her associates said.

Among the limitations cited by the investigators are lack of neuroimaging and neuropsychological data.

This study was supported by the National Institutes of Health’s National Institute of Nursing Research and the Center for Neuroscience and Regenerative Medicine, which is a collaborative program between the Department of Defense and the NIH. Dr. Olivera reported having no relevant financial disclosures. One of her associates reported ties to Quanterix, developer of the ultrahigh-sensitivity Simoa technology used in this study, which allows measurement of extremely low levels of tau and other CNS-derived biomarkers in the plasma or serum.

Peripheral plasma levels of the CNS protein tau are chronically elevated after traumatic brain injury and appear to correlate with the severity of postconcussive symptoms, according to a report published Aug. 3 in JAMA Neurology.

If these findings are confirmed, this will be the first biomarker that is sensitive and specific to persistent traumatic brain injury–related symptoms. The results also suggest that “months to years after the primary brain injury, there may be a continuation of secondary injuries with residual axonal degeneration and blood-brain barrier disruptions in this population that may contribute to the maintenance of postconcussive disorder symptoms and affect symptom severity,” wrote Anlys Olivera, Ph.D., of the National Institute of Nursing Research, Bethesda, Md., and her associates.

Tau is a protein that stabilizes the structure of the axonal cytoskeleton. It is elevated in the cerebrospinal fluid and the peripheral blood (albeit in extremely low concentrations) of patients with severe traumatic brain injury (TBI), professional boxers, and athletes who sustain concussions. The extremely low levels of tau in the peripheral blood have been very difficult to measure until the recent development of an ultrahigh-sensitivity immunoassay technology. Using this innovation, the researchers were able to examine for the first time the associations between plasma tau levels and the frequency and severity of deployment-related TBIs.

Over a 2-year period, Dr. Olivera and her associates assessed tau levels in 70 members of the military who self-reported one or more TBIs and 28 control subjects without TBI who were matched for age, sex, race, time since deployment, and number of deployments. Almost all of those in the TBI group had been injured at least 18 months previously. The most common sources of TBI were blows to the head, exposure to blasts, vehicular crashes, and sports-related concussions.

Total tau was significantly increased in the TBI group (mean level, 1.13 pg/mL), compared with the control group (0.63 pg/mL). Total tau also increased with increasing severity of the initial brain injury, with increasing numbers of TBIs, and increasing severity of present-day postconcussive symptoms. These associations, moreover, were independent of symptoms of posttraumatic brain disorder (PTSD) and depression, which were prevalent in the TBI group, the investigators said (JAMA Neurol. 2015 Aug 3 doi: 10.1001/jamaneurol.2015.1383).

Tau is not only a marker of brain injury; it also can contribute to secondary injury processes such as inflammation, which makes it a potential target for therapy. If the findings of this study are confirmed and extended to demonstrate a direct mechanistic relationship between TBI and tau aggregation, treatments such as the direct delivery of proteasomes “would be invaluable, considering the dearth of treatments for TBIs and chronic [postconcussive disorder] symptoms,” Dr. Olivera and her associates said.

Among the limitations cited by the investigators are lack of neuroimaging and neuropsychological data.

This study was supported by the National Institutes of Health’s National Institute of Nursing Research and the Center for Neuroscience and Regenerative Medicine, which is a collaborative program between the Department of Defense and the NIH. Dr. Olivera reported having no relevant financial disclosures. One of her associates reported ties to Quanterix, developer of the ultrahigh-sensitivity Simoa technology used in this study, which allows measurement of extremely low levels of tau and other CNS-derived biomarkers in the plasma or serum.

Half of moderate to severe traumatic brain injury patients had markedly impaired corpus callosum (CC) functioning and structural integrity that is associated with poor neurocognitive functioning, according to a study of children aged 8-19 years.

The researchers used high angular resolution diffusion-weighted imaging to determine the structural integrities of the CC in 32 children who had suffered a traumatic brain injury (TBI) and of the CC in 31 healthy children. Patients in the experimental group had suffered from a moderate to severe TBI 1-5 months prior to the study. The researchers assessed CC function through interhemispheric transfer time (IHTT) – the time required to transfer stimulus-locked neural activity between the left and right brain hemispheres. Each participant’s IHTT was calculated from recording electroencephalography, while he or she completed a computerized, pattern-matching task with bilateral field advantage.

Half of the TBI patients had significantly slower IHTTs than did the control group. The IHTTs of this so-called IHTT-slow TBI group deviated by at least 1.5 standard deviations from data for the healthy control group.

The IHTT-slow TBI group also demonstrated lower CC integrity and poorer neurocognitive functioning than did both the control group and the remaining members of the experimental group. Lower fractional anisotropy (FA) – a common sign of impaired white matter (WM) – and slower IHTTs also predicted poor neurocognitive function.

“When we compared the IHTT-slow TBI group to the healthy control group, we found significant differences in callosal WM integrity, as well as the integrity of the association and projection tract systems tested. Lower FA and higher mean diffusivity (MD) in the IHTT-slow group suggests myelin disruption,” noted Emily L Dennis of the University of Southern California, Marina del Rey, and her colleagues. “When we compared the IHTT-normal TBI group to the healthy control group, we found only a few areas where the TBI group had significantly lower FA and no significant differences in MD [mean diffusivity].”

Read the full study in the Journal of Neuroscience (doi:10.1523/JNEUROSCI.1595-15.2015).

[email protected]

Half of moderate to severe traumatic brain injury patients had markedly impaired corpus callosum (CC) functioning and structural integrity that is associated with poor neurocognitive functioning, according to a study of children aged 8-19 years.

The researchers used high angular resolution diffusion-weighted imaging to determine the structural integrities of the CC in 32 children who had suffered a traumatic brain injury (TBI) and of the CC in 31 healthy children. Patients in the experimental group had suffered from a moderate to severe TBI 1-5 months prior to the study. The researchers assessed CC function through interhemispheric transfer time (IHTT) – the time required to transfer stimulus-locked neural activity between the left and right brain hemispheres. Each participant’s IHTT was calculated from recording electroencephalography, while he or she completed a computerized, pattern-matching task with bilateral field advantage.

Half of the TBI patients had significantly slower IHTTs than did the control group. The IHTTs of this so-called IHTT-slow TBI group deviated by at least 1.5 standard deviations from data for the healthy control group.

The IHTT-slow TBI group also demonstrated lower CC integrity and poorer neurocognitive functioning than did both the control group and the remaining members of the experimental group. Lower fractional anisotropy (FA) – a common sign of impaired white matter (WM) – and slower IHTTs also predicted poor neurocognitive function.

“When we compared the IHTT-slow TBI group to the healthy control group, we found significant differences in callosal WM integrity, as well as the integrity of the association and projection tract systems tested. Lower FA and higher mean diffusivity (MD) in the IHTT-slow group suggests myelin disruption,” noted Emily L Dennis of the University of Southern California, Marina del Rey, and her colleagues. “When we compared the IHTT-normal TBI group to the healthy control group, we found only a few areas where the TBI group had significantly lower FA and no significant differences in MD [mean diffusivity].”

Read the full study in the Journal of Neuroscience (doi:10.1523/JNEUROSCI.1595-15.2015).

[email protected]

Half of moderate to severe traumatic brain injury patients had markedly impaired corpus callosum (CC) functioning and structural integrity that is associated with poor neurocognitive functioning, according to a study of children aged 8-19 years.

The researchers used high angular resolution diffusion-weighted imaging to determine the structural integrities of the CC in 32 children who had suffered a traumatic brain injury (TBI) and of the CC in 31 healthy children. Patients in the experimental group had suffered from a moderate to severe TBI 1-5 months prior to the study. The researchers assessed CC function through interhemispheric transfer time (IHTT) – the time required to transfer stimulus-locked neural activity between the left and right brain hemispheres. Each participant’s IHTT was calculated from recording electroencephalography, while he or she completed a computerized, pattern-matching task with bilateral field advantage.

Half of the TBI patients had significantly slower IHTTs than did the control group. The IHTTs of this so-called IHTT-slow TBI group deviated by at least 1.5 standard deviations from data for the healthy control group.

The IHTT-slow TBI group also demonstrated lower CC integrity and poorer neurocognitive functioning than did both the control group and the remaining members of the experimental group. Lower fractional anisotropy (FA) – a common sign of impaired white matter (WM) – and slower IHTTs also predicted poor neurocognitive function.

“When we compared the IHTT-slow TBI group to the healthy control group, we found significant differences in callosal WM integrity, as well as the integrity of the association and projection tract systems tested. Lower FA and higher mean diffusivity (MD) in the IHTT-slow group suggests myelin disruption,” noted Emily L Dennis of the University of Southern California, Marina del Rey, and her colleagues. “When we compared the IHTT-normal TBI group to the healthy control group, we found only a few areas where the TBI group had significantly lower FA and no significant differences in MD [mean diffusivity].”

Read the full study in the Journal of Neuroscience (doi:10.1523/JNEUROSCI.1595-15.2015).

[email protected]

Head contact with other players, not with the ball, is the main source of concussions among high-school soccer players of both sexes, according to a report published online July 13 in JAMA Pediatrics.

Several studies have shown that “heading” the ball during soccer practices and games is responsible for many soccer-related concussions, and some have called for banning such heading, especially among children and adolescents, to make the sport safer. But until now, no large study has examined the exact mechanism of head injuries among school-aged soccer players, so such prevention efforts cannot be considered evidence based, said R. Dawn Comstock, Ph.D., an epidemiologist at the University of Colorado Denver, Aurora, and her associates.

©James Boulette/iStockphoto.com

The investigators performed a retrospective analysis of data from a large, Internet-based sports injury surveillance study, focusing on concussions sustained during soccer practices or games which required medical attention and restricted the athlete’s participation for 1 or more days. They assessed nationally representative samples of 100 high schools every year for a 9-year period. There were 627 concussions during 1,393,753 athletic exposures among girls (4.50 per 10,000 exposures) and 442 concussions during 1,592,238 athletic exposures among boys (2.78 per 10,000 exposures).

The most common mechanism of concussion was player-to-player contact among both boys (68.8% of concussions) and girls (51.3% of concussions). In contrast, contact with the ball accounted for 17% of concussions among boys and 29% among girls.

The number and types of concussion symptoms were the same, regardless of whether the concussion was caused by player-to-player contact or player-to-ball contact. However, symptom resolution time was slightly but significantly longer for both boys and girls when the concussion was caused by collision with a ball or goal post (JAMA Pediatr. 2015 July 13 [doi:10.1001/jamapediatrics.2015.1062]).

“We postulate that banning heading from soccer will have limited effectiveness as a primary prevention mechanism (i.e., in preventing concussion injuries) unless such a ban is combined with concurrent efforts to reduce athlete-athlete contact throughout the game,” Dr. Comstock and her associates said.

Moreover, “it may be culturally more tolerable to the soccer community to attempt to reduce athlete-athlete contact across all phases of play through better enforcement of existing rules, enhanced education of athletes on the rules of the game, and improved coaching of activities such as heading,” rather than simply banning heading, they added.

Head contact with other players, not with the ball, is the main source of concussions among high-school soccer players of both sexes, according to a report published online July 13 in JAMA Pediatrics.

Several studies have shown that “heading” the ball during soccer practices and games is responsible for many soccer-related concussions, and some have called for banning such heading, especially among children and adolescents, to make the sport safer. But until now, no large study has examined the exact mechanism of head injuries among school-aged soccer players, so such prevention efforts cannot be considered evidence based, said R. Dawn Comstock, Ph.D., an epidemiologist at the University of Colorado Denver, Aurora, and her associates.

©James Boulette/iStockphoto.com

The investigators performed a retrospective analysis of data from a large, Internet-based sports injury surveillance study, focusing on concussions sustained during soccer practices or games which required medical attention and restricted the athlete’s participation for 1 or more days. They assessed nationally representative samples of 100 high schools every year for a 9-year period. There were 627 concussions during 1,393,753 athletic exposures among girls (4.50 per 10,000 exposures) and 442 concussions during 1,592,238 athletic exposures among boys (2.78 per 10,000 exposures).

The most common mechanism of concussion was player-to-player contact among both boys (68.8% of concussions) and girls (51.3% of concussions). In contrast, contact with the ball accounted for 17% of concussions among boys and 29% among girls.

The number and types of concussion symptoms were the same, regardless of whether the concussion was caused by player-to-player contact or player-to-ball contact. However, symptom resolution time was slightly but significantly longer for both boys and girls when the concussion was caused by collision with a ball or goal post (JAMA Pediatr. 2015 July 13 [doi:10.1001/jamapediatrics.2015.1062]).

“We postulate that banning heading from soccer will have limited effectiveness as a primary prevention mechanism (i.e., in preventing concussion injuries) unless such a ban is combined with concurrent efforts to reduce athlete-athlete contact throughout the game,” Dr. Comstock and her associates said.

Moreover, “it may be culturally more tolerable to the soccer community to attempt to reduce athlete-athlete contact across all phases of play through better enforcement of existing rules, enhanced education of athletes on the rules of the game, and improved coaching of activities such as heading,” rather than simply banning heading, they added.

Head contact with other players, not with the ball, is the main source of concussions among high-school soccer players of both sexes, according to a report published online July 13 in JAMA Pediatrics.

Several studies have shown that “heading” the ball during soccer practices and games is responsible for many soccer-related concussions, and some have called for banning such heading, especially among children and adolescents, to make the sport safer. But until now, no large study has examined the exact mechanism of head injuries among school-aged soccer players, so such prevention efforts cannot be considered evidence based, said R. Dawn Comstock, Ph.D., an epidemiologist at the University of Colorado Denver, Aurora, and her associates.

©James Boulette/iStockphoto.com

The investigators performed a retrospective analysis of data from a large, Internet-based sports injury surveillance study, focusing on concussions sustained during soccer practices or games which required medical attention and restricted the athlete’s participation for 1 or more days. They assessed nationally representative samples of 100 high schools every year for a 9-year period. There were 627 concussions during 1,393,753 athletic exposures among girls (4.50 per 10,000 exposures) and 442 concussions during 1,592,238 athletic exposures among boys (2.78 per 10,000 exposures).

The most common mechanism of concussion was player-to-player contact among both boys (68.8% of concussions) and girls (51.3% of concussions). In contrast, contact with the ball accounted for 17% of concussions among boys and 29% among girls.

The number and types of concussion symptoms were the same, regardless of whether the concussion was caused by player-to-player contact or player-to-ball contact. However, symptom resolution time was slightly but significantly longer for both boys and girls when the concussion was caused by collision with a ball or goal post (JAMA Pediatr. 2015 July 13 [doi:10.1001/jamapediatrics.2015.1062]).

“We postulate that banning heading from soccer will have limited effectiveness as a primary prevention mechanism (i.e., in preventing concussion injuries) unless such a ban is combined with concurrent efforts to reduce athlete-athlete contact throughout the game,” Dr. Comstock and her associates said.

Moreover, “it may be culturally more tolerable to the soccer community to attempt to reduce athlete-athlete contact across all phases of play through better enforcement of existing rules, enhanced education of athletes on the rules of the game, and improved coaching of activities such as heading,” rather than simply banning heading, they added.

WASHINGTON – Regardless of the number of tests and tools for helping to diagnose pediatric sports concussions, Dr. Christopher Giza, professor of pediatric neurology and neurosurgery at the University of California, Los Angeles, says it’s important for clinicians to remember that “concussion is a clinical diagnosis.”

In this video interview recorded at Summit in Neurology & Psychiatry, Dr. Giza offers pearls and insights into the latest in sports concussion management. He describes the four “Rs” of treating sports concussions and urges primary care personnel to offer anticipatory guidance to patients and their families. Such guidance can lead to a 20% decrease in chronic postconcussion syndrome in children and adolescents, he said at the meeting held by Global Academy for Medical Education. Global Academy and this news organization are owned by the same company.

[email protected]

On Twitter @whitneymcknight

WASHINGTON – Regardless of the number of tests and tools for helping to diagnose pediatric sports concussions, Dr. Christopher Giza, professor of pediatric neurology and neurosurgery at the University of California, Los Angeles, says it’s important for clinicians to remember that “concussion is a clinical diagnosis.”

In this video interview recorded at Summit in Neurology & Psychiatry, Dr. Giza offers pearls and insights into the latest in sports concussion management. He describes the four “Rs” of treating sports concussions and urges primary care personnel to offer anticipatory guidance to patients and their families. Such guidance can lead to a 20% decrease in chronic postconcussion syndrome in children and adolescents, he said at the meeting held by Global Academy for Medical Education. Global Academy and this news organization are owned by the same company.

[email protected]

On Twitter @whitneymcknight

WASHINGTON – Regardless of the number of tests and tools for helping to diagnose pediatric sports concussions, Dr. Christopher Giza, professor of pediatric neurology and neurosurgery at the University of California, Los Angeles, says it’s important for clinicians to remember that “concussion is a clinical diagnosis.”

In this video interview recorded at Summit in Neurology & Psychiatry, Dr. Giza offers pearls and insights into the latest in sports concussion management. He describes the four “Rs” of treating sports concussions and urges primary care personnel to offer anticipatory guidance to patients and their families. Such guidance can lead to a 20% decrease in chronic postconcussion syndrome in children and adolescents, he said at the meeting held by Global Academy for Medical Education. Global Academy and this news organization are owned by the same company.

[email protected]

On Twitter @whitneymcknight

VIENNA – Sonothrombolysis proved to be an effective alternative to endovascular treatment in patients with large intracranial occlusions, but clot removal via a retrievable stent appeared to have the edge when it came to achieving a good functional outcome, according to data presented at the annual European Stroke Conference.

In the first head-to-head comparison of the two strategies, there was no difference in the primary end point of the final modified Rankin Scale (mRS) score at the end of neurorehabilitation or death within 90 days. The mean final mRS was 3.78 with endovascular treatment and 3.95 with sonothrombolysis, with a nonsignificant (P = .12) odds ratio of 1.70 favoring the noninvasive procedure.

However, patients who underwent endovascular therapy were 3.89 times more likely than were those who had sonothrombolysis to achieve the secondary end point of a good functional outcome defined as a final mRS of 0-2 (24.7% vs. 13.6%; P = .02). Early recanalization was also possible in more patients with endovascular therapy than with sonothrombolysis (82.2% vs. 32.2%; OR, 15.77; P < .001).

“At the moment, everything veers toward using stent retrieval with thrombectomy, which requires very high costs at present and cannot be performed in every center,” noted study investigator Matthias Reinhard of the University Medical Center Freiburg (Germany) in an interview. On the other hand, Dr. Reinhard said, “sonothrombolysis is much less invasive and does not need specific interventionists, and it can be done with normal ultrasound devices, which are already available in every stroke unit.”

Sonothrombolysis enhances the thrombolytic activity of recombinant tissue plasminogen activator (rTPA) near to the clot, he explained, and has been shown in a Cochrane review to double the odds for functional independence, as well as upping the chances for recanalization around threefold (Cochrane Database Syst. Rev. 2012;10:CD008348). This is on a par with the results obtained with endovascular treatment in recent trials.

Since the two methods for enhancing thrombolysis with rTPA had not been directly compared before, Dr. Reinhard and his associates decided to look back at the medical records of patients with acute anterior circulation stroke with M1 or carotid T occlusion who were treated at two adjacent medical centers that used one or other of the methods as a standard treatment. After thrombolysis with rTPA, patients at one center underwent endovascular treatment with stent retrieval while patients at the other center had sonothrombolysis.

A total of 132 patients were assessed: 73 underwent endovascular treatment and 59 had sonothrombolysis. The median age in each group was 71 and 75 years, respectively, with around half the participants in each group being male. The groups had similar mean National Institutes of Health Stroke Scale scores (15 and 13). The majority of patients in each group had M1 vessel occlusions (60% and 69%) with the remainder (40% and 31%) having carotid T vessel occlusions. The mean onset to rTPA was 117 minutes and 105 minutes, respectively.

Subgroup analysis showed a significant benefit for endovascular treatment over sonothrombolysis in patients with carotid T occlusions, with an adjusted OR of 5.61 (P = .008). However, the two methods were comparable (OR, 1.07; P = .880) in patients with M1 occlusions.

“The main finding was that sonothrombolysis might perhaps be as equally effective as endovascular treatment in moderate-size occlusions such as middle cerebral artery occlusions but not in the very proximal occlusions of the carotid T,” Dr. Reinhard said. “So, one strategy might be to first apply sonothrombolysis and if this does not work, then to move the patient to the endovascular treatment,” he suggested, noting that this might be a better strategy to test in a future clinical trial than directly comparing the methods in a larger number of patients.

In terms of safety, there was no significant advantage of using one procedure over the other, despite three (4.1%) patients in the endovascular group and none in the sonothrombolysis group experiencing symptomatic intracranial hemorrhage (P = .25). Type 1 parenchymal hematomas were more common in patients who had sonothrombolysis than in those who had endovascular therapy (15.3% vs. 5.5%, P = .09). Mortality at 90 days was around 20% in both groups.

Dr. Reinhard had no disclosures.

VIENNA – Sonothrombolysis proved to be an effective alternative to endovascular treatment in patients with large intracranial occlusions, but clot removal via a retrievable stent appeared to have the edge when it came to achieving a good functional outcome, according to data presented at the annual European Stroke Conference.

In the first head-to-head comparison of the two strategies, there was no difference in the primary end point of the final modified Rankin Scale (mRS) score at the end of neurorehabilitation or death within 90 days. The mean final mRS was 3.78 with endovascular treatment and 3.95 with sonothrombolysis, with a nonsignificant (P = .12) odds ratio of 1.70 favoring the noninvasive procedure.

However, patients who underwent endovascular therapy were 3.89 times more likely than were those who had sonothrombolysis to achieve the secondary end point of a good functional outcome defined as a final mRS of 0-2 (24.7% vs. 13.6%; P = .02). Early recanalization was also possible in more patients with endovascular therapy than with sonothrombolysis (82.2% vs. 32.2%; OR, 15.77; P < .001).

“At the moment, everything veers toward using stent retrieval with thrombectomy, which requires very high costs at present and cannot be performed in every center,” noted study investigator Matthias Reinhard of the University Medical Center Freiburg (Germany) in an interview. On the other hand, Dr. Reinhard said, “sonothrombolysis is much less invasive and does not need specific interventionists, and it can be done with normal ultrasound devices, which are already available in every stroke unit.”

Sonothrombolysis enhances the thrombolytic activity of recombinant tissue plasminogen activator (rTPA) near to the clot, he explained, and has been shown in a Cochrane review to double the odds for functional independence, as well as upping the chances for recanalization around threefold (Cochrane Database Syst. Rev. 2012;10:CD008348). This is on a par with the results obtained with endovascular treatment in recent trials.

Since the two methods for enhancing thrombolysis with rTPA had not been directly compared before, Dr. Reinhard and his associates decided to look back at the medical records of patients with acute anterior circulation stroke with M1 or carotid T occlusion who were treated at two adjacent medical centers that used one or other of the methods as a standard treatment. After thrombolysis with rTPA, patients at one center underwent endovascular treatment with stent retrieval while patients at the other center had sonothrombolysis.

A total of 132 patients were assessed: 73 underwent endovascular treatment and 59 had sonothrombolysis. The median age in each group was 71 and 75 years, respectively, with around half the participants in each group being male. The groups had similar mean National Institutes of Health Stroke Scale scores (15 and 13). The majority of patients in each group had M1 vessel occlusions (60% and 69%) with the remainder (40% and 31%) having carotid T vessel occlusions. The mean onset to rTPA was 117 minutes and 105 minutes, respectively.

Subgroup analysis showed a significant benefit for endovascular treatment over sonothrombolysis in patients with carotid T occlusions, with an adjusted OR of 5.61 (P = .008). However, the two methods were comparable (OR, 1.07; P = .880) in patients with M1 occlusions.

“The main finding was that sonothrombolysis might perhaps be as equally effective as endovascular treatment in moderate-size occlusions such as middle cerebral artery occlusions but not in the very proximal occlusions of the carotid T,” Dr. Reinhard said. “So, one strategy might be to first apply sonothrombolysis and if this does not work, then to move the patient to the endovascular treatment,” he suggested, noting that this might be a better strategy to test in a future clinical trial than directly comparing the methods in a larger number of patients.

In terms of safety, there was no significant advantage of using one procedure over the other, despite three (4.1%) patients in the endovascular group and none in the sonothrombolysis group experiencing symptomatic intracranial hemorrhage (P = .25). Type 1 parenchymal hematomas were more common in patients who had sonothrombolysis than in those who had endovascular therapy (15.3% vs. 5.5%, P = .09). Mortality at 90 days was around 20% in both groups.

Dr. Reinhard had no disclosures.

VIENNA – Sonothrombolysis proved to be an effective alternative to endovascular treatment in patients with large intracranial occlusions, but clot removal via a retrievable stent appeared to have the edge when it came to achieving a good functional outcome, according to data presented at the annual European Stroke Conference.

In the first head-to-head comparison of the two strategies, there was no difference in the primary end point of the final modified Rankin Scale (mRS) score at the end of neurorehabilitation or death within 90 days. The mean final mRS was 3.78 with endovascular treatment and 3.95 with sonothrombolysis, with a nonsignificant (P = .12) odds ratio of 1.70 favoring the noninvasive procedure.

However, patients who underwent endovascular therapy were 3.89 times more likely than were those who had sonothrombolysis to achieve the secondary end point of a good functional outcome defined as a final mRS of 0-2 (24.7% vs. 13.6%; P = .02). Early recanalization was also possible in more patients with endovascular therapy than with sonothrombolysis (82.2% vs. 32.2%; OR, 15.77; P < .001).

“At the moment, everything veers toward using stent retrieval with thrombectomy, which requires very high costs at present and cannot be performed in every center,” noted study investigator Matthias Reinhard of the University Medical Center Freiburg (Germany) in an interview. On the other hand, Dr. Reinhard said, “sonothrombolysis is much less invasive and does not need specific interventionists, and it can be done with normal ultrasound devices, which are already available in every stroke unit.”

Sonothrombolysis enhances the thrombolytic activity of recombinant tissue plasminogen activator (rTPA) near to the clot, he explained, and has been shown in a Cochrane review to double the odds for functional independence, as well as upping the chances for recanalization around threefold (Cochrane Database Syst. Rev. 2012;10:CD008348). This is on a par with the results obtained with endovascular treatment in recent trials.

Since the two methods for enhancing thrombolysis with rTPA had not been directly compared before, Dr. Reinhard and his associates decided to look back at the medical records of patients with acute anterior circulation stroke with M1 or carotid T occlusion who were treated at two adjacent medical centers that used one or other of the methods as a standard treatment. After thrombolysis with rTPA, patients at one center underwent endovascular treatment with stent retrieval while patients at the other center had sonothrombolysis.

A total of 132 patients were assessed: 73 underwent endovascular treatment and 59 had sonothrombolysis. The median age in each group was 71 and 75 years, respectively, with around half the participants in each group being male. The groups had similar mean National Institutes of Health Stroke Scale scores (15 and 13). The majority of patients in each group had M1 vessel occlusions (60% and 69%) with the remainder (40% and 31%) having carotid T vessel occlusions. The mean onset to rTPA was 117 minutes and 105 minutes, respectively.

Subgroup analysis showed a significant benefit for endovascular treatment over sonothrombolysis in patients with carotid T occlusions, with an adjusted OR of 5.61 (P = .008). However, the two methods were comparable (OR, 1.07; P = .880) in patients with M1 occlusions.

“The main finding was that sonothrombolysis might perhaps be as equally effective as endovascular treatment in moderate-size occlusions such as middle cerebral artery occlusions but not in the very proximal occlusions of the carotid T,” Dr. Reinhard said. “So, one strategy might be to first apply sonothrombolysis and if this does not work, then to move the patient to the endovascular treatment,” he suggested, noting that this might be a better strategy to test in a future clinical trial than directly comparing the methods in a larger number of patients.

In terms of safety, there was no significant advantage of using one procedure over the other, despite three (4.1%) patients in the endovascular group and none in the sonothrombolysis group experiencing symptomatic intracranial hemorrhage (P = .25). Type 1 parenchymal hematomas were more common in patients who had sonothrombolysis than in those who had endovascular therapy (15.3% vs. 5.5%, P = .09). Mortality at 90 days was around 20% in both groups.

Dr. Reinhard had no disclosures.

At best, only moderate-quality evidence supports the use of medical cannabinoids, and for only two conditions. And low-quality evidence only “suggests” that these agents may improve other medical conditions, but that limited effectiveness applies only to the four conditions that have been studied, according to a report published online June 23 in JAMA.

This doesn’t necessarily mean that cannabinoids have poor efficacy but instead likely reflects the dearth of high-quality research into their medical usefulness.

In what they described as the first comprehensive review to evaluate the efficacy of numerous cannabinoids across a broad range of indications, researchers analyzed data from 79 studies involving 6,462 participants performed from 1975 to early 2015. The studies assessed nabilone, dronabinol, nabiximols, levonantradol, THC, THC/CBD, and ajuvenic acid, delivered via oral capsules, cigarettes, vaporizers, oromucosal sprays, or intramuscular injection, said Penny F. Whiting, Ph.D., of University Hospitals Bristol (England) and her associates.

Most of the studies suggested that cannabinoids improved symptoms for nearly all the 10 medical conditions included in this meta-analysis, but most of the studies were of poor quality so their conclusions were questionable. These agents’ efficacy did not vary according to the type of cannabinoid assessed or the mode of delivery.

Moderate-quality evidence indicated that cannabinoids may be beneficial for chronic neuropathic or cancer pain, and moderate-quality evidence indicated that they may also be beneficial for spasticity due to multiple sclerosis or traumatic paraplegia. Low-quality evidence suggested that cannabinoids may improve nausea and vomiting due to chemotherapy, may improve appetite and induce weight gain in HIV infection, and may improve sleep in primary sleep disorders as well as in conditions that disrupt sleep such as fibromyalgia, multiple sclerosis, and chronic pain. Very low-quality evidence (due to extremely small sample sizes) suggested that cannabinoids may greatly improve tic severity in Tourette’s syndrome, Dr. Whiting and her associates said (JAMA 2015 June 23 [doi:10.1001/jama.2015.6358]).

Otherwise, the evidence did not support cannabinoids’ efficacy in anxiety, depression, psychosis, or glaucoma. Adverse events included asthenia, problems with balance, confusion, dizziness, disorientation, dry mouth, fatigue, and somnolence.

At best, only moderate-quality evidence supports the use of medical cannabinoids, and for only two conditions. And low-quality evidence only “suggests” that these agents may improve other medical conditions, but that limited effectiveness applies only to the four conditions that have been studied, according to a report published online June 23 in JAMA.

This doesn’t necessarily mean that cannabinoids have poor efficacy but instead likely reflects the dearth of high-quality research into their medical usefulness.

In what they described as the first comprehensive review to evaluate the efficacy of numerous cannabinoids across a broad range of indications, researchers analyzed data from 79 studies involving 6,462 participants performed from 1975 to early 2015. The studies assessed nabilone, dronabinol, nabiximols, levonantradol, THC, THC/CBD, and ajuvenic acid, delivered via oral capsules, cigarettes, vaporizers, oromucosal sprays, or intramuscular injection, said Penny F. Whiting, Ph.D., of University Hospitals Bristol (England) and her associates.

Most of the studies suggested that cannabinoids improved symptoms for nearly all the 10 medical conditions included in this meta-analysis, but most of the studies were of poor quality so their conclusions were questionable. These agents’ efficacy did not vary according to the type of cannabinoid assessed or the mode of delivery.

Moderate-quality evidence indicated that cannabinoids may be beneficial for chronic neuropathic or cancer pain, and moderate-quality evidence indicated that they may also be beneficial for spasticity due to multiple sclerosis or traumatic paraplegia. Low-quality evidence suggested that cannabinoids may improve nausea and vomiting due to chemotherapy, may improve appetite and induce weight gain in HIV infection, and may improve sleep in primary sleep disorders as well as in conditions that disrupt sleep such as fibromyalgia, multiple sclerosis, and chronic pain. Very low-quality evidence (due to extremely small sample sizes) suggested that cannabinoids may greatly improve tic severity in Tourette’s syndrome, Dr. Whiting and her associates said (JAMA 2015 June 23 [doi:10.1001/jama.2015.6358]).

Otherwise, the evidence did not support cannabinoids’ efficacy in anxiety, depression, psychosis, or glaucoma. Adverse events included asthenia, problems with balance, confusion, dizziness, disorientation, dry mouth, fatigue, and somnolence.

At best, only moderate-quality evidence supports the use of medical cannabinoids, and for only two conditions. And low-quality evidence only “suggests” that these agents may improve other medical conditions, but that limited effectiveness applies only to the four conditions that have been studied, according to a report published online June 23 in JAMA.

This doesn’t necessarily mean that cannabinoids have poor efficacy but instead likely reflects the dearth of high-quality research into their medical usefulness.

In what they described as the first comprehensive review to evaluate the efficacy of numerous cannabinoids across a broad range of indications, researchers analyzed data from 79 studies involving 6,462 participants performed from 1975 to early 2015. The studies assessed nabilone, dronabinol, nabiximols, levonantradol, THC, THC/CBD, and ajuvenic acid, delivered via oral capsules, cigarettes, vaporizers, oromucosal sprays, or intramuscular injection, said Penny F. Whiting, Ph.D., of University Hospitals Bristol (England) and her associates.

Most of the studies suggested that cannabinoids improved symptoms for nearly all the 10 medical conditions included in this meta-analysis, but most of the studies were of poor quality so their conclusions were questionable. These agents’ efficacy did not vary according to the type of cannabinoid assessed or the mode of delivery.

Moderate-quality evidence indicated that cannabinoids may be beneficial for chronic neuropathic or cancer pain, and moderate-quality evidence indicated that they may also be beneficial for spasticity due to multiple sclerosis or traumatic paraplegia. Low-quality evidence suggested that cannabinoids may improve nausea and vomiting due to chemotherapy, may improve appetite and induce weight gain in HIV infection, and may improve sleep in primary sleep disorders as well as in conditions that disrupt sleep such as fibromyalgia, multiple sclerosis, and chronic pain. Very low-quality evidence (due to extremely small sample sizes) suggested that cannabinoids may greatly improve tic severity in Tourette’s syndrome, Dr. Whiting and her associates said (JAMA 2015 June 23 [doi:10.1001/jama.2015.6358]).

Otherwise, the evidence did not support cannabinoids’ efficacy in anxiety, depression, psychosis, or glaucoma. Adverse events included asthenia, problems with balance, confusion, dizziness, disorientation, dry mouth, fatigue, and somnolence.

WASHINGTON – Soldiers who experience traumatic brain injury (TBI) while deployed have a much higher rate of unemployment than those who experience no TBI during their tour of duty, according to a study presented at the annual meeting of the American Headache Society.

“We know that TBI and PTSD [post-traumatic stress disorder] can lead to headaches, depression, and loss of libido, but there’s very little data on the long-term effects of TBI on [veterans], and therefore very little control data,” explained Dr. James R. Couch of the University of Oklahoma in Oklahoma City.

Dr. Couch and his coinvestigators looked at 5,743 veterans of Operation Iraqi Freedom and Operation Enduring Freedom who had been deployed between June 2008 and April 2011, 1,325 (23%) of whom had experienced TBI while serving. The first 500 subjects seen were then frequency matched with a control subject who did not experience TBI, based on age, sex, race, and deployment length.

From this pool, 67 pairs were finally selected for inclusion, all of whom were 2-11 years post TBI: 39 pairs were 2-7 years post TBI and the remaining 28 pairs were 8-11 years post TBI. All subjects were 25-60 years old. Marital and employment data were collected from each subject, and each subject completed a TBI questionnaire, headache questionnaire, Beck Depression Inventory 2, and post-traumatic stress disorder questionnaire, from which bivariate analyses were performed.

Although marital status was not found to be significantly tied to TBI experience while deployed, unemployment rates were consistently and significantly higher in the TBI cohort, compared with their non-TBI counterparts. In the 2-7 years post-TBI group, 35.9% of subjects were unemployed, while only 10.3% of non-TBI subjects were without a job (P = .014). In the 8-11 years post-TBI cohort, 50.0% of subjects were unemployed, compared with 7.1% of controls who were unemployed. No significant association, however, was found between frequency of headache or severity of TBI with either unemployment or marital status.

The most important thing to take away, said Dr. Couch, is “the marked difference in unemployment from 4-11 years after TBI, and that things seem to be getting worse as time goes along. Headache, depression, PTSD – none of these stand out as singular causes but are all known to be related to [TBI], and severity of TBI was not strongly associated.”

Dr. Couch disclosed receiving consulting fees/honoraria from St. Jude Medical.

[email protected]

WASHINGTON – Soldiers who experience traumatic brain injury (TBI) while deployed have a much higher rate of unemployment than those who experience no TBI during their tour of duty, according to a study presented at the annual meeting of the American Headache Society.

“We know that TBI and PTSD [post-traumatic stress disorder] can lead to headaches, depression, and loss of libido, but there’s very little data on the long-term effects of TBI on [veterans], and therefore very little control data,” explained Dr. James R. Couch of the University of Oklahoma in Oklahoma City.

Dr. Couch and his coinvestigators looked at 5,743 veterans of Operation Iraqi Freedom and Operation Enduring Freedom who had been deployed between June 2008 and April 2011, 1,325 (23%) of whom had experienced TBI while serving. The first 500 subjects seen were then frequency matched with a control subject who did not experience TBI, based on age, sex, race, and deployment length.

From this pool, 67 pairs were finally selected for inclusion, all of whom were 2-11 years post TBI: 39 pairs were 2-7 years post TBI and the remaining 28 pairs were 8-11 years post TBI. All subjects were 25-60 years old. Marital and employment data were collected from each subject, and each subject completed a TBI questionnaire, headache questionnaire, Beck Depression Inventory 2, and post-traumatic stress disorder questionnaire, from which bivariate analyses were performed.

Although marital status was not found to be significantly tied to TBI experience while deployed, unemployment rates were consistently and significantly higher in the TBI cohort, compared with their non-TBI counterparts. In the 2-7 years post-TBI group, 35.9% of subjects were unemployed, while only 10.3% of non-TBI subjects were without a job (P = .014). In the 8-11 years post-TBI cohort, 50.0% of subjects were unemployed, compared with 7.1% of controls who were unemployed. No significant association, however, was found between frequency of headache or severity of TBI with either unemployment or marital status.

The most important thing to take away, said Dr. Couch, is “the marked difference in unemployment from 4-11 years after TBI, and that things seem to be getting worse as time goes along. Headache, depression, PTSD – none of these stand out as singular causes but are all known to be related to [TBI], and severity of TBI was not strongly associated.”

Dr. Couch disclosed receiving consulting fees/honoraria from St. Jude Medical.

[email protected]

WASHINGTON – Soldiers who experience traumatic brain injury (TBI) while deployed have a much higher rate of unemployment than those who experience no TBI during their tour of duty, according to a study presented at the annual meeting of the American Headache Society.

“We know that TBI and PTSD [post-traumatic stress disorder] can lead to headaches, depression, and loss of libido, but there’s very little data on the long-term effects of TBI on [veterans], and therefore very little control data,” explained Dr. James R. Couch of the University of Oklahoma in Oklahoma City.

Dr. Couch and his coinvestigators looked at 5,743 veterans of Operation Iraqi Freedom and Operation Enduring Freedom who had been deployed between June 2008 and April 2011, 1,325 (23%) of whom had experienced TBI while serving. The first 500 subjects seen were then frequency matched with a control subject who did not experience TBI, based on age, sex, race, and deployment length.

From this pool, 67 pairs were finally selected for inclusion, all of whom were 2-11 years post TBI: 39 pairs were 2-7 years post TBI and the remaining 28 pairs were 8-11 years post TBI. All subjects were 25-60 years old. Marital and employment data were collected from each subject, and each subject completed a TBI questionnaire, headache questionnaire, Beck Depression Inventory 2, and post-traumatic stress disorder questionnaire, from which bivariate analyses were performed.

Although marital status was not found to be significantly tied to TBI experience while deployed, unemployment rates were consistently and significantly higher in the TBI cohort, compared with their non-TBI counterparts. In the 2-7 years post-TBI group, 35.9% of subjects were unemployed, while only 10.3% of non-TBI subjects were without a job (P = .014). In the 8-11 years post-TBI cohort, 50.0% of subjects were unemployed, compared with 7.1% of controls who were unemployed. No significant association, however, was found between frequency of headache or severity of TBI with either unemployment or marital status.

The most important thing to take away, said Dr. Couch, is “the marked difference in unemployment from 4-11 years after TBI, and that things seem to be getting worse as time goes along. Headache, depression, PTSD – none of these stand out as singular causes but are all known to be related to [TBI], and severity of TBI was not strongly associated.”

Dr. Couch disclosed receiving consulting fees/honoraria from St. Jude Medical.

[email protected]

VIENNA – Decompressive hemicraniectomy for malignant middle cerebral artery infarction was associated with high rates of in-hospital and late complications in a clinical practice setting, according to research reported at the annual European Stroke Conference.

The retrospective findings showed that 88.1% of the 48 patients who underwent the surgery experienced complications such as intracranial hemorrhage (ICH) or symptomatic epilepsy while hospitalized, and 89.5% experienced complications in the later months of their recovery.

While these complication rates are higher than those seen in the randomized controlled clinical studies, the operation still proved life saving for many, with in-hospital and overall mortality rates of 12.5% and 14.6%, respectively, which is similar to the mortality rate seen in the DESTINY trial (Stroke 2007;38:2518-25) after 6 months.

“Patients who underwent [decompressive hemicraniectomy] are a complication-prone collective”, said Dr. Hans-Werner Pledl, resident physician at the department of neurology, UniversitätsMedizin Mannheim, University of Heidelberg (Germany). “Especially in the elderly, recovery stays limited in relevant factors such as ambulation and conversation for self-sufficiency,” he added.

To date, four clinical trials – DECIMAL (Stroke 2007;38:2506-17), HAMLET (Lancet Neurol 2009;8:326-33) and DESTINY and DESTINY II (Int J Stroke 2011;6:79-86) – have looked at the efficacy and safety of DHC in small numbers of patients with life-threatening middle cerebral artery (MCA) infarction. Of these, only DESTINY II included patients over 60 years of age so while there was evidence that the pressure-relieving surgery reduced mortality if performed early, albeit with an increase in functional disability, experience in older patients was less clear. To look at the complication rates in a real-world practice setting, Dr. Pledl of University Hospital Mannheim’s stroke unit, examined the medical records of 48 patients with MCA infarction who underwent DHC between 2008 and 2014. At the time of admission, the 21 male and 27 female patients were aged 28 to 70 years, with the mean age being 57 years. Dr. Pledl noted that two out of every five (41.7%) patients was over the age of 60 years.

On average, patients were referred to the stroke unit within 3 hours and 44 minutes of the incident event, but some were seen within 30 minutes and others within 5 days. A total of 43.8% of patients had an MCA infarction involving the dominant hemisphere and just under 60% received thrombolytic therapy with rtPA. The median time to surgery was 1.3 days, with just over one-fifth (21.7%) of patients undergoing DHC more than 48 hours after their stroke.

The median National Institutes of Health Stroke Scale scores at admission and discharge were 19 and 18, respectively, while the modified Rankin Scale (mRS) score was 5 at both time points. The Barthel Index was 0 at admission, signifying that the patient was heavily dependent on a carer to perform basic living activities, and 7.5 at discharge, indicating some only marginal improvement in patients’ independence.

The majority (75%) of patients achieved reasonable recovery with early (phase B) rehabilitation, 44% with continued poststroke (phase C) rehabilitation, and 6% were able to become self-sufficient and some even returning to work (phase D). “Remarkably, nearly half (48.9%) of patients return home after rehabilitation and do not stay in a clinical or institutional care facility,” Dr. Pledl said.

In-hospital neurological or psychiatric complications included ICH (seven patients), symptomatic epilepsy (six patients), and delirium (five patients). Perioperative complications included meningitis (three patients), wound healing disorders (three patients), and two patients had epidural hemorrhage (EDH). Common infections included pneumonia (13 patients) and urinary tract infections (UTI, eight patients), and other complications included anemia (14 patients) and cardiac complications (nine patients).

During the recovery phase, the most common neurological or psychiatric complications were central pain syndrome and symptomatic epilepsy, affecting nine patients each. Patients again experienced EDH (five patients), with some cases of hydrocephalus (four patients) and wound-healing problems (three patients). UTIs were the most common type of infection, seen in 14 patients. Other late complications included dysphagia (41.7%) and tracheostomy (35.4%), and post-rehab depression (54.2%).

Dr. Pledl suggested that the findings could be used to help better inform patients and their carers so they can have “realistic expectations” of the procedure’s likely outcomes and decide whether or not to have the surgery performed. These “real world” data could also help physicians to be more aware of the likely complications and perhaps address them in some way so that they have minimal impact on patients’ quality of life.

Although patients who experienced complications in this study were not asked if they regretted the decision to undergo the surgery, there is evidence to show that patients and carers can accept a significant level of disability without having significantly impaired quality of life. Nevertheless, the decision on whether DHC should be performed should be made on an individual case basis, especially in older patients, Dr. Pledl concluded.

The next step is to see if there are any subgroups of patients who might fare better or worse after DHC and hopefully identify some predictive imaging markers that could help the decision-making process.

Dr. Pledl reported no conflicts.

VIENNA – Decompressive hemicraniectomy for malignant middle cerebral artery infarction was associated with high rates of in-hospital and late complications in a clinical practice setting, according to research reported at the annual European Stroke Conference.

The retrospective findings showed that 88.1% of the 48 patients who underwent the surgery experienced complications such as intracranial hemorrhage (ICH) or symptomatic epilepsy while hospitalized, and 89.5% experienced complications in the later months of their recovery.

While these complication rates are higher than those seen in the randomized controlled clinical studies, the operation still proved life saving for many, with in-hospital and overall mortality rates of 12.5% and 14.6%, respectively, which is similar to the mortality rate seen in the DESTINY trial (Stroke 2007;38:2518-25) after 6 months.

“Patients who underwent [decompressive hemicraniectomy] are a complication-prone collective”, said Dr. Hans-Werner Pledl, resident physician at the department of neurology, UniversitätsMedizin Mannheim, University of Heidelberg (Germany). “Especially in the elderly, recovery stays limited in relevant factors such as ambulation and conversation for self-sufficiency,” he added.

To date, four clinical trials – DECIMAL (Stroke 2007;38:2506-17), HAMLET (Lancet Neurol 2009;8:326-33) and DESTINY and DESTINY II (Int J Stroke 2011;6:79-86) – have looked at the efficacy and safety of DHC in small numbers of patients with life-threatening middle cerebral artery (MCA) infarction. Of these, only DESTINY II included patients over 60 years of age so while there was evidence that the pressure-relieving surgery reduced mortality if performed early, albeit with an increase in functional disability, experience in older patients was less clear. To look at the complication rates in a real-world practice setting, Dr. Pledl of University Hospital Mannheim’s stroke unit, examined the medical records of 48 patients with MCA infarction who underwent DHC between 2008 and 2014. At the time of admission, the 21 male and 27 female patients were aged 28 to 70 years, with the mean age being 57 years. Dr. Pledl noted that two out of every five (41.7%) patients was over the age of 60 years.

On average, patients were referred to the stroke unit within 3 hours and 44 minutes of the incident event, but some were seen within 30 minutes and others within 5 days. A total of 43.8% of patients had an MCA infarction involving the dominant hemisphere and just under 60% received thrombolytic therapy with rtPA. The median time to surgery was 1.3 days, with just over one-fifth (21.7%) of patients undergoing DHC more than 48 hours after their stroke.

The median National Institutes of Health Stroke Scale scores at admission and discharge were 19 and 18, respectively, while the modified Rankin Scale (mRS) score was 5 at both time points. The Barthel Index was 0 at admission, signifying that the patient was heavily dependent on a carer to perform basic living activities, and 7.5 at discharge, indicating some only marginal improvement in patients’ independence.

The majority (75%) of patients achieved reasonable recovery with early (phase B) rehabilitation, 44% with continued poststroke (phase C) rehabilitation, and 6% were able to become self-sufficient and some even returning to work (phase D). “Remarkably, nearly half (48.9%) of patients return home after rehabilitation and do not stay in a clinical or institutional care facility,” Dr. Pledl said.

In-hospital neurological or psychiatric complications included ICH (seven patients), symptomatic epilepsy (six patients), and delirium (five patients). Perioperative complications included meningitis (three patients), wound healing disorders (three patients), and two patients had epidural hemorrhage (EDH). Common infections included pneumonia (13 patients) and urinary tract infections (UTI, eight patients), and other complications included anemia (14 patients) and cardiac complications (nine patients).

During the recovery phase, the most common neurological or psychiatric complications were central pain syndrome and symptomatic epilepsy, affecting nine patients each. Patients again experienced EDH (five patients), with some cases of hydrocephalus (four patients) and wound-healing problems (three patients). UTIs were the most common type of infection, seen in 14 patients. Other late complications included dysphagia (41.7%) and tracheostomy (35.4%), and post-rehab depression (54.2%).

Dr. Pledl suggested that the findings could be used to help better inform patients and their carers so they can have “realistic expectations” of the procedure’s likely outcomes and decide whether or not to have the surgery performed. These “real world” data could also help physicians to be more aware of the likely complications and perhaps address them in some way so that they have minimal impact on patients’ quality of life.

Although patients who experienced complications in this study were not asked if they regretted the decision to undergo the surgery, there is evidence to show that patients and carers can accept a significant level of disability without having significantly impaired quality of life. Nevertheless, the decision on whether DHC should be performed should be made on an individual case basis, especially in older patients, Dr. Pledl concluded.

The next step is to see if there are any subgroups of patients who might fare better or worse after DHC and hopefully identify some predictive imaging markers that could help the decision-making process.

Dr. Pledl reported no conflicts.

VIENNA – Decompressive hemicraniectomy for malignant middle cerebral artery infarction was associated with high rates of in-hospital and late complications in a clinical practice setting, according to research reported at the annual European Stroke Conference.

The retrospective findings showed that 88.1% of the 48 patients who underwent the surgery experienced complications such as intracranial hemorrhage (ICH) or symptomatic epilepsy while hospitalized, and 89.5% experienced complications in the later months of their recovery.

While these complication rates are higher than those seen in the randomized controlled clinical studies, the operation still proved life saving for many, with in-hospital and overall mortality rates of 12.5% and 14.6%, respectively, which is similar to the mortality rate seen in the DESTINY trial (Stroke 2007;38:2518-25) after 6 months.

“Patients who underwent [decompressive hemicraniectomy] are a complication-prone collective”, said Dr. Hans-Werner Pledl, resident physician at the department of neurology, UniversitätsMedizin Mannheim, University of Heidelberg (Germany). “Especially in the elderly, recovery stays limited in relevant factors such as ambulation and conversation for self-sufficiency,” he added.

To date, four clinical trials – DECIMAL (Stroke 2007;38:2506-17), HAMLET (Lancet Neurol 2009;8:326-33) and DESTINY and DESTINY II (Int J Stroke 2011;6:79-86) – have looked at the efficacy and safety of DHC in small numbers of patients with life-threatening middle cerebral artery (MCA) infarction. Of these, only DESTINY II included patients over 60 years of age so while there was evidence that the pressure-relieving surgery reduced mortality if performed early, albeit with an increase in functional disability, experience in older patients was less clear. To look at the complication rates in a real-world practice setting, Dr. Pledl of University Hospital Mannheim’s stroke unit, examined the medical records of 48 patients with MCA infarction who underwent DHC between 2008 and 2014. At the time of admission, the 21 male and 27 female patients were aged 28 to 70 years, with the mean age being 57 years. Dr. Pledl noted that two out of every five (41.7%) patients was over the age of 60 years.

On average, patients were referred to the stroke unit within 3 hours and 44 minutes of the incident event, but some were seen within 30 minutes and others within 5 days. A total of 43.8% of patients had an MCA infarction involving the dominant hemisphere and just under 60% received thrombolytic therapy with rtPA. The median time to surgery was 1.3 days, with just over one-fifth (21.7%) of patients undergoing DHC more than 48 hours after their stroke.

The median National Institutes of Health Stroke Scale scores at admission and discharge were 19 and 18, respectively, while the modified Rankin Scale (mRS) score was 5 at both time points. The Barthel Index was 0 at admission, signifying that the patient was heavily dependent on a carer to perform basic living activities, and 7.5 at discharge, indicating some only marginal improvement in patients’ independence.

The majority (75%) of patients achieved reasonable recovery with early (phase B) rehabilitation, 44% with continued poststroke (phase C) rehabilitation, and 6% were able to become self-sufficient and some even returning to work (phase D). “Remarkably, nearly half (48.9%) of patients return home after rehabilitation and do not stay in a clinical or institutional care facility,” Dr. Pledl said.

In-hospital neurological or psychiatric complications included ICH (seven patients), symptomatic epilepsy (six patients), and delirium (five patients). Perioperative complications included meningitis (three patients), wound healing disorders (three patients), and two patients had epidural hemorrhage (EDH). Common infections included pneumonia (13 patients) and urinary tract infections (UTI, eight patients), and other complications included anemia (14 patients) and cardiac complications (nine patients).

During the recovery phase, the most common neurological or psychiatric complications were central pain syndrome and symptomatic epilepsy, affecting nine patients each. Patients again experienced EDH (five patients), with some cases of hydrocephalus (four patients) and wound-healing problems (three patients). UTIs were the most common type of infection, seen in 14 patients. Other late complications included dysphagia (41.7%) and tracheostomy (35.4%), and post-rehab depression (54.2%).

Dr. Pledl suggested that the findings could be used to help better inform patients and their carers so they can have “realistic expectations” of the procedure’s likely outcomes and decide whether or not to have the surgery performed. These “real world” data could also help physicians to be more aware of the likely complications and perhaps address them in some way so that they have minimal impact on patients’ quality of life.

Although patients who experienced complications in this study were not asked if they regretted the decision to undergo the surgery, there is evidence to show that patients and carers can accept a significant level of disability without having significantly impaired quality of life. Nevertheless, the decision on whether DHC should be performed should be made on an individual case basis, especially in older patients, Dr. Pledl concluded.

The next step is to see if there are any subgroups of patients who might fare better or worse after DHC and hopefully identify some predictive imaging markers that could help the decision-making process.

Dr. Pledl reported no conflicts.

SAN DIEGO – Many patients with traumatic brain injury (TBI) can be safely managed by trauma surgeons or intensive care physicians, if a guideline-based individual protocol is followed. In a recent single-center study using this protocol, charges fell, repeat imaging decreased, and patient outcomes did not suffer when neurosurgery consults were reserved for individuals with more severe brain injuries.

Every year, emergency departments see 2.5 million visits for traumatic brain injuries ranging from concussions to devastating open injuries, and 11% of those seen are hospitalized. Still, only 10% of patients with TBI will require neurosurgical intervention, Dr. Bellal Joseph of the University of Arizona said at the annual meeting of the American Surgical Association.

Finding a way to conserve resources is important, said Dr. Joseph, since the total number of emergency department visits for TBI is increasing, but resources remain constrained: neurosurgeons are in shorter supply than ever. Further, TBI management may not be changed by numerous repeat head CTs, which are costly and can expose patients to significant amounts of radiation.

Dr. Joseph and his coinvestigators at the University of Arizona had previously developed Brain Injury Guidelines (BIG), which would mandate repeat head CTs and neurosurgery consults only for larger intracranial bleeds and displaced skull fractures. The guidelines are used as part of an individualized protocol that includes overall clinical assessment and patient-specific factors, such as anticoagulation status and whether the patient was intoxicated at the time of injury.

After a period of education regarding the guidelines, the University of Arizona’s Level I trauma center – the only one in the state – implemented BIG use in 2012. For the 5-year period from 2009 to 2014 encompassing implementation of the guidelines, investigators followed all patients admitted for TBI and tracked use of hospital resources and patient outcomes during the study period.

A total of 2,184 patients with TBI were included in the study, divided into five cohorts by year of admission, and stratified by severity of brain injury. Patients were included if they were admitted for TBI from the emergency department and the initial head CT found a skull fracture or intracranial hemorrhage. Dr. Bellal and his colleagues collected data regarding the number of neurosurgery consults, repeat head CTs, and patient demographic and injury characteristics. They tracked patient outcomes including in-hospital mortality, any progression on repeat head CT, and patient disposition on discharge.

TBI injuries were classified by Glasgow Coma Scale scoring (13-15 for mild TBI; 9-12 for moderate; and less than 8 for severe).

Over time, the proportion of patients with severe brain injury who received repeat head CTs did not change significantly. However, scans for those with less severe injury declined significantly, with a marked drop in repeat head CTs seen at the time of implementation of the BIG guidelines (P < .001 for mild and P = .012 for moderate brain injuries).

Similarly, 100% of patients with severe TBI received a neurosurgical consult in each year of the study period, but the number of consults declined significantly for those with mild and moderate injuries (P < .001 for both mild and moderate injuries).

Hospital length of stay decreased from a mean 6.2 days to 4.7 at the end of the study period (P = .028), and total hospital costs fell by nearly half, from a total $8.1 million for the 2009-2010 cohort to $4.3 million for the 2013-2014 cohort (P < .001).

Mortality, discharge score on the Glasgow Coma scale, and the proportion of patients discharged to home after their hospital stay did not change significantly over the study period.

Study limitations included potential lack of generalizability to smaller or more rural centers, and the potential for confounding by changes in other institutional factors over the study period. The study did not track long-term neurologic or quality of life outcomes.

Discussant Dr. Karen Brasel of Oregon Health & Science University, Portland, said that the study is the latest in a series of reports in the TBI field that speak to the need to avoid “knee-jerk use of resources based on diagnosis alone.” She cautioned that it is still important to examine individual patient outcomes for the few patients who did not receive a neurosurgery consult but then deteriorated, to better evaluate who is at most risk for poor outcomes.

Still, said Dr. Joseph, a “guideline-based individualized protocol for traumatic brain injury can help reduce the burden on neurological services. Life changes, and so does medicine.”

The authors reported no conflicts of interest.

The complete manuscript of this study and its presentation at the American Surgical Association’s 135th Annual Meeting, April 2015, in San Diego, California, are anticipated to be published in the Annals of Surgery pending editorial review.

SAN DIEGO – Many patients with traumatic brain injury (TBI) can be safely managed by trauma surgeons or intensive care physicians, if a guideline-based individual protocol is followed. In a recent single-center study using this protocol, charges fell, repeat imaging decreased, and patient outcomes did not suffer when neurosurgery consults were reserved for individuals with more severe brain injuries.

Every year, emergency departments see 2.5 million visits for traumatic brain injuries ranging from concussions to devastating open injuries, and 11% of those seen are hospitalized. Still, only 10% of patients with TBI will require neurosurgical intervention, Dr. Bellal Joseph of the University of Arizona said at the annual meeting of the American Surgical Association.

Finding a way to conserve resources is important, said Dr. Joseph, since the total number of emergency department visits for TBI is increasing, but resources remain constrained: neurosurgeons are in shorter supply than ever. Further, TBI management may not be changed by numerous repeat head CTs, which are costly and can expose patients to significant amounts of radiation.

Dr. Joseph and his coinvestigators at the University of Arizona had previously developed Brain Injury Guidelines (BIG), which would mandate repeat head CTs and neurosurgery consults only for larger intracranial bleeds and displaced skull fractures. The guidelines are used as part of an individualized protocol that includes overall clinical assessment and patient-specific factors, such as anticoagulation status and whether the patient was intoxicated at the time of injury.

After a period of education regarding the guidelines, the University of Arizona’s Level I trauma center – the only one in the state – implemented BIG use in 2012. For the 5-year period from 2009 to 2014 encompassing implementation of the guidelines, investigators followed all patients admitted for TBI and tracked use of hospital resources and patient outcomes during the study period.

A total of 2,184 patients with TBI were included in the study, divided into five cohorts by year of admission, and stratified by severity of brain injury. Patients were included if they were admitted for TBI from the emergency department and the initial head CT found a skull fracture or intracranial hemorrhage. Dr. Bellal and his colleagues collected data regarding the number of neurosurgery consults, repeat head CTs, and patient demographic and injury characteristics. They tracked patient outcomes including in-hospital mortality, any progression on repeat head CT, and patient disposition on discharge.

TBI injuries were classified by Glasgow Coma Scale scoring (13-15 for mild TBI; 9-12 for moderate; and less than 8 for severe).

Over time, the proportion of patients with severe brain injury who received repeat head CTs did not change significantly. However, scans for those with less severe injury declined significantly, with a marked drop in repeat head CTs seen at the time of implementation of the BIG guidelines (P < .001 for mild and P = .012 for moderate brain injuries).

Similarly, 100% of patients with severe TBI received a neurosurgical consult in each year of the study period, but the number of consults declined significantly for those with mild and moderate injuries (P < .001 for both mild and moderate injuries).

Hospital length of stay decreased from a mean 6.2 days to 4.7 at the end of the study period (P = .028), and total hospital costs fell by nearly half, from a total $8.1 million for the 2009-2010 cohort to $4.3 million for the 2013-2014 cohort (P < .001).

Mortality, discharge score on the Glasgow Coma scale, and the proportion of patients discharged to home after their hospital stay did not change significantly over the study period.

Study limitations included potential lack of generalizability to smaller or more rural centers, and the potential for confounding by changes in other institutional factors over the study period. The study did not track long-term neurologic or quality of life outcomes.

Discussant Dr. Karen Brasel of Oregon Health & Science University, Portland, said that the study is the latest in a series of reports in the TBI field that speak to the need to avoid “knee-jerk use of resources based on diagnosis alone.” She cautioned that it is still important to examine individual patient outcomes for the few patients who did not receive a neurosurgery consult but then deteriorated, to better evaluate who is at most risk for poor outcomes.

Still, said Dr. Joseph, a “guideline-based individualized protocol for traumatic brain injury can help reduce the burden on neurological services. Life changes, and so does medicine.”

The authors reported no conflicts of interest.

The complete manuscript of this study and its presentation at the American Surgical Association’s 135th Annual Meeting, April 2015, in San Diego, California, are anticipated to be published in the Annals of Surgery pending editorial review.

SAN DIEGO – Many patients with traumatic brain injury (TBI) can be safely managed by trauma surgeons or intensive care physicians, if a guideline-based individual protocol is followed. In a recent single-center study using this protocol, charges fell, repeat imaging decreased, and patient outcomes did not suffer when neurosurgery consults were reserved for individuals with more severe brain injuries.

Every year, emergency departments see 2.5 million visits for traumatic brain injuries ranging from concussions to devastating open injuries, and 11% of those seen are hospitalized. Still, only 10% of patients with TBI will require neurosurgical intervention, Dr. Bellal Joseph of the University of Arizona said at the annual meeting of the American Surgical Association.

Finding a way to conserve resources is important, said Dr. Joseph, since the total number of emergency department visits for TBI is increasing, but resources remain constrained: neurosurgeons are in shorter supply than ever. Further, TBI management may not be changed by numerous repeat head CTs, which are costly and can expose patients to significant amounts of radiation.

Dr. Joseph and his coinvestigators at the University of Arizona had previously developed Brain Injury Guidelines (BIG), which would mandate repeat head CTs and neurosurgery consults only for larger intracranial bleeds and displaced skull fractures. The guidelines are used as part of an individualized protocol that includes overall clinical assessment and patient-specific factors, such as anticoagulation status and whether the patient was intoxicated at the time of injury.

After a period of education regarding the guidelines, the University of Arizona’s Level I trauma center – the only one in the state – implemented BIG use in 2012. For the 5-year period from 2009 to 2014 encompassing implementation of the guidelines, investigators followed all patients admitted for TBI and tracked use of hospital resources and patient outcomes during the study period.

A total of 2,184 patients with TBI were included in the study, divided into five cohorts by year of admission, and stratified by severity of brain injury. Patients were included if they were admitted for TBI from the emergency department and the initial head CT found a skull fracture or intracranial hemorrhage. Dr. Bellal and his colleagues collected data regarding the number of neurosurgery consults, repeat head CTs, and patient demographic and injury characteristics. They tracked patient outcomes including in-hospital mortality, any progression on repeat head CT, and patient disposition on discharge.

TBI injuries were classified by Glasgow Coma Scale scoring (13-15 for mild TBI; 9-12 for moderate; and less than 8 for severe).

Over time, the proportion of patients with severe brain injury who received repeat head CTs did not change significantly. However, scans for those with less severe injury declined significantly, with a marked drop in repeat head CTs seen at the time of implementation of the BIG guidelines (P < .001 for mild and P = .012 for moderate brain injuries).

Similarly, 100% of patients with severe TBI received a neurosurgical consult in each year of the study period, but the number of consults declined significantly for those with mild and moderate injuries (P < .001 for both mild and moderate injuries).

Hospital length of stay decreased from a mean 6.2 days to 4.7 at the end of the study period (P = .028), and total hospital costs fell by nearly half, from a total $8.1 million for the 2009-2010 cohort to $4.3 million for the 2013-2014 cohort (P < .001).

Mortality, discharge score on the Glasgow Coma scale, and the proportion of patients discharged to home after their hospital stay did not change significantly over the study period.

Study limitations included potential lack of generalizability to smaller or more rural centers, and the potential for confounding by changes in other institutional factors over the study period. The study did not track long-term neurologic or quality of life outcomes.

Discussant Dr. Karen Brasel of Oregon Health & Science University, Portland, said that the study is the latest in a series of reports in the TBI field that speak to the need to avoid “knee-jerk use of resources based on diagnosis alone.” She cautioned that it is still important to examine individual patient outcomes for the few patients who did not receive a neurosurgery consult but then deteriorated, to better evaluate who is at most risk for poor outcomes.

Still, said Dr. Joseph, a “guideline-based individualized protocol for traumatic brain injury can help reduce the burden on neurological services. Life changes, and so does medicine.”

The authors reported no conflicts of interest.

The complete manuscript of this study and its presentation at the American Surgical Association’s 135th Annual Meeting, April 2015, in San Diego, California, are anticipated to be published in the Annals of Surgery pending editorial review.