Traumatic Brain Injury

BOSTON—Prolonged exposure therapy is associated with less improvement in symptoms of insomnia and post-traumatic stress disorder (PTSD) among patients with traumatic brain injury (TBI) than among patients without TBI. By the end of therapy, nightmare intensity had increased and total sleep time had decreased from baseline among patients with TBI, according to research presented at the 26th Annual Meeting of the Associated Professional Sleep Societies.

Jessica L. Beltran, a community health program representative at the University of California, San Diego, and colleagues studied 48 veterans diagnosed with PTSD and insomnia. Participants’ mean age was approximately 35, and seven were female. The researchers categorized the patients into a TBI group (25 patients) and a non-TBI group (23 patients) after screening. All subjects kept daily sleep diaries that included information about total sleep time, sleep efficiency, sleep latency, number of awakenings, wake after sleep onset, and nightmare rate and intensity.

In addition, the investigators administered several psychiatric questionnaires to the patients at baseline, including the Insomnia Severity Index, Clinician-Administered PTSD Scale (CAPS), PTSD Checklist Stressor Specific (PCL-S), and Patient Health Questionnaire (PHQ-9). After the participants had undergone prolonged exposure therapy, the researchers administered the questionnaires again. Baseline and post-therapy variables were analyzed with an independent samples t-test.

Ms. Beltran observed no statistically significant differences in sleep-diary variables and questionnaire scores between the TBI group and the non-TBI group at baseline. After treatment, mean nightmare intensity increased from approximately 6 to approximately 7 (on a 10-point scale) in the TBI group, compared with a decrease from about 6 to about 4.5 in the non-TBI group. Mean total sleep time decreased from 350 minutes to 325 minutes in the TBI group, compared with an increase from 350 minutes to 400 minutes for the non-TBI group.

For patients in the TBI group, mean CAPS score decreased from 80 to 70 after therapy, compared with a decrease from 75 to 50 for the non-TBI group. These scores indicated that the TBI group still had severe PTSD after therapy. Mean PHQ-9 score decreased from 15 to 14 for the TBI group, compared with a decrease from 17 to 7 for the non-TBI group. Patients with TBI “might benefit from a combination of multiple therapies that address their specific needs—for instance, more support during the in vivo component of prolonged exposure therapy, as well as a greater focus on cognitive difficulties,” said Ms. Beltran.   

BOSTON—Prolonged exposure therapy is associated with less improvement in symptoms of insomnia and post-traumatic stress disorder (PTSD) among patients with traumatic brain injury (TBI) than among patients without TBI. By the end of therapy, nightmare intensity had increased and total sleep time had decreased from baseline among patients with TBI, according to research presented at the 26th Annual Meeting of the Associated Professional Sleep Societies.

Jessica L. Beltran, a community health program representative at the University of California, San Diego, and colleagues studied 48 veterans diagnosed with PTSD and insomnia. Participants’ mean age was approximately 35, and seven were female. The researchers categorized the patients into a TBI group (25 patients) and a non-TBI group (23 patients) after screening. All subjects kept daily sleep diaries that included information about total sleep time, sleep efficiency, sleep latency, number of awakenings, wake after sleep onset, and nightmare rate and intensity.

In addition, the investigators administered several psychiatric questionnaires to the patients at baseline, including the Insomnia Severity Index, Clinician-Administered PTSD Scale (CAPS), PTSD Checklist Stressor Specific (PCL-S), and Patient Health Questionnaire (PHQ-9). After the participants had undergone prolonged exposure therapy, the researchers administered the questionnaires again. Baseline and post-therapy variables were analyzed with an independent samples t-test.

Ms. Beltran observed no statistically significant differences in sleep-diary variables and questionnaire scores between the TBI group and the non-TBI group at baseline. After treatment, mean nightmare intensity increased from approximately 6 to approximately 7 (on a 10-point scale) in the TBI group, compared with a decrease from about 6 to about 4.5 in the non-TBI group. Mean total sleep time decreased from 350 minutes to 325 minutes in the TBI group, compared with an increase from 350 minutes to 400 minutes for the non-TBI group.

For patients in the TBI group, mean CAPS score decreased from 80 to 70 after therapy, compared with a decrease from 75 to 50 for the non-TBI group. These scores indicated that the TBI group still had severe PTSD after therapy. Mean PHQ-9 score decreased from 15 to 14 for the TBI group, compared with a decrease from 17 to 7 for the non-TBI group. Patients with TBI “might benefit from a combination of multiple therapies that address their specific needs—for instance, more support during the in vivo component of prolonged exposure therapy, as well as a greater focus on cognitive difficulties,” said Ms. Beltran.   

BOSTON—Prolonged exposure therapy is associated with less improvement in symptoms of insomnia and post-traumatic stress disorder (PTSD) among patients with traumatic brain injury (TBI) than among patients without TBI. By the end of therapy, nightmare intensity had increased and total sleep time had decreased from baseline among patients with TBI, according to research presented at the 26th Annual Meeting of the Associated Professional Sleep Societies.

Jessica L. Beltran, a community health program representative at the University of California, San Diego, and colleagues studied 48 veterans diagnosed with PTSD and insomnia. Participants’ mean age was approximately 35, and seven were female. The researchers categorized the patients into a TBI group (25 patients) and a non-TBI group (23 patients) after screening. All subjects kept daily sleep diaries that included information about total sleep time, sleep efficiency, sleep latency, number of awakenings, wake after sleep onset, and nightmare rate and intensity.

In addition, the investigators administered several psychiatric questionnaires to the patients at baseline, including the Insomnia Severity Index, Clinician-Administered PTSD Scale (CAPS), PTSD Checklist Stressor Specific (PCL-S), and Patient Health Questionnaire (PHQ-9). After the participants had undergone prolonged exposure therapy, the researchers administered the questionnaires again. Baseline and post-therapy variables were analyzed with an independent samples t-test.

Ms. Beltran observed no statistically significant differences in sleep-diary variables and questionnaire scores between the TBI group and the non-TBI group at baseline. After treatment, mean nightmare intensity increased from approximately 6 to approximately 7 (on a 10-point scale) in the TBI group, compared with a decrease from about 6 to about 4.5 in the non-TBI group. Mean total sleep time decreased from 350 minutes to 325 minutes in the TBI group, compared with an increase from 350 minutes to 400 minutes for the non-TBI group.

For patients in the TBI group, mean CAPS score decreased from 80 to 70 after therapy, compared with a decrease from 75 to 50 for the non-TBI group. These scores indicated that the TBI group still had severe PTSD after therapy. Mean PHQ-9 score decreased from 15 to 14 for the TBI group, compared with a decrease from 17 to 7 for the non-TBI group. Patients with TBI “might benefit from a combination of multiple therapies that address their specific needs—for instance, more support during the in vivo component of prolonged exposure therapy, as well as a greater focus on cognitive difficulties,” said Ms. Beltran.   

Fewer patients receiving amantadine remained in a vegetative state compared with patients receiving placebo.

Patients with post-traumatic disorders of consciousness who received amantadine hydrochloride experienced a more rapid rate of functional recovery than those treated with a placebo, according to an article published in the March 1 New England Journal of Medicine. The benefit of the drug was evident in patients diagnosed with a vegetative or minimally conscious state at baseline, regardless of when they were enrolled in the trial.

Fewer patients who received amantadine, a drug used to treat Parkinson’s disease, remained in a vegetative state, compared with patients who received placebo, according to Joseph T. Giacino, PhD, Director of Rehabilitation Neuropsychology at Spaulding Rehabilitation Hospital and Associate Professor at Harvard Medical School in Boston. In addition, a greater percentage of patients receiving amantadine met key behavioral milestones for recovery (eg, consistent following of commands and object recognition) by the end of the treatment period, compared with the control group. Treatment did not increase patients’ risk of adverse medical events.

After patients stopped receiving amantadine, their level of improvement continued to increase, albeit at a significantly slower rate. Two weeks after treatment ended, the disability scores of the experimental and control groups were similar.

Treating Post-Traumatic Disorders of Consciousness
Dr. Giacino and his colleagues conducted a prospective, double-blind, randomized trial to evaluate the effectiveness of amantadine in helping patients with post-traumatic trauma recover from a vegetative or minimally conscious state. The study followed 184 patients at 11 clinical sites in three countries.

Eligible patients had experienced traumatic brain injury four to 16 weeks before enrollment, and they were receiving care at in-patient facilities. Participants had disability rating scores (DRS) greater than 11, could not follow commands, and could not engage in functional communication. Nearly 87% of patients were white, and approximately 72% were male.

After randomization, the experimental group received 100 mg of amantadine twice daily for 14 days. The dose was increased to 150 mg twice daily at week three, and to 200 mg twice daily at week four for any patient in the group whose DRS had not improved by two points from baseline. After four weeks, treatment ceased, but DRS scores continued to be assessed for two additional weeks. The control group received a placebo for four weeks.

Amantadine May Shorten In-Patient Stays
“We conclude that amantadine is effective in accelerating the pace of recovery during acute rehabilitation in patients with prolonged post-traumatic disturbances in consciousness,” said Dr. Giacino. “The favorable neurobehavioral effects of amantadine may reflect enhanced neurotransmission in the dopamine-dependent nigrostriatal, mesolimbic, and frontostriatal circuits that are responsible for mediating arousal, drive, and attentional functions.”

The researchers limited the length of the treatment period for practical and ethical reasons. Therefore, the study results leave open the question of whether amantadine improves patients’ long-term outcome or accelerates recovery to the end point that an untreated patient would reach. “In view of health care cost constraints and declining lengths of stay for in-patient rehabilitation, amantadine-induced acceleration of recovery may represent an important advance,” said Dr. Giacino. Future studies should identify which patients are likely to respond to amantadine, the effective dose, and the optimal duration of treatment, he concluded.   

Fewer patients receiving amantadine remained in a vegetative state compared with patients receiving placebo.

Patients with post-traumatic disorders of consciousness who received amantadine hydrochloride experienced a more rapid rate of functional recovery than those treated with a placebo, according to an article published in the March 1 New England Journal of Medicine. The benefit of the drug was evident in patients diagnosed with a vegetative or minimally conscious state at baseline, regardless of when they were enrolled in the trial.

Fewer patients who received amantadine, a drug used to treat Parkinson’s disease, remained in a vegetative state, compared with patients who received placebo, according to Joseph T. Giacino, PhD, Director of Rehabilitation Neuropsychology at Spaulding Rehabilitation Hospital and Associate Professor at Harvard Medical School in Boston. In addition, a greater percentage of patients receiving amantadine met key behavioral milestones for recovery (eg, consistent following of commands and object recognition) by the end of the treatment period, compared with the control group. Treatment did not increase patients’ risk of adverse medical events.

After patients stopped receiving amantadine, their level of improvement continued to increase, albeit at a significantly slower rate. Two weeks after treatment ended, the disability scores of the experimental and control groups were similar.

Treating Post-Traumatic Disorders of Consciousness
Dr. Giacino and his colleagues conducted a prospective, double-blind, randomized trial to evaluate the effectiveness of amantadine in helping patients with post-traumatic trauma recover from a vegetative or minimally conscious state. The study followed 184 patients at 11 clinical sites in three countries.

Eligible patients had experienced traumatic brain injury four to 16 weeks before enrollment, and they were receiving care at in-patient facilities. Participants had disability rating scores (DRS) greater than 11, could not follow commands, and could not engage in functional communication. Nearly 87% of patients were white, and approximately 72% were male.

After randomization, the experimental group received 100 mg of amantadine twice daily for 14 days. The dose was increased to 150 mg twice daily at week three, and to 200 mg twice daily at week four for any patient in the group whose DRS had not improved by two points from baseline. After four weeks, treatment ceased, but DRS scores continued to be assessed for two additional weeks. The control group received a placebo for four weeks.

Amantadine May Shorten In-Patient Stays
“We conclude that amantadine is effective in accelerating the pace of recovery during acute rehabilitation in patients with prolonged post-traumatic disturbances in consciousness,” said Dr. Giacino. “The favorable neurobehavioral effects of amantadine may reflect enhanced neurotransmission in the dopamine-dependent nigrostriatal, mesolimbic, and frontostriatal circuits that are responsible for mediating arousal, drive, and attentional functions.”

The researchers limited the length of the treatment period for practical and ethical reasons. Therefore, the study results leave open the question of whether amantadine improves patients’ long-term outcome or accelerates recovery to the end point that an untreated patient would reach. “In view of health care cost constraints and declining lengths of stay for in-patient rehabilitation, amantadine-induced acceleration of recovery may represent an important advance,” said Dr. Giacino. Future studies should identify which patients are likely to respond to amantadine, the effective dose, and the optimal duration of treatment, he concluded.   

Fewer patients receiving amantadine remained in a vegetative state compared with patients receiving placebo.

Patients with post-traumatic disorders of consciousness who received amantadine hydrochloride experienced a more rapid rate of functional recovery than those treated with a placebo, according to an article published in the March 1 New England Journal of Medicine. The benefit of the drug was evident in patients diagnosed with a vegetative or minimally conscious state at baseline, regardless of when they were enrolled in the trial.

Fewer patients who received amantadine, a drug used to treat Parkinson’s disease, remained in a vegetative state, compared with patients who received placebo, according to Joseph T. Giacino, PhD, Director of Rehabilitation Neuropsychology at Spaulding Rehabilitation Hospital and Associate Professor at Harvard Medical School in Boston. In addition, a greater percentage of patients receiving amantadine met key behavioral milestones for recovery (eg, consistent following of commands and object recognition) by the end of the treatment period, compared with the control group. Treatment did not increase patients’ risk of adverse medical events.

After patients stopped receiving amantadine, their level of improvement continued to increase, albeit at a significantly slower rate. Two weeks after treatment ended, the disability scores of the experimental and control groups were similar.

Treating Post-Traumatic Disorders of Consciousness
Dr. Giacino and his colleagues conducted a prospective, double-blind, randomized trial to evaluate the effectiveness of amantadine in helping patients with post-traumatic trauma recover from a vegetative or minimally conscious state. The study followed 184 patients at 11 clinical sites in three countries.

Eligible patients had experienced traumatic brain injury four to 16 weeks before enrollment, and they were receiving care at in-patient facilities. Participants had disability rating scores (DRS) greater than 11, could not follow commands, and could not engage in functional communication. Nearly 87% of patients were white, and approximately 72% were male.

After randomization, the experimental group received 100 mg of amantadine twice daily for 14 days. The dose was increased to 150 mg twice daily at week three, and to 200 mg twice daily at week four for any patient in the group whose DRS had not improved by two points from baseline. After four weeks, treatment ceased, but DRS scores continued to be assessed for two additional weeks. The control group received a placebo for four weeks.

Amantadine May Shorten In-Patient Stays
“We conclude that amantadine is effective in accelerating the pace of recovery during acute rehabilitation in patients with prolonged post-traumatic disturbances in consciousness,” said Dr. Giacino. “The favorable neurobehavioral effects of amantadine may reflect enhanced neurotransmission in the dopamine-dependent nigrostriatal, mesolimbic, and frontostriatal circuits that are responsible for mediating arousal, drive, and attentional functions.”

The researchers limited the length of the treatment period for practical and ethical reasons. Therefore, the study results leave open the question of whether amantadine improves patients’ long-term outcome or accelerates recovery to the end point that an untreated patient would reach. “In view of health care cost constraints and declining lengths of stay for in-patient rehabilitation, amantadine-induced acceleration of recovery may represent an important advance,” said Dr. Giacino. Future studies should identify which patients are likely to respond to amantadine, the effective dose, and the optimal duration of treatment, he concluded.   

Adolescent girls with TBI may have an increased risk of headache one year after injury compared with controls, according to investigators.

SAVANNAH, GA—Children who experience traumatic brain injury (TBI) are at an increased risk for headache three months later—but for most children, this risk returns to normal one year after injury, researchers reported at the 40th Annual Meeting of the Child Neurology Society.

“The association between pediatric TBI and headache is significant overall and for girls and adolescents following mild TBI, as well as for younger children following moderate/severe TBI,” said Heidi K. Blume, MD, Assistant Professor of Neurology at Seattle Children’s Hospital and the University of Washington, Seattle.

TBI Versus Arm Injury
To determine whether pediatric TBI is associated with long-term headache, the investigators compared headache prevalence in children with TBI with that in children with an arm injury, who served as controls. They also examined age- and sex-related differences in headache frequency following mild and moderate/severe TBI. The study was open to all patients ages 5 to 17 who were treated for a TBI or an arm fracture in one of 10 study hospitals. At baseline, the researchers interviewed a parent/guardian of each child, and at three and 12 months, they conducted follow-up interviews with parents and adolescents ages 14 and older.

In the follow-up interviews, parents were asked to “rate any headache pain by indicating the child’s headache on average in the last week” on a scale of 0 to 10. Adolescents were asked to indicate how much they were bothered by headaches in the past week, as well as to rate their headache pain during the past week on a scale of 0 to 10 and on the Wong-Baker FACES scale.

The investigators defined “headache” as a pain score of 1 or more. They defined “serious headache” as a pain score of 5 or more on the parent surveys and as “bothered a lot,” a score of 5 or more, or report of C-F headache on the FACES scale in the adolescent surveys. The CDC Mild TBI Work Group report and patients’ Glasgow Coma Scale scores after injury were used to define mild, moderate, and severe TBI. Patients ages 5 to 12 were defined as children, and patients ages 13 to 17 were defined as adolescents.

A Three-Month Association
The study included 649 patients: 441 with mild TBI, 71 with moderate/severe TBI, and 137 with arm injury.
At three months, headache prevalence was significantly higher in patients with mild TBI than in controls among the overall cohort (43% vs 26.2%), adolescents (46.4% vs 25%), and girls (58.8% vs 23.8%). In addition, headache prevalence was higher in patients with moderate/severe TBI than in controls among younger children (60% vs 27%). For girls, serious headache was significantly more frequent after mild TBI than after arm injury, and for young children, serious headache was significantly more frequent after moderate/serious TBI than after arm injury. “The prevalence of headache increased with age in girls with mild TBI but not in boys or controls of either sex,” the researchers added.

In the three-month adolescent survey, 55% of girls with mild TBI versus 23% of control girls reported serious headache. In addition, 32% of girls with mild TBI versus 8% of control girls reported that they were “bothered a lot” by headache, and 64% of girls with mild TBI versus 11% of control girls indicated C-F on the FACES scale. However, there were no significant associations between mild TBI and headache for adolescent boys or between moderate/severe TBI and headache for adolescents of either sex.

At 12 months, headache prevalence was not significantly associated with mild TBI or moderate/severe TBI. However, serious headache was more common among girls with mild TBI than among control girls (27% vs 10%).

In the 12-month adolescent survey, girls with mild TBI reported more headaches than control girls on all questions, but the differences did not reach statistical significance. There were similar trends for girls with moderate/severe TBI.

“Adolescent girls with TBI may have an increased risk of headache one year after injury compared to controls,” the researchers concluded. “The epidemiology of headache following pediatric TBI appears to share some features with primary headache disorders such as migraine.

Adolescent girls with TBI may have an increased risk of headache one year after injury compared with controls, according to investigators.

SAVANNAH, GA—Children who experience traumatic brain injury (TBI) are at an increased risk for headache three months later—but for most children, this risk returns to normal one year after injury, researchers reported at the 40th Annual Meeting of the Child Neurology Society.

“The association between pediatric TBI and headache is significant overall and for girls and adolescents following mild TBI, as well as for younger children following moderate/severe TBI,” said Heidi K. Blume, MD, Assistant Professor of Neurology at Seattle Children’s Hospital and the University of Washington, Seattle.

TBI Versus Arm Injury
To determine whether pediatric TBI is associated with long-term headache, the investigators compared headache prevalence in children with TBI with that in children with an arm injury, who served as controls. They also examined age- and sex-related differences in headache frequency following mild and moderate/severe TBI. The study was open to all patients ages 5 to 17 who were treated for a TBI or an arm fracture in one of 10 study hospitals. At baseline, the researchers interviewed a parent/guardian of each child, and at three and 12 months, they conducted follow-up interviews with parents and adolescents ages 14 and older.

In the follow-up interviews, parents were asked to “rate any headache pain by indicating the child’s headache on average in the last week” on a scale of 0 to 10. Adolescents were asked to indicate how much they were bothered by headaches in the past week, as well as to rate their headache pain during the past week on a scale of 0 to 10 and on the Wong-Baker FACES scale.

The investigators defined “headache” as a pain score of 1 or more. They defined “serious headache” as a pain score of 5 or more on the parent surveys and as “bothered a lot,” a score of 5 or more, or report of C-F headache on the FACES scale in the adolescent surveys. The CDC Mild TBI Work Group report and patients’ Glasgow Coma Scale scores after injury were used to define mild, moderate, and severe TBI. Patients ages 5 to 12 were defined as children, and patients ages 13 to 17 were defined as adolescents.

A Three-Month Association
The study included 649 patients: 441 with mild TBI, 71 with moderate/severe TBI, and 137 with arm injury.
At three months, headache prevalence was significantly higher in patients with mild TBI than in controls among the overall cohort (43% vs 26.2%), adolescents (46.4% vs 25%), and girls (58.8% vs 23.8%). In addition, headache prevalence was higher in patients with moderate/severe TBI than in controls among younger children (60% vs 27%). For girls, serious headache was significantly more frequent after mild TBI than after arm injury, and for young children, serious headache was significantly more frequent after moderate/serious TBI than after arm injury. “The prevalence of headache increased with age in girls with mild TBI but not in boys or controls of either sex,” the researchers added.

In the three-month adolescent survey, 55% of girls with mild TBI versus 23% of control girls reported serious headache. In addition, 32% of girls with mild TBI versus 8% of control girls reported that they were “bothered a lot” by headache, and 64% of girls with mild TBI versus 11% of control girls indicated C-F on the FACES scale. However, there were no significant associations between mild TBI and headache for adolescent boys or between moderate/severe TBI and headache for adolescents of either sex.

At 12 months, headache prevalence was not significantly associated with mild TBI or moderate/severe TBI. However, serious headache was more common among girls with mild TBI than among control girls (27% vs 10%).

In the 12-month adolescent survey, girls with mild TBI reported more headaches than control girls on all questions, but the differences did not reach statistical significance. There were similar trends for girls with moderate/severe TBI.

“Adolescent girls with TBI may have an increased risk of headache one year after injury compared to controls,” the researchers concluded. “The epidemiology of headache following pediatric TBI appears to share some features with primary headache disorders such as migraine.

Adolescent girls with TBI may have an increased risk of headache one year after injury compared with controls, according to investigators.

SAVANNAH, GA—Children who experience traumatic brain injury (TBI) are at an increased risk for headache three months later—but for most children, this risk returns to normal one year after injury, researchers reported at the 40th Annual Meeting of the Child Neurology Society.

“The association between pediatric TBI and headache is significant overall and for girls and adolescents following mild TBI, as well as for younger children following moderate/severe TBI,” said Heidi K. Blume, MD, Assistant Professor of Neurology at Seattle Children’s Hospital and the University of Washington, Seattle.

TBI Versus Arm Injury
To determine whether pediatric TBI is associated with long-term headache, the investigators compared headache prevalence in children with TBI with that in children with an arm injury, who served as controls. They also examined age- and sex-related differences in headache frequency following mild and moderate/severe TBI. The study was open to all patients ages 5 to 17 who were treated for a TBI or an arm fracture in one of 10 study hospitals. At baseline, the researchers interviewed a parent/guardian of each child, and at three and 12 months, they conducted follow-up interviews with parents and adolescents ages 14 and older.

In the follow-up interviews, parents were asked to “rate any headache pain by indicating the child’s headache on average in the last week” on a scale of 0 to 10. Adolescents were asked to indicate how much they were bothered by headaches in the past week, as well as to rate their headache pain during the past week on a scale of 0 to 10 and on the Wong-Baker FACES scale.

The investigators defined “headache” as a pain score of 1 or more. They defined “serious headache” as a pain score of 5 or more on the parent surveys and as “bothered a lot,” a score of 5 or more, or report of C-F headache on the FACES scale in the adolescent surveys. The CDC Mild TBI Work Group report and patients’ Glasgow Coma Scale scores after injury were used to define mild, moderate, and severe TBI. Patients ages 5 to 12 were defined as children, and patients ages 13 to 17 were defined as adolescents.

A Three-Month Association
The study included 649 patients: 441 with mild TBI, 71 with moderate/severe TBI, and 137 with arm injury.
At three months, headache prevalence was significantly higher in patients with mild TBI than in controls among the overall cohort (43% vs 26.2%), adolescents (46.4% vs 25%), and girls (58.8% vs 23.8%). In addition, headache prevalence was higher in patients with moderate/severe TBI than in controls among younger children (60% vs 27%). For girls, serious headache was significantly more frequent after mild TBI than after arm injury, and for young children, serious headache was significantly more frequent after moderate/serious TBI than after arm injury. “The prevalence of headache increased with age in girls with mild TBI but not in boys or controls of either sex,” the researchers added.

In the three-month adolescent survey, 55% of girls with mild TBI versus 23% of control girls reported serious headache. In addition, 32% of girls with mild TBI versus 8% of control girls reported that they were “bothered a lot” by headache, and 64% of girls with mild TBI versus 11% of control girls indicated C-F on the FACES scale. However, there were no significant associations between mild TBI and headache for adolescent boys or between moderate/severe TBI and headache for adolescents of either sex.

At 12 months, headache prevalence was not significantly associated with mild TBI or moderate/severe TBI. However, serious headache was more common among girls with mild TBI than among control girls (27% vs 10%).

In the 12-month adolescent survey, girls with mild TBI reported more headaches than control girls on all questions, but the differences did not reach statistical significance. There were similar trends for girls with moderate/severe TBI.

“Adolescent girls with TBI may have an increased risk of headache one year after injury compared to controls,” the researchers concluded. “The epidemiology of headache following pediatric TBI appears to share some features with primary headache disorders such as migraine.

Children with traumatic brain injury, particularly in cases of abusive head trauma, have a high likelihood of developing seizures within the first week postinjury.

SAVANNAH, GA—Nearly 10% of children with moderate to severe traumatic brain injury (TBI) show evidence of subclinical seizures, according to a report presented at the 40th Annual Meeting of the Child Neurology Society.

Jason T. Lerner, MD, from the Brain Injury Research Center and Department of Pediatrics at the University of California in Los Angeles, and colleagues followed a group of pediatric patients with moderate to severe TBI, and they determined that a significant portion of these children had evidence of subclinical seizures on video EEG monitoring.

Characterizing Posttraumatic Seizure Occurrence in a Pediatric TBI Population
“Nonconvulsive (subclinical) seizures have been demonstrated in adults after TBI and have been shown to be associated with additional physiologic problems such as increased intracranial pressure,” the researchers noted. However, “the incidence, risk factors, and subsequent effects of these seizures are unknown in children.”

Dr. Lerner and his colleagues sought to determine the frequency of subclinical and clinical early posttraumatic seizures in a pediatric population with moderate to severe TBI, using continuous video EEG monitoring.

The team of investigators prospectively collected data from all children admitted to a pediatric intensive care unit with moderate to severe TBI. All patients underwent at least 24 hours of video EEG telemetry monitoring and were followed for at least two years as outpatients. Early posttraumatic epilepsy was defined as seizures occurring within the first week after injury, and late posttraumatic epilepsy was defined as seizures occurring after the first week postinjury.

To date, 67 patients (age range, 1 month to 17 years) were enrolled in the study. “One patient was in subclinical status epilepticus with seizures lasting up to 90 seconds,” the investigators reported. Twenty-nine patients had severe TBI, and 38 had moderate TBI. Posttraumatic seizures occurred in 27 (40%) patients; six of these cases were identified only as subclinical. The most common mechanisms of injury were a fall (23 cases), abusive head trauma (20), and motor vehicle accident (14).

Risk Factors for Posttraumatic Epilepsy After TBI
Dr. Lerner and his colleagues found that the mean age of patients with seizures was significantly lower than for those without seizures (4.7 vs 6.9). Patients who experienced abusive head trauma were six times more likely to have seizures than were those with any other mechanism of injury, making abusive head trauma a significant risk factor for posttraumatic epilepsy.

TBI in the pediatric population is a leading cause of morbidity and mortality, the researchers noted. “Seizures are a common morbidity associated with TBI and may in themselves contribute to additional morbidity,” stated the study authors. “The incidence of seizures after TBI is approximately 10% to 20%. However, the exact number is not known, because seizures in children can be particularly difficult to detect.

“Abusive head trauma and younger age were risk factors for early posttraumatic seizures,” Dr. Lerner and colleagues concluded. “The use of video EEG monitoring for pediatric TBI may permit targeting of prophylactic anticonvulsant therapy to children who require it mostand may spare other children the potential toxicities of such medications.”

Children with traumatic brain injury, particularly in cases of abusive head trauma, have a high likelihood of developing seizures within the first week postinjury.

SAVANNAH, GA—Nearly 10% of children with moderate to severe traumatic brain injury (TBI) show evidence of subclinical seizures, according to a report presented at the 40th Annual Meeting of the Child Neurology Society.

Jason T. Lerner, MD, from the Brain Injury Research Center and Department of Pediatrics at the University of California in Los Angeles, and colleagues followed a group of pediatric patients with moderate to severe TBI, and they determined that a significant portion of these children had evidence of subclinical seizures on video EEG monitoring.

Characterizing Posttraumatic Seizure Occurrence in a Pediatric TBI Population
“Nonconvulsive (subclinical) seizures have been demonstrated in adults after TBI and have been shown to be associated with additional physiologic problems such as increased intracranial pressure,” the researchers noted. However, “the incidence, risk factors, and subsequent effects of these seizures are unknown in children.”

Dr. Lerner and his colleagues sought to determine the frequency of subclinical and clinical early posttraumatic seizures in a pediatric population with moderate to severe TBI, using continuous video EEG monitoring.

The team of investigators prospectively collected data from all children admitted to a pediatric intensive care unit with moderate to severe TBI. All patients underwent at least 24 hours of video EEG telemetry monitoring and were followed for at least two years as outpatients. Early posttraumatic epilepsy was defined as seizures occurring within the first week after injury, and late posttraumatic epilepsy was defined as seizures occurring after the first week postinjury.

To date, 67 patients (age range, 1 month to 17 years) were enrolled in the study. “One patient was in subclinical status epilepticus with seizures lasting up to 90 seconds,” the investigators reported. Twenty-nine patients had severe TBI, and 38 had moderate TBI. Posttraumatic seizures occurred in 27 (40%) patients; six of these cases were identified only as subclinical. The most common mechanisms of injury were a fall (23 cases), abusive head trauma (20), and motor vehicle accident (14).

Risk Factors for Posttraumatic Epilepsy After TBI
Dr. Lerner and his colleagues found that the mean age of patients with seizures was significantly lower than for those without seizures (4.7 vs 6.9). Patients who experienced abusive head trauma were six times more likely to have seizures than were those with any other mechanism of injury, making abusive head trauma a significant risk factor for posttraumatic epilepsy.

TBI in the pediatric population is a leading cause of morbidity and mortality, the researchers noted. “Seizures are a common morbidity associated with TBI and may in themselves contribute to additional morbidity,” stated the study authors. “The incidence of seizures after TBI is approximately 10% to 20%. However, the exact number is not known, because seizures in children can be particularly difficult to detect.

“Abusive head trauma and younger age were risk factors for early posttraumatic seizures,” Dr. Lerner and colleagues concluded. “The use of video EEG monitoring for pediatric TBI may permit targeting of prophylactic anticonvulsant therapy to children who require it mostand may spare other children the potential toxicities of such medications.”

Children with traumatic brain injury, particularly in cases of abusive head trauma, have a high likelihood of developing seizures within the first week postinjury.

SAVANNAH, GA—Nearly 10% of children with moderate to severe traumatic brain injury (TBI) show evidence of subclinical seizures, according to a report presented at the 40th Annual Meeting of the Child Neurology Society.

Jason T. Lerner, MD, from the Brain Injury Research Center and Department of Pediatrics at the University of California in Los Angeles, and colleagues followed a group of pediatric patients with moderate to severe TBI, and they determined that a significant portion of these children had evidence of subclinical seizures on video EEG monitoring.

Characterizing Posttraumatic Seizure Occurrence in a Pediatric TBI Population
“Nonconvulsive (subclinical) seizures have been demonstrated in adults after TBI and have been shown to be associated with additional physiologic problems such as increased intracranial pressure,” the researchers noted. However, “the incidence, risk factors, and subsequent effects of these seizures are unknown in children.”

Dr. Lerner and his colleagues sought to determine the frequency of subclinical and clinical early posttraumatic seizures in a pediatric population with moderate to severe TBI, using continuous video EEG monitoring.

The team of investigators prospectively collected data from all children admitted to a pediatric intensive care unit with moderate to severe TBI. All patients underwent at least 24 hours of video EEG telemetry monitoring and were followed for at least two years as outpatients. Early posttraumatic epilepsy was defined as seizures occurring within the first week after injury, and late posttraumatic epilepsy was defined as seizures occurring after the first week postinjury.

To date, 67 patients (age range, 1 month to 17 years) were enrolled in the study. “One patient was in subclinical status epilepticus with seizures lasting up to 90 seconds,” the investigators reported. Twenty-nine patients had severe TBI, and 38 had moderate TBI. Posttraumatic seizures occurred in 27 (40%) patients; six of these cases were identified only as subclinical. The most common mechanisms of injury were a fall (23 cases), abusive head trauma (20), and motor vehicle accident (14).

Risk Factors for Posttraumatic Epilepsy After TBI
Dr. Lerner and his colleagues found that the mean age of patients with seizures was significantly lower than for those without seizures (4.7 vs 6.9). Patients who experienced abusive head trauma were six times more likely to have seizures than were those with any other mechanism of injury, making abusive head trauma a significant risk factor for posttraumatic epilepsy.

TBI in the pediatric population is a leading cause of morbidity and mortality, the researchers noted. “Seizures are a common morbidity associated with TBI and may in themselves contribute to additional morbidity,” stated the study authors. “The incidence of seizures after TBI is approximately 10% to 20%. However, the exact number is not known, because seizures in children can be particularly difficult to detect.

“Abusive head trauma and younger age were risk factors for early posttraumatic seizures,” Dr. Lerner and colleagues concluded. “The use of video EEG monitoring for pediatric TBI may permit targeting of prophylactic anticonvulsant therapy to children who require it mostand may spare other children the potential toxicities of such medications.”

Inefficient sleep appears to be associated with impairment on tasks requiring higher levels of cognitive processing in war veterans with mild to moderate TBI.

MINNEAPOLIS—Insomnia and other types of sleep disturbance may play a significant role in cognitive deficits, psychiatric symptoms, and recovery of normal performance among war veterans with mild to moderate traumatic brain injury (TBI), according to research presented at the 25th Anniversary Meeting of the Associated Professional Sleep Societies.
“Levels of sleep disturbance among war veterans exceeded the general population prevalence,” reported Henry J. Orff, PhD, of the Department of Psychiatry, University of California, San Diego, and colleagues. “Poor sleep is a pervasive complaint in veterans with mild to moderate TBI.”
Dr. Orff’s group conducted retrospective chart reviews of 300 veterans from the wars in Iraq and Afghanistan regarding their clinical sleep, as well as their psychiatric and neuropsychologic test data.
The mean age of participants was 32, and their mean education was 13.5 years. Each veteran had a mean of two TBIs, with a mean longest loss of consciousness of 16 minutes and a mean longest length of posttraumatic amnesia of 137 minutes; 86.5% of all TBIs were mild, and 13.5% were moderate. The mechanisms of injury included blast-related TBI (25.6%), blunt force TBI (38.4%), and both blast and blunt force mechanisms (36%).
Eighty-five percent of the veterans reported sleep disturbance as measured by the scores on item #16 of the Beck Depression Inventory, a question that addresses changes in sleeping patterns from normal in the past week. In addition, 71% of the sample reported getting less sleep. In a subset of 86 veterans who were administered the Pittsburgh Sleep Quality Inventory (PSQI), 100% reported clinically significant sleep disturbance (PSQI global score >5). Furthermore, self-reported sleep latencies averaged 54 minutes, total sleep times averaged 5.4 hours, and sleep efficiencies averaged 77% in this sample.
Depressive symptoms were significantly correlated with a host of sleep complaints, including poorer sleep quality, longer sleep latencies, shorter sleep times, lower sleep efficiencies, more use of medications, and greater daytime dysfunction. Postconcussive symptoms were correlated with poorer sleep quality, shorter sleep duration, and greater self-reported daytime dysfunction.
“Overall, the results suggest that poor sleep in this population may have ramifications for performance on tasks requiring higher levels of cognitive processing, such as executive tasks with a timed component, while having less  impact on more basic cognitive tasks, such as those involving attention and verbal memory,” stated Dr. Orff and colleagues.

Inefficient sleep appears to be associated with impairment on tasks requiring higher levels of cognitive processing in war veterans with mild to moderate TBI.

MINNEAPOLIS—Insomnia and other types of sleep disturbance may play a significant role in cognitive deficits, psychiatric symptoms, and recovery of normal performance among war veterans with mild to moderate traumatic brain injury (TBI), according to research presented at the 25th Anniversary Meeting of the Associated Professional Sleep Societies.
“Levels of sleep disturbance among war veterans exceeded the general population prevalence,” reported Henry J. Orff, PhD, of the Department of Psychiatry, University of California, San Diego, and colleagues. “Poor sleep is a pervasive complaint in veterans with mild to moderate TBI.”
Dr. Orff’s group conducted retrospective chart reviews of 300 veterans from the wars in Iraq and Afghanistan regarding their clinical sleep, as well as their psychiatric and neuropsychologic test data.
The mean age of participants was 32, and their mean education was 13.5 years. Each veteran had a mean of two TBIs, with a mean longest loss of consciousness of 16 minutes and a mean longest length of posttraumatic amnesia of 137 minutes; 86.5% of all TBIs were mild, and 13.5% were moderate. The mechanisms of injury included blast-related TBI (25.6%), blunt force TBI (38.4%), and both blast and blunt force mechanisms (36%).
Eighty-five percent of the veterans reported sleep disturbance as measured by the scores on item #16 of the Beck Depression Inventory, a question that addresses changes in sleeping patterns from normal in the past week. In addition, 71% of the sample reported getting less sleep. In a subset of 86 veterans who were administered the Pittsburgh Sleep Quality Inventory (PSQI), 100% reported clinically significant sleep disturbance (PSQI global score >5). Furthermore, self-reported sleep latencies averaged 54 minutes, total sleep times averaged 5.4 hours, and sleep efficiencies averaged 77% in this sample.
Depressive symptoms were significantly correlated with a host of sleep complaints, including poorer sleep quality, longer sleep latencies, shorter sleep times, lower sleep efficiencies, more use of medications, and greater daytime dysfunction. Postconcussive symptoms were correlated with poorer sleep quality, shorter sleep duration, and greater self-reported daytime dysfunction.
“Overall, the results suggest that poor sleep in this population may have ramifications for performance on tasks requiring higher levels of cognitive processing, such as executive tasks with a timed component, while having less  impact on more basic cognitive tasks, such as those involving attention and verbal memory,” stated Dr. Orff and colleagues.

Inefficient sleep appears to be associated with impairment on tasks requiring higher levels of cognitive processing in war veterans with mild to moderate TBI.

MINNEAPOLIS—Insomnia and other types of sleep disturbance may play a significant role in cognitive deficits, psychiatric symptoms, and recovery of normal performance among war veterans with mild to moderate traumatic brain injury (TBI), according to research presented at the 25th Anniversary Meeting of the Associated Professional Sleep Societies.
“Levels of sleep disturbance among war veterans exceeded the general population prevalence,” reported Henry J. Orff, PhD, of the Department of Psychiatry, University of California, San Diego, and colleagues. “Poor sleep is a pervasive complaint in veterans with mild to moderate TBI.”
Dr. Orff’s group conducted retrospective chart reviews of 300 veterans from the wars in Iraq and Afghanistan regarding their clinical sleep, as well as their psychiatric and neuropsychologic test data.
The mean age of participants was 32, and their mean education was 13.5 years. Each veteran had a mean of two TBIs, with a mean longest loss of consciousness of 16 minutes and a mean longest length of posttraumatic amnesia of 137 minutes; 86.5% of all TBIs were mild, and 13.5% were moderate. The mechanisms of injury included blast-related TBI (25.6%), blunt force TBI (38.4%), and both blast and blunt force mechanisms (36%).
Eighty-five percent of the veterans reported sleep disturbance as measured by the scores on item #16 of the Beck Depression Inventory, a question that addresses changes in sleeping patterns from normal in the past week. In addition, 71% of the sample reported getting less sleep. In a subset of 86 veterans who were administered the Pittsburgh Sleep Quality Inventory (PSQI), 100% reported clinically significant sleep disturbance (PSQI global score >5). Furthermore, self-reported sleep latencies averaged 54 minutes, total sleep times averaged 5.4 hours, and sleep efficiencies averaged 77% in this sample.
Depressive symptoms were significantly correlated with a host of sleep complaints, including poorer sleep quality, longer sleep latencies, shorter sleep times, lower sleep efficiencies, more use of medications, and greater daytime dysfunction. Postconcussive symptoms were correlated with poorer sleep quality, shorter sleep duration, and greater self-reported daytime dysfunction.
“Overall, the results suggest that poor sleep in this population may have ramifications for performance on tasks requiring higher levels of cognitive processing, such as executive tasks with a timed component, while having less  impact on more basic cognitive tasks, such as those involving attention and verbal memory,” stated Dr. Orff and colleagues.

Older adults with TBI should be monitored for signs of cognitive impairment, researchers advise.

PARIS—Older veterans with traumatic brain injury (TBI) have more than a twofold increased risk for dementia, according to research presented at the 2011 Alzheimer’s Association International Conference.
Kristine Yaffe, MD, Professor of Psychiatry, Neurology, and Epidemiology at the University of California, San Francisco and Director of the Memory Disorders Program at the San Francisco VA Medical center, and colleagues reviewed medical records of 281,540 US veterans. All participants were ages 55 or older and received care through the Veterans Health Administration, had at least one inpatient or outpatient visit from 1997 to 2000 and a follow-up between 2001 and 2007, and did not have a dementia diagnosis at the start of the study. The investigators searched the database for TBI and dementia diagnoses and investigated whether TBI of any type was associated with greater risk of dementia, while taking into account demographics and other medical conditions, including psychiatric disorders.
The risk of dementia was 15.3% in those with a TBI diagnosis, compared with 6.8% in those without a TBI diagnosis, the researchers reported. The adjusted hazard ratio for incident dementia in those with any TBI diagnosis was 2.3 for the risk of developing dementia over seven years and was significant for all TBI types. Approximately 2% of older veterans had a TBI diagnosis during the study period.
“This issue is important, because TBI is very common,” said Dr. Yaffe. “About 1.7 million people experience a TBI each year in the US, primarily due to falls and car crashes. TBI is also referred to as the ‘signature wound’ of the conflicts in Iraq and Afghanistan, where TBI accounts for 22% of casualties overall and 59% of blast-related injuries.
“The data suggest that TBI in older veterans may predispose them toward symptomatic dementia, and they raise concern about the potential long-term consequences of TBI in younger veterans,” she said.
The researchers suggest that there are several potential mechanisms by which TBI could increase dementia risk. TBI is associated with swelling of axons, which is accompanied by accumulation of proteins, including beta-amyloid.
According to the investigators, amyloid plaques similar to those found in the brains of patients with Alzheimer’s disease are present in up to 30% of TBI patients who do not survive their injuries, regardless of age. It is possible that these injuries result in the death of axons and neurons, even after a single TBI. Loss of axons and neurons could result in earlier manifestation of Alzheimer’s disease symptoms.
“Our findings raise hope that early treatment and rehabilitation following TBI may help prevent long-term consequences such as dementia,” Dr. Yaffe said. “They also suggest that older adults who experience a TBI should be monitored for signs of cognitive impairment following their injuries.”

Older adults with TBI should be monitored for signs of cognitive impairment, researchers advise.

PARIS—Older veterans with traumatic brain injury (TBI) have more than a twofold increased risk for dementia, according to research presented at the 2011 Alzheimer’s Association International Conference.
Kristine Yaffe, MD, Professor of Psychiatry, Neurology, and Epidemiology at the University of California, San Francisco and Director of the Memory Disorders Program at the San Francisco VA Medical center, and colleagues reviewed medical records of 281,540 US veterans. All participants were ages 55 or older and received care through the Veterans Health Administration, had at least one inpatient or outpatient visit from 1997 to 2000 and a follow-up between 2001 and 2007, and did not have a dementia diagnosis at the start of the study. The investigators searched the database for TBI and dementia diagnoses and investigated whether TBI of any type was associated with greater risk of dementia, while taking into account demographics and other medical conditions, including psychiatric disorders.
The risk of dementia was 15.3% in those with a TBI diagnosis, compared with 6.8% in those without a TBI diagnosis, the researchers reported. The adjusted hazard ratio for incident dementia in those with any TBI diagnosis was 2.3 for the risk of developing dementia over seven years and was significant for all TBI types. Approximately 2% of older veterans had a TBI diagnosis during the study period.
“This issue is important, because TBI is very common,” said Dr. Yaffe. “About 1.7 million people experience a TBI each year in the US, primarily due to falls and car crashes. TBI is also referred to as the ‘signature wound’ of the conflicts in Iraq and Afghanistan, where TBI accounts for 22% of casualties overall and 59% of blast-related injuries.
“The data suggest that TBI in older veterans may predispose them toward symptomatic dementia, and they raise concern about the potential long-term consequences of TBI in younger veterans,” she said.
The researchers suggest that there are several potential mechanisms by which TBI could increase dementia risk. TBI is associated with swelling of axons, which is accompanied by accumulation of proteins, including beta-amyloid.
According to the investigators, amyloid plaques similar to those found in the brains of patients with Alzheimer’s disease are present in up to 30% of TBI patients who do not survive their injuries, regardless of age. It is possible that these injuries result in the death of axons and neurons, even after a single TBI. Loss of axons and neurons could result in earlier manifestation of Alzheimer’s disease symptoms.
“Our findings raise hope that early treatment and rehabilitation following TBI may help prevent long-term consequences such as dementia,” Dr. Yaffe said. “They also suggest that older adults who experience a TBI should be monitored for signs of cognitive impairment following their injuries.”

Older adults with TBI should be monitored for signs of cognitive impairment, researchers advise.

PARIS—Older veterans with traumatic brain injury (TBI) have more than a twofold increased risk for dementia, according to research presented at the 2011 Alzheimer’s Association International Conference.
Kristine Yaffe, MD, Professor of Psychiatry, Neurology, and Epidemiology at the University of California, San Francisco and Director of the Memory Disorders Program at the San Francisco VA Medical center, and colleagues reviewed medical records of 281,540 US veterans. All participants were ages 55 or older and received care through the Veterans Health Administration, had at least one inpatient or outpatient visit from 1997 to 2000 and a follow-up between 2001 and 2007, and did not have a dementia diagnosis at the start of the study. The investigators searched the database for TBI and dementia diagnoses and investigated whether TBI of any type was associated with greater risk of dementia, while taking into account demographics and other medical conditions, including psychiatric disorders.
The risk of dementia was 15.3% in those with a TBI diagnosis, compared with 6.8% in those without a TBI diagnosis, the researchers reported. The adjusted hazard ratio for incident dementia in those with any TBI diagnosis was 2.3 for the risk of developing dementia over seven years and was significant for all TBI types. Approximately 2% of older veterans had a TBI diagnosis during the study period.
“This issue is important, because TBI is very common,” said Dr. Yaffe. “About 1.7 million people experience a TBI each year in the US, primarily due to falls and car crashes. TBI is also referred to as the ‘signature wound’ of the conflicts in Iraq and Afghanistan, where TBI accounts for 22% of casualties overall and 59% of blast-related injuries.
“The data suggest that TBI in older veterans may predispose them toward symptomatic dementia, and they raise concern about the potential long-term consequences of TBI in younger veterans,” she said.
The researchers suggest that there are several potential mechanisms by which TBI could increase dementia risk. TBI is associated with swelling of axons, which is accompanied by accumulation of proteins, including beta-amyloid.
According to the investigators, amyloid plaques similar to those found in the brains of patients with Alzheimer’s disease are present in up to 30% of TBI patients who do not survive their injuries, regardless of age. It is possible that these injuries result in the death of axons and neurons, even after a single TBI. Loss of axons and neurons could result in earlier manifestation of Alzheimer’s disease symptoms.
“Our findings raise hope that early treatment and rehabilitation following TBI may help prevent long-term consequences such as dementia,” Dr. Yaffe said. “They also suggest that older adults who experience a TBI should be monitored for signs of cognitive impairment following their injuries.”

A tool used for evaluating mild traumatic brain injury in service members may not be sensitive enough in the absence of further evaluation, according to study results.

HONOLULU—One of the Department of Defense’s (DoD’s) tests for evaluating traumatic brain injury (TBI) in service members may be insufficiently sensitive when used by itself, according to study results presented at the 63rd Annual Meeting of the American Academy of Neurology.
“The bottom line is that there is no one test for determining who is able or unable to return to the fight after a concussion that is reliable, free of confounding factors, reproducible, and possible for a combat medic to administer on the battlefield,” COL Richard Young, MD, of the University of Connecticut School of Medicine, told Neurology Reviews.
Dr. Young and Kevin Scott, MD, Associate Professor of Neurology at the Pennsylvania State College of Medicine in Hershey, compared the effects of combat TBI and noncombat TBI by evaluating a cohort of 42 service members, 28 of whom had combat TBI exposure and 14 of whom had noncombat TBI exposure. One of the tests used in their evaluations was the Military Acute Concussion Evaluation (MACE), which the DoD has used as a TBI screening tool since 2006. The researchers found that while there was a trend toward worse MACE scores in patients with combat TBI compared with noncombat TBI (19.7 vs 27.4), the difference did not meet statistical significance.
These results suggest that “the MACE, in isolation, is likely not sensitive enough to stratify patients or differentiate between the two [types of injury] for the purposes of management in the setting of a forward unit without easy access to higher-level medical care (eg, neurologists),” said Dr. Scott. “It provides useful data for any individual soldier to follow their recovery or lack thereof, but is best used in combination” with further evaluations. He noted, however, that the study sample was not large enough to provide definitive statistical conclusions.
Challenges of Military Evaluations
The DoD’s evidence-based guidelines for evaluating nonpenetrating TBI, which has been called the signature injury of Operation Iraqi Freedom and Operation Enduring Freedom, are still a “work in progress,” said Dr. Scott. “With the focus on these types of injury, today’s soldiers have significantly better protection and better medical care that emphasizes early assessment and prevention of cumulative damage. Outcome measures often take time to be developed, and I think there will be a lot learned with respect to the value of medications, counseling, rehabilitation, and timing of imaging.”
At present, the best method of determining when a service member can return to duty is a careful neurologic examination, Dr. Young added. “The neurologic evaluation can best evaluate the nature of the injury, the results of cognitive testing, the service member’s degree of psychological stress, the MACE results, the prior educational status, and imaging results (if available). However, there is often no neurologist in theatre, or, only at one base. To obtain a neurologic assessment often necessitates sending the service member to Landstuhl Regional Medical Center [in Germany], with a turnaround time of two to three weeks.
“I know of no research regarding when soldiers are returned to duty,” he continued. “Current doctrine is to remove soldiers from action after a head injury.
Return to duty is a commander’s decision (the physician makes a recommendation to the commander; the commander decides) and is often dictated by the operational needs of the mission. In addition, some soldiers return to duty immediately without seeking medical attention, much as high school football players ‘shake off’ a TBI and return to play without informing their coaches of a concussion.”
Both MACE and the Automated Neuropsychological Assessment Metrics, a computerized assessment that the DoD uses to evaluate TBI, lack specificity and sensitivity, according to Dr. Young. He added that there are additional problems with using these assessments to evaluate deployed soldiers.
“There is a paucity of information about the MACE and its usefulness in the field,” said Dr. Young. “However, the MACE is identical to the Acute Sports Concussion Examination (ASCE), which is used by trainers to evaluate football players and others engaging in contact sports. Scores on the ASCE decline significantly following a concussion, but they may return to baseline within 24 hours. One of the major problems with mild TBI in Iraq is that it may be days before the service member can seek medical attention. By that time, the MACE results may be less reliable.”
Dr. Young said that his experience with service members deployed in Iraq suggests that preexisting cognitive issues may hinder the accuracy of TBI evaluations. “Several soldiers at the Joint Base Balad TBI clinic performed particularly poorly on the mathematics section of the ANAM or the entire test,” he said. “The psychologist at the TBI clinic referred these patients to me for neurologic evaluation. He and I agreed that the soldiers’ poor performance on the ANAM was due to pre-existing cognitive issues—in all likelihood, unrelated to their head injury.”
He added that ANAM is unavailable in Iraq outside of Joint Base Balad and that many service members do not have a baseline ANAM with which a post-TBI ANAM can be compared.
Combat TBI Versus Noncombat TBI
Drs. Young and Scott found some differences between injured service members depending on whether they had combat or noncombat TBI. All of the combat injuries were caused by improvised explosive devices, while the causes of noncombat injuries included falls, motor vehicle accidents, and sports.
Patients with combat TBI were significantly more likely than those with noncombat TBI to experience memory loss (44% vs 13%) and tinnitus (44% vs 6%). Headache, the most common symptom both in combat TBI and in noncombat TBI, was more common in the former injury (70% vs 50%), though the difference was not statistically significant. Patients with combat TBI also showed a nonsignificant trend toward concentration problems (43% vs 14%).
These differences may have been due to a greater severity of injury with combat TBI and to a greater lapse of time before evaluation in noncombat TBI, said Dr. Young. “It is possible that this lapse of time allowed the headache/concentration problems in the noncombat TBI to begin to resolve,” he said. He added that further research is needed to determine whether the circumstances surrounding a TBI play an important role in the injury, which could result in different outcomes for similar injuries depending on whether they occurred on the battlefield.

A tool used for evaluating mild traumatic brain injury in service members may not be sensitive enough in the absence of further evaluation, according to study results.

HONOLULU—One of the Department of Defense’s (DoD’s) tests for evaluating traumatic brain injury (TBI) in service members may be insufficiently sensitive when used by itself, according to study results presented at the 63rd Annual Meeting of the American Academy of Neurology.
“The bottom line is that there is no one test for determining who is able or unable to return to the fight after a concussion that is reliable, free of confounding factors, reproducible, and possible for a combat medic to administer on the battlefield,” COL Richard Young, MD, of the University of Connecticut School of Medicine, told Neurology Reviews.
Dr. Young and Kevin Scott, MD, Associate Professor of Neurology at the Pennsylvania State College of Medicine in Hershey, compared the effects of combat TBI and noncombat TBI by evaluating a cohort of 42 service members, 28 of whom had combat TBI exposure and 14 of whom had noncombat TBI exposure. One of the tests used in their evaluations was the Military Acute Concussion Evaluation (MACE), which the DoD has used as a TBI screening tool since 2006. The researchers found that while there was a trend toward worse MACE scores in patients with combat TBI compared with noncombat TBI (19.7 vs 27.4), the difference did not meet statistical significance.
These results suggest that “the MACE, in isolation, is likely not sensitive enough to stratify patients or differentiate between the two [types of injury] for the purposes of management in the setting of a forward unit without easy access to higher-level medical care (eg, neurologists),” said Dr. Scott. “It provides useful data for any individual soldier to follow their recovery or lack thereof, but is best used in combination” with further evaluations. He noted, however, that the study sample was not large enough to provide definitive statistical conclusions.
Challenges of Military Evaluations
The DoD’s evidence-based guidelines for evaluating nonpenetrating TBI, which has been called the signature injury of Operation Iraqi Freedom and Operation Enduring Freedom, are still a “work in progress,” said Dr. Scott. “With the focus on these types of injury, today’s soldiers have significantly better protection and better medical care that emphasizes early assessment and prevention of cumulative damage. Outcome measures often take time to be developed, and I think there will be a lot learned with respect to the value of medications, counseling, rehabilitation, and timing of imaging.”
At present, the best method of determining when a service member can return to duty is a careful neurologic examination, Dr. Young added. “The neurologic evaluation can best evaluate the nature of the injury, the results of cognitive testing, the service member’s degree of psychological stress, the MACE results, the prior educational status, and imaging results (if available). However, there is often no neurologist in theatre, or, only at one base. To obtain a neurologic assessment often necessitates sending the service member to Landstuhl Regional Medical Center [in Germany], with a turnaround time of two to three weeks.
“I know of no research regarding when soldiers are returned to duty,” he continued. “Current doctrine is to remove soldiers from action after a head injury.
Return to duty is a commander’s decision (the physician makes a recommendation to the commander; the commander decides) and is often dictated by the operational needs of the mission. In addition, some soldiers return to duty immediately without seeking medical attention, much as high school football players ‘shake off’ a TBI and return to play without informing their coaches of a concussion.”
Both MACE and the Automated Neuropsychological Assessment Metrics, a computerized assessment that the DoD uses to evaluate TBI, lack specificity and sensitivity, according to Dr. Young. He added that there are additional problems with using these assessments to evaluate deployed soldiers.
“There is a paucity of information about the MACE and its usefulness in the field,” said Dr. Young. “However, the MACE is identical to the Acute Sports Concussion Examination (ASCE), which is used by trainers to evaluate football players and others engaging in contact sports. Scores on the ASCE decline significantly following a concussion, but they may return to baseline within 24 hours. One of the major problems with mild TBI in Iraq is that it may be days before the service member can seek medical attention. By that time, the MACE results may be less reliable.”
Dr. Young said that his experience with service members deployed in Iraq suggests that preexisting cognitive issues may hinder the accuracy of TBI evaluations. “Several soldiers at the Joint Base Balad TBI clinic performed particularly poorly on the mathematics section of the ANAM or the entire test,” he said. “The psychologist at the TBI clinic referred these patients to me for neurologic evaluation. He and I agreed that the soldiers’ poor performance on the ANAM was due to pre-existing cognitive issues—in all likelihood, unrelated to their head injury.”
He added that ANAM is unavailable in Iraq outside of Joint Base Balad and that many service members do not have a baseline ANAM with which a post-TBI ANAM can be compared.
Combat TBI Versus Noncombat TBI
Drs. Young and Scott found some differences between injured service members depending on whether they had combat or noncombat TBI. All of the combat injuries were caused by improvised explosive devices, while the causes of noncombat injuries included falls, motor vehicle accidents, and sports.
Patients with combat TBI were significantly more likely than those with noncombat TBI to experience memory loss (44% vs 13%) and tinnitus (44% vs 6%). Headache, the most common symptom both in combat TBI and in noncombat TBI, was more common in the former injury (70% vs 50%), though the difference was not statistically significant. Patients with combat TBI also showed a nonsignificant trend toward concentration problems (43% vs 14%).
These differences may have been due to a greater severity of injury with combat TBI and to a greater lapse of time before evaluation in noncombat TBI, said Dr. Young. “It is possible that this lapse of time allowed the headache/concentration problems in the noncombat TBI to begin to resolve,” he said. He added that further research is needed to determine whether the circumstances surrounding a TBI play an important role in the injury, which could result in different outcomes for similar injuries depending on whether they occurred on the battlefield.

A tool used for evaluating mild traumatic brain injury in service members may not be sensitive enough in the absence of further evaluation, according to study results.

HONOLULU—One of the Department of Defense’s (DoD’s) tests for evaluating traumatic brain injury (TBI) in service members may be insufficiently sensitive when used by itself, according to study results presented at the 63rd Annual Meeting of the American Academy of Neurology.
“The bottom line is that there is no one test for determining who is able or unable to return to the fight after a concussion that is reliable, free of confounding factors, reproducible, and possible for a combat medic to administer on the battlefield,” COL Richard Young, MD, of the University of Connecticut School of Medicine, told Neurology Reviews.
Dr. Young and Kevin Scott, MD, Associate Professor of Neurology at the Pennsylvania State College of Medicine in Hershey, compared the effects of combat TBI and noncombat TBI by evaluating a cohort of 42 service members, 28 of whom had combat TBI exposure and 14 of whom had noncombat TBI exposure. One of the tests used in their evaluations was the Military Acute Concussion Evaluation (MACE), which the DoD has used as a TBI screening tool since 2006. The researchers found that while there was a trend toward worse MACE scores in patients with combat TBI compared with noncombat TBI (19.7 vs 27.4), the difference did not meet statistical significance.
These results suggest that “the MACE, in isolation, is likely not sensitive enough to stratify patients or differentiate between the two [types of injury] for the purposes of management in the setting of a forward unit without easy access to higher-level medical care (eg, neurologists),” said Dr. Scott. “It provides useful data for any individual soldier to follow their recovery or lack thereof, but is best used in combination” with further evaluations. He noted, however, that the study sample was not large enough to provide definitive statistical conclusions.
Challenges of Military Evaluations
The DoD’s evidence-based guidelines for evaluating nonpenetrating TBI, which has been called the signature injury of Operation Iraqi Freedom and Operation Enduring Freedom, are still a “work in progress,” said Dr. Scott. “With the focus on these types of injury, today’s soldiers have significantly better protection and better medical care that emphasizes early assessment and prevention of cumulative damage. Outcome measures often take time to be developed, and I think there will be a lot learned with respect to the value of medications, counseling, rehabilitation, and timing of imaging.”
At present, the best method of determining when a service member can return to duty is a careful neurologic examination, Dr. Young added. “The neurologic evaluation can best evaluate the nature of the injury, the results of cognitive testing, the service member’s degree of psychological stress, the MACE results, the prior educational status, and imaging results (if available). However, there is often no neurologist in theatre, or, only at one base. To obtain a neurologic assessment often necessitates sending the service member to Landstuhl Regional Medical Center [in Germany], with a turnaround time of two to three weeks.
“I know of no research regarding when soldiers are returned to duty,” he continued. “Current doctrine is to remove soldiers from action after a head injury.
Return to duty is a commander’s decision (the physician makes a recommendation to the commander; the commander decides) and is often dictated by the operational needs of the mission. In addition, some soldiers return to duty immediately without seeking medical attention, much as high school football players ‘shake off’ a TBI and return to play without informing their coaches of a concussion.”
Both MACE and the Automated Neuropsychological Assessment Metrics, a computerized assessment that the DoD uses to evaluate TBI, lack specificity and sensitivity, according to Dr. Young. He added that there are additional problems with using these assessments to evaluate deployed soldiers.
“There is a paucity of information about the MACE and its usefulness in the field,” said Dr. Young. “However, the MACE is identical to the Acute Sports Concussion Examination (ASCE), which is used by trainers to evaluate football players and others engaging in contact sports. Scores on the ASCE decline significantly following a concussion, but they may return to baseline within 24 hours. One of the major problems with mild TBI in Iraq is that it may be days before the service member can seek medical attention. By that time, the MACE results may be less reliable.”
Dr. Young said that his experience with service members deployed in Iraq suggests that preexisting cognitive issues may hinder the accuracy of TBI evaluations. “Several soldiers at the Joint Base Balad TBI clinic performed particularly poorly on the mathematics section of the ANAM or the entire test,” he said. “The psychologist at the TBI clinic referred these patients to me for neurologic evaluation. He and I agreed that the soldiers’ poor performance on the ANAM was due to pre-existing cognitive issues—in all likelihood, unrelated to their head injury.”
He added that ANAM is unavailable in Iraq outside of Joint Base Balad and that many service members do not have a baseline ANAM with which a post-TBI ANAM can be compared.
Combat TBI Versus Noncombat TBI
Drs. Young and Scott found some differences between injured service members depending on whether they had combat or noncombat TBI. All of the combat injuries were caused by improvised explosive devices, while the causes of noncombat injuries included falls, motor vehicle accidents, and sports.
Patients with combat TBI were significantly more likely than those with noncombat TBI to experience memory loss (44% vs 13%) and tinnitus (44% vs 6%). Headache, the most common symptom both in combat TBI and in noncombat TBI, was more common in the former injury (70% vs 50%), though the difference was not statistically significant. Patients with combat TBI also showed a nonsignificant trend toward concentration problems (43% vs 14%).
These differences may have been due to a greater severity of injury with combat TBI and to a greater lapse of time before evaluation in noncombat TBI, said Dr. Young. “It is possible that this lapse of time allowed the headache/concentration problems in the noncombat TBI to begin to resolve,” he said. He added that further research is needed to determine whether the circumstances surrounding a TBI play an important role in the injury, which could result in different outcomes for similar injuries depending on whether they occurred on the battlefield.

One third of patients with pathologically confirmed early-onset Alzheimer’s disease presented with atypical symptoms, and 53% of patients with nonamnestic presentations were initially misdiagnosed, according to a study in the May 17 Neurology. Researchers conducted a retrospective review of clinical data from patients with confirmed early-onset Alzheimer’s disease to determine the frequency and types of incorrect diagnoses. The majority of these cases were diagnosed with other types of dementia, including pseudodementia with depression, semantic dementia, and primary progressive aphasia. “Early-onset Alzheimer’s disease diagnosis often represents a challenge because of the high frequency of atypical presentations,” the study authors wrote. More than one-third (37.5%) of patients presented with atypical symptoms other than memory problems; the most prevalent of these was behavioral/executive dysfunction.

Neuronal activity may be a potential mechanism for vulnerability to amyloid-β deposition in certain areas of the brain, researchers reported in the May 1 online Nature Neuroscience. The investigators examined endogenous neuronal activity in mice with Alzheimer’s disease and determined that this activity regulates the regional concentration of interstitial fluid amyloid-β, which drives local aggregation of amyloid-β. Using unilateral vibrissal stimulation in the contralateral barrel cortex, they found that activity increased interstitial fluid amyloid-β. Unilateral vibrissal deprivation decreased interstitial fluid amyloid-β deposition; long-term deprivation also decreased amyloid plaque formation and growth. “Our results suggest a mechanism to account for the vulnerability of specific brain regions to amyloid-β deposition in Alzheimer’s disease,” the authors concluded.

A newly confirmed genetic risk allele of the clusterin gene contributes to white matter degeneration in young adults and may increase the risk for Alzheimer’s disease later in life, according to results published in the May 4 Journal of Neuroscience. Investigators used diffusion-tensor MRI to scan the brains of 398 healthy young adults (mean age, 23.6) and to evaluate whether the C-allele clusterin risk variant was associated with lower white matter integrity. “Each C-allele copy of the clusterin variant was associated with lower fractional anisotropy—a widely accepted measure of white matter integrity—in multiple brain regions,” the authors wrote. These regions included the splenium of the corpus callosum, the fornix, cingulum, and superior and inferior longitudinal fasciculi in both brain hemispheres. “Young healthy carriers of the clusterin gene risk variant showed a distinct profile of lower white matter integrity that may increase vulnerability to developing Alzheimer’s disease later in life,” the researchers concluded.

A higher BMI may improve survival in patients with amyotrophic lateral sclerosis (ALS). As published in the May 23 online Muscle & Nerve, investigators aimed to determine whether cholesterol levels are an independent predictor of ALS survival. They measured cholesterol levels in 427 people with ALS from three clinical trial databases and found that the low-density and high-density lipoprotein level ratio did not decrease over time, even though BMI significantly declined. “After adjusting for BMI, forced vital capacity, and age, the lipid ratio was not associated with survival,” the investigators wrote. The highest survival rate, though, was found among patients with a BMI between 30 and 35, or mild obesity. “We found that dyslipidemia is not an independent predictor of survival in ALS,” the researchers concluded, whereas, “BMI is an independent prognostic factor for survival after adjusting for markers of disease severity.”

Patients with a history of intracerebral hemorrhage (ICH) should avoid using statins for prevention of ischemic cardiac and cerebrovascular disease, according to a study in the May Archives of Neurology. Statins are widely prescribed for disease prevention, the authors noted, and “although serious adverse effects are uncommon, results from a recent clinical trial suggested increased risk of ICH associated with statin use.” To determine if statin therapy should be avoided in patients with a baseline elevated risk of ICH, investigators evaluated the risks and benefits of the therapy in patients with prior ICH using clinical parameters such as hemorrhage location (deep or lobar). For survivors of ICH both with and without prior cardiovascular events, the benefits of statin therapy were not strong enough to offset the increased risk for hemorrhage recurrence.

Adverse changes in sleep duration are associated with poorer cognitive function in middle-aged adults, per a study in the May 1 Sleep. Researchers conducted cross-sectional studies of women and men (age range, 45 to 69) to examine the effect of changes in sleep duration on cognitive function. Participants’ cognitive function was assessed at baseline, and their sleep duration on an average weeknight was measured once at baseline and again an average of 5.4 years later. After adjustment for age, gender, education, and occupation, the authors reported that “firm evidence remained for an association between an increase from seven or eight hours sleep and lower cognitive function for all tests, except memory, and between a decrease from six or eight hours sleep and poorer reasoning, vocabulary, and Mini-Mental State Examination score.” These adverse changes in duration were equivalent to a four- to seven-year increase in age.

African Americans with multiple sclerosis (MS) have lower vitamin D levels than their healthy counterparts, according to a study published in the May 24 Neurology. Researchers conducted a cross-sectional study of 339 African-American patients with MS and 342 without MS to determine if vitamin D levels were associated with MS disease severity. Between 71% and 77% of all participants were vitamin D–deficient and 93% to 94% were vitamin D–insufficient, the authors reported. Overall, vitamin D levels were lower in patients with MS, but this was due to differences in climate and geography and did not have an impact on disease severity. “These results are consistent with observations in other populations that lower [vitamin D level] is associated with having MS,” the investigators concluded, “but also highlight the importance of climate and ancestry in determining vitamin D status.”

Protein-based human-induced pluripotent stem cells (hiPSCs) and those derived from human embryonic stem cells (hESCs) may be effective in the treatment of Parkinson’s disease, according to a study in the May 16 Journal of Clinical Investigation. Results showed that neuronal precursors cells derived from hESCs and protein-based hiPSCs reversed disease when transplanted into the brains of rats modeling Parkinson’s disease. The researchers attempted to use neuronal cells derived from virus-based hiPSCs but were unable to do so because these virus-based cells exhibited apoptotic cell death. “[hiPSCs] are a potentially unlimited source of patient-specific cells for transplantation…. These data support the clinical potential of protein-based hiPSCs for personalized cell therapy of Parkinson’s disease,” the investigators concluded.

Women may have a greater risk than men for adverse events following certain stroke prevention procedures, as reported in the May 6 online Lancet Neurology. A total of 2,502 patients with symptomatic and asymptomatic stenosis were randomized to undergo carotid endarterectomy or carotid artery stenting. The rates of periprocedural stroke, myocardial infarction, and death were similar in men who underwent endarterectomy (4.9%) and stenting (4.3%). In women, however, a significant difference in rates of adverse events was observed—3.8% for endarterectomy versus 6.8% for stenting. “Periprocedural risk of events seems to be higher in women who have carotid artery stenting than those who have carotid endarterectomy, whereas there is little difference in men,” the authors concluded. “Additional data are needed to confirm whether this differential risk should be taken into account in decisions for treatment of carotid disease in women.”

About 14% of ischemic strokes presented at emergency departments are wake-up strokes, researchers reported in the May 10 Neurology. Wake-up strokes, according to the authors, cannot be distinguished from other types of stroke based on clinical features or outcome, making them difficult to treat with effective clot-busting therapies. The researchers analyzed data from patients presenting at emergency departments with ischemic stroke; they identified 1,854 ischemic stroke cases, 273 of which were wake-up strokes. “There were no differences between wake-up strokes and all other strokes with regard to clinical features or outcomes except for minor differences in age and baseline retrospective NIH Stroke Scale score,” the authors reported. “Of the wake-up strokes, at least 98 (35.9%) would have been eligible for thrombolysis if arrival time were not a factor.”

The annual rate of coronary artery bypass graft surgeries decreased 30% between 2001 and 2008, while rates of other percutaneous coronary interventions remained stable, according to an examination of national trends published in the May 4 JAMA. Investigators conducted a serial cross-sectional study to examine time trends of patients undergoing revascularization procedures, and determined that the annual surgery rate decreased from 1,742 to 1,081 per million adults in 2008. “Between 2001 and 2008, the number of hospitals … providing [coronary artery bypass graft surgery] increased by 12%, and the number of [percutaneous coronary interventions] hospitals increased by 26%,” the authors reported. They noted that new revascularization technologies, new clinical evidence from trials, and updated clinical guidelines may have affected the volume and distribution of coronary revascularizations.

Patients with traumatic brain injury (TBI) and refractory intracranial hypertension may benefit from decompressive craniectomy, but they may also experience unfavorable outcomes, according to a study in the April 21 New England Journal of Medicine. Researchers randomly assigned 155 adults with TBI and intracranial hypertension to undergo either bifrontotemporoparietal decompressive craniectomy or standard care. The results revealed that the standard-care group had higher levels of intracranial pressure and longer stays in the intensive care unit. “However, patients undergoing craniectomy had worse scores on the Extended Glasgow Outcome Scale than those receiving standard care,” the authors noted. Patients with craniectomy were also more than twice as likely to experience an unfavorable outcome, including death, vegetative state, or severe disability.

One third of patients with pathologically confirmed early-onset Alzheimer’s disease presented with atypical symptoms, and 53% of patients with nonamnestic presentations were initially misdiagnosed, according to a study in the May 17 Neurology. Researchers conducted a retrospective review of clinical data from patients with confirmed early-onset Alzheimer’s disease to determine the frequency and types of incorrect diagnoses. The majority of these cases were diagnosed with other types of dementia, including pseudodementia with depression, semantic dementia, and primary progressive aphasia. “Early-onset Alzheimer’s disease diagnosis often represents a challenge because of the high frequency of atypical presentations,” the study authors wrote. More than one-third (37.5%) of patients presented with atypical symptoms other than memory problems; the most prevalent of these was behavioral/executive dysfunction.

Neuronal activity may be a potential mechanism for vulnerability to amyloid-β deposition in certain areas of the brain, researchers reported in the May 1 online Nature Neuroscience. The investigators examined endogenous neuronal activity in mice with Alzheimer’s disease and determined that this activity regulates the regional concentration of interstitial fluid amyloid-β, which drives local aggregation of amyloid-β. Using unilateral vibrissal stimulation in the contralateral barrel cortex, they found that activity increased interstitial fluid amyloid-β. Unilateral vibrissal deprivation decreased interstitial fluid amyloid-β deposition; long-term deprivation also decreased amyloid plaque formation and growth. “Our results suggest a mechanism to account for the vulnerability of specific brain regions to amyloid-β deposition in Alzheimer’s disease,” the authors concluded.

A newly confirmed genetic risk allele of the clusterin gene contributes to white matter degeneration in young adults and may increase the risk for Alzheimer’s disease later in life, according to results published in the May 4 Journal of Neuroscience. Investigators used diffusion-tensor MRI to scan the brains of 398 healthy young adults (mean age, 23.6) and to evaluate whether the C-allele clusterin risk variant was associated with lower white matter integrity. “Each C-allele copy of the clusterin variant was associated with lower fractional anisotropy—a widely accepted measure of white matter integrity—in multiple brain regions,” the authors wrote. These regions included the splenium of the corpus callosum, the fornix, cingulum, and superior and inferior longitudinal fasciculi in both brain hemispheres. “Young healthy carriers of the clusterin gene risk variant showed a distinct profile of lower white matter integrity that may increase vulnerability to developing Alzheimer’s disease later in life,” the researchers concluded.

A higher BMI may improve survival in patients with amyotrophic lateral sclerosis (ALS). As published in the May 23 online Muscle & Nerve, investigators aimed to determine whether cholesterol levels are an independent predictor of ALS survival. They measured cholesterol levels in 427 people with ALS from three clinical trial databases and found that the low-density and high-density lipoprotein level ratio did not decrease over time, even though BMI significantly declined. “After adjusting for BMI, forced vital capacity, and age, the lipid ratio was not associated with survival,” the investigators wrote. The highest survival rate, though, was found among patients with a BMI between 30 and 35, or mild obesity. “We found that dyslipidemia is not an independent predictor of survival in ALS,” the researchers concluded, whereas, “BMI is an independent prognostic factor for survival after adjusting for markers of disease severity.”

Patients with a history of intracerebral hemorrhage (ICH) should avoid using statins for prevention of ischemic cardiac and cerebrovascular disease, according to a study in the May Archives of Neurology. Statins are widely prescribed for disease prevention, the authors noted, and “although serious adverse effects are uncommon, results from a recent clinical trial suggested increased risk of ICH associated with statin use.” To determine if statin therapy should be avoided in patients with a baseline elevated risk of ICH, investigators evaluated the risks and benefits of the therapy in patients with prior ICH using clinical parameters such as hemorrhage location (deep or lobar). For survivors of ICH both with and without prior cardiovascular events, the benefits of statin therapy were not strong enough to offset the increased risk for hemorrhage recurrence.

Adverse changes in sleep duration are associated with poorer cognitive function in middle-aged adults, per a study in the May 1 Sleep. Researchers conducted cross-sectional studies of women and men (age range, 45 to 69) to examine the effect of changes in sleep duration on cognitive function. Participants’ cognitive function was assessed at baseline, and their sleep duration on an average weeknight was measured once at baseline and again an average of 5.4 years later. After adjustment for age, gender, education, and occupation, the authors reported that “firm evidence remained for an association between an increase from seven or eight hours sleep and lower cognitive function for all tests, except memory, and between a decrease from six or eight hours sleep and poorer reasoning, vocabulary, and Mini-Mental State Examination score.” These adverse changes in duration were equivalent to a four- to seven-year increase in age.

African Americans with multiple sclerosis (MS) have lower vitamin D levels than their healthy counterparts, according to a study published in the May 24 Neurology. Researchers conducted a cross-sectional study of 339 African-American patients with MS and 342 without MS to determine if vitamin D levels were associated with MS disease severity. Between 71% and 77% of all participants were vitamin D–deficient and 93% to 94% were vitamin D–insufficient, the authors reported. Overall, vitamin D levels were lower in patients with MS, but this was due to differences in climate and geography and did not have an impact on disease severity. “These results are consistent with observations in other populations that lower [vitamin D level] is associated with having MS,” the investigators concluded, “but also highlight the importance of climate and ancestry in determining vitamin D status.”

Protein-based human-induced pluripotent stem cells (hiPSCs) and those derived from human embryonic stem cells (hESCs) may be effective in the treatment of Parkinson’s disease, according to a study in the May 16 Journal of Clinical Investigation. Results showed that neuronal precursors cells derived from hESCs and protein-based hiPSCs reversed disease when transplanted into the brains of rats modeling Parkinson’s disease. The researchers attempted to use neuronal cells derived from virus-based hiPSCs but were unable to do so because these virus-based cells exhibited apoptotic cell death. “[hiPSCs] are a potentially unlimited source of patient-specific cells for transplantation…. These data support the clinical potential of protein-based hiPSCs for personalized cell therapy of Parkinson’s disease,” the investigators concluded.

Women may have a greater risk than men for adverse events following certain stroke prevention procedures, as reported in the May 6 online Lancet Neurology. A total of 2,502 patients with symptomatic and asymptomatic stenosis were randomized to undergo carotid endarterectomy or carotid artery stenting. The rates of periprocedural stroke, myocardial infarction, and death were similar in men who underwent endarterectomy (4.9%) and stenting (4.3%). In women, however, a significant difference in rates of adverse events was observed—3.8% for endarterectomy versus 6.8% for stenting. “Periprocedural risk of events seems to be higher in women who have carotid artery stenting than those who have carotid endarterectomy, whereas there is little difference in men,” the authors concluded. “Additional data are needed to confirm whether this differential risk should be taken into account in decisions for treatment of carotid disease in women.”

About 14% of ischemic strokes presented at emergency departments are wake-up strokes, researchers reported in the May 10 Neurology. Wake-up strokes, according to the authors, cannot be distinguished from other types of stroke based on clinical features or outcome, making them difficult to treat with effective clot-busting therapies. The researchers analyzed data from patients presenting at emergency departments with ischemic stroke; they identified 1,854 ischemic stroke cases, 273 of which were wake-up strokes. “There were no differences between wake-up strokes and all other strokes with regard to clinical features or outcomes except for minor differences in age and baseline retrospective NIH Stroke Scale score,” the authors reported. “Of the wake-up strokes, at least 98 (35.9%) would have been eligible for thrombolysis if arrival time were not a factor.”

The annual rate of coronary artery bypass graft surgeries decreased 30% between 2001 and 2008, while rates of other percutaneous coronary interventions remained stable, according to an examination of national trends published in the May 4 JAMA. Investigators conducted a serial cross-sectional study to examine time trends of patients undergoing revascularization procedures, and determined that the annual surgery rate decreased from 1,742 to 1,081 per million adults in 2008. “Between 2001 and 2008, the number of hospitals … providing [coronary artery bypass graft surgery] increased by 12%, and the number of [percutaneous coronary interventions] hospitals increased by 26%,” the authors reported. They noted that new revascularization technologies, new clinical evidence from trials, and updated clinical guidelines may have affected the volume and distribution of coronary revascularizations.

Patients with traumatic brain injury (TBI) and refractory intracranial hypertension may benefit from decompressive craniectomy, but they may also experience unfavorable outcomes, according to a study in the April 21 New England Journal of Medicine. Researchers randomly assigned 155 adults with TBI and intracranial hypertension to undergo either bifrontotemporoparietal decompressive craniectomy or standard care. The results revealed that the standard-care group had higher levels of intracranial pressure and longer stays in the intensive care unit. “However, patients undergoing craniectomy had worse scores on the Extended Glasgow Outcome Scale than those receiving standard care,” the authors noted. Patients with craniectomy were also more than twice as likely to experience an unfavorable outcome, including death, vegetative state, or severe disability.

One third of patients with pathologically confirmed early-onset Alzheimer’s disease presented with atypical symptoms, and 53% of patients with nonamnestic presentations were initially misdiagnosed, according to a study in the May 17 Neurology. Researchers conducted a retrospective review of clinical data from patients with confirmed early-onset Alzheimer’s disease to determine the frequency and types of incorrect diagnoses. The majority of these cases were diagnosed with other types of dementia, including pseudodementia with depression, semantic dementia, and primary progressive aphasia. “Early-onset Alzheimer’s disease diagnosis often represents a challenge because of the high frequency of atypical presentations,” the study authors wrote. More than one-third (37.5%) of patients presented with atypical symptoms other than memory problems; the most prevalent of these was behavioral/executive dysfunction.

Neuronal activity may be a potential mechanism for vulnerability to amyloid-β deposition in certain areas of the brain, researchers reported in the May 1 online Nature Neuroscience. The investigators examined endogenous neuronal activity in mice with Alzheimer’s disease and determined that this activity regulates the regional concentration of interstitial fluid amyloid-β, which drives local aggregation of amyloid-β. Using unilateral vibrissal stimulation in the contralateral barrel cortex, they found that activity increased interstitial fluid amyloid-β. Unilateral vibrissal deprivation decreased interstitial fluid amyloid-β deposition; long-term deprivation also decreased amyloid plaque formation and growth. “Our results suggest a mechanism to account for the vulnerability of specific brain regions to amyloid-β deposition in Alzheimer’s disease,” the authors concluded.

A newly confirmed genetic risk allele of the clusterin gene contributes to white matter degeneration in young adults and may increase the risk for Alzheimer’s disease later in life, according to results published in the May 4 Journal of Neuroscience. Investigators used diffusion-tensor MRI to scan the brains of 398 healthy young adults (mean age, 23.6) and to evaluate whether the C-allele clusterin risk variant was associated with lower white matter integrity. “Each C-allele copy of the clusterin variant was associated with lower fractional anisotropy—a widely accepted measure of white matter integrity—in multiple brain regions,” the authors wrote. These regions included the splenium of the corpus callosum, the fornix, cingulum, and superior and inferior longitudinal fasciculi in both brain hemispheres. “Young healthy carriers of the clusterin gene risk variant showed a distinct profile of lower white matter integrity that may increase vulnerability to developing Alzheimer’s disease later in life,” the researchers concluded.

A higher BMI may improve survival in patients with amyotrophic lateral sclerosis (ALS). As published in the May 23 online Muscle & Nerve, investigators aimed to determine whether cholesterol levels are an independent predictor of ALS survival. They measured cholesterol levels in 427 people with ALS from three clinical trial databases and found that the low-density and high-density lipoprotein level ratio did not decrease over time, even though BMI significantly declined. “After adjusting for BMI, forced vital capacity, and age, the lipid ratio was not associated with survival,” the investigators wrote. The highest survival rate, though, was found among patients with a BMI between 30 and 35, or mild obesity. “We found that dyslipidemia is not an independent predictor of survival in ALS,” the researchers concluded, whereas, “BMI is an independent prognostic factor for survival after adjusting for markers of disease severity.”

Patients with a history of intracerebral hemorrhage (ICH) should avoid using statins for prevention of ischemic cardiac and cerebrovascular disease, according to a study in the May Archives of Neurology. Statins are widely prescribed for disease prevention, the authors noted, and “although serious adverse effects are uncommon, results from a recent clinical trial suggested increased risk of ICH associated with statin use.” To determine if statin therapy should be avoided in patients with a baseline elevated risk of ICH, investigators evaluated the risks and benefits of the therapy in patients with prior ICH using clinical parameters such as hemorrhage location (deep or lobar). For survivors of ICH both with and without prior cardiovascular events, the benefits of statin therapy were not strong enough to offset the increased risk for hemorrhage recurrence.

Adverse changes in sleep duration are associated with poorer cognitive function in middle-aged adults, per a study in the May 1 Sleep. Researchers conducted cross-sectional studies of women and men (age range, 45 to 69) to examine the effect of changes in sleep duration on cognitive function. Participants’ cognitive function was assessed at baseline, and their sleep duration on an average weeknight was measured once at baseline and again an average of 5.4 years later. After adjustment for age, gender, education, and occupation, the authors reported that “firm evidence remained for an association between an increase from seven or eight hours sleep and lower cognitive function for all tests, except memory, and between a decrease from six or eight hours sleep and poorer reasoning, vocabulary, and Mini-Mental State Examination score.” These adverse changes in duration were equivalent to a four- to seven-year increase in age.

African Americans with multiple sclerosis (MS) have lower vitamin D levels than their healthy counterparts, according to a study published in the May 24 Neurology. Researchers conducted a cross-sectional study of 339 African-American patients with MS and 342 without MS to determine if vitamin D levels were associated with MS disease severity. Between 71% and 77% of all participants were vitamin D–deficient and 93% to 94% were vitamin D–insufficient, the authors reported. Overall, vitamin D levels were lower in patients with MS, but this was due to differences in climate and geography and did not have an impact on disease severity. “These results are consistent with observations in other populations that lower [vitamin D level] is associated with having MS,” the investigators concluded, “but also highlight the importance of climate and ancestry in determining vitamin D status.”

Protein-based human-induced pluripotent stem cells (hiPSCs) and those derived from human embryonic stem cells (hESCs) may be effective in the treatment of Parkinson’s disease, according to a study in the May 16 Journal of Clinical Investigation. Results showed that neuronal precursors cells derived from hESCs and protein-based hiPSCs reversed disease when transplanted into the brains of rats modeling Parkinson’s disease. The researchers attempted to use neuronal cells derived from virus-based hiPSCs but were unable to do so because these virus-based cells exhibited apoptotic cell death. “[hiPSCs] are a potentially unlimited source of patient-specific cells for transplantation…. These data support the clinical potential of protein-based hiPSCs for personalized cell therapy of Parkinson’s disease,” the investigators concluded.

Women may have a greater risk than men for adverse events following certain stroke prevention procedures, as reported in the May 6 online Lancet Neurology. A total of 2,502 patients with symptomatic and asymptomatic stenosis were randomized to undergo carotid endarterectomy or carotid artery stenting. The rates of periprocedural stroke, myocardial infarction, and death were similar in men who underwent endarterectomy (4.9%) and stenting (4.3%). In women, however, a significant difference in rates of adverse events was observed—3.8% for endarterectomy versus 6.8% for stenting. “Periprocedural risk of events seems to be higher in women who have carotid artery stenting than those who have carotid endarterectomy, whereas there is little difference in men,” the authors concluded. “Additional data are needed to confirm whether this differential risk should be taken into account in decisions for treatment of carotid disease in women.”

About 14% of ischemic strokes presented at emergency departments are wake-up strokes, researchers reported in the May 10 Neurology. Wake-up strokes, according to the authors, cannot be distinguished from other types of stroke based on clinical features or outcome, making them difficult to treat with effective clot-busting therapies. The researchers analyzed data from patients presenting at emergency departments with ischemic stroke; they identified 1,854 ischemic stroke cases, 273 of which were wake-up strokes. “There were no differences between wake-up strokes and all other strokes with regard to clinical features or outcomes except for minor differences in age and baseline retrospective NIH Stroke Scale score,” the authors reported. “Of the wake-up strokes, at least 98 (35.9%) would have been eligible for thrombolysis if arrival time were not a factor.”

The annual rate of coronary artery bypass graft surgeries decreased 30% between 2001 and 2008, while rates of other percutaneous coronary interventions remained stable, according to an examination of national trends published in the May 4 JAMA. Investigators conducted a serial cross-sectional study to examine time trends of patients undergoing revascularization procedures, and determined that the annual surgery rate decreased from 1,742 to 1,081 per million adults in 2008. “Between 2001 and 2008, the number of hospitals … providing [coronary artery bypass graft surgery] increased by 12%, and the number of [percutaneous coronary interventions] hospitals increased by 26%,” the authors reported. They noted that new revascularization technologies, new clinical evidence from trials, and updated clinical guidelines may have affected the volume and distribution of coronary revascularizations.

Patients with traumatic brain injury (TBI) and refractory intracranial hypertension may benefit from decompressive craniectomy, but they may also experience unfavorable outcomes, according to a study in the April 21 New England Journal of Medicine. Researchers randomly assigned 155 adults with TBI and intracranial hypertension to undergo either bifrontotemporoparietal decompressive craniectomy or standard care. The results revealed that the standard-care group had higher levels of intracranial pressure and longer stays in the intensive care unit. “However, patients undergoing craniectomy had worse scores on the Extended Glasgow Outcome Scale than those receiving standard care,” the authors noted. Patients with craniectomy were also more than twice as likely to experience an unfavorable outcome, including death, vegetative state, or severe disability.