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New Emergency Room Diagnosis Guidelines for Mild Traumatic Brain Injury

The American College of Emergency Room Physicians (ACEP) in collaboration with the Centers for Disease Control and Prevention (CDC) revised the clinical diagnosis guidelines for mild traumatic brain injury (MTBI).  These guidelines are designed to improve patient outcomes for the more than one million people who visit emergency departments every year for mild traumatic brain injury.

"People with traumatic brain injuries may appear to be normal and their symptoms may be mild, but there can be hidden dangers," said Richard C. Hunt, MD, Director of the Division of Injury Response at the Centers for Disease Control and Prevention.  "TBI's can also lead to significant, life-long impairments that prevent a person's ability to function both physically and mentally.  These revised guidelines can help ensure that patients with even mild TBI's are identified early and receive the care they need."

The real incidence of traumatic brain injury (TBI) is unknown since many patients who sustain an injury never seek medical care. The majority of these injuries are classified as mild, meaning the patient is alert, oriented and functional when they are assessed in the emergency department. It is estimated that 10 percent of patients with a mild TBI have evidence of an intracranial injury on head computed tomography (CT), and that approximately one percent of patients with mild TBI harbor a life-threatening neurosurgical lesion. The challenge for the emergency physician is to identify which patients with a head injury have an acute traumatic intracranial injury, and which patients can be safely sent home.

ACEP and CDC recogize in the revised guidelines that MTBI results from direct trauma to the head or from an acceleration/deceleration stress to the brain, and that MTBI poses a risk for short-term difficulties with symptoms such as headache, difficulty with balance, thinking, concentrating and sleeping. Up to 80 percent of patients report some symptoms related to the injury at three months. If MTBI results in long-term problems, it is often referred to as post-concussive syndrome.

For more information on traumatic brain injury (TBI), visit CDC on the Web at: www.cdc.gov/Injury.

Cognitive Rehabilitation Helps People With Acquired Brain Injury

Researchers at the University of South Alabama and the University of North Carolina at Charlotte analyzed and updated the data found in systematic reviews of several hundred studies of cognitive rehabilitation. The researchers took those studies whose samples and methods were most amenable to rigorous statistical techniques and documented the extent to which various treatments improve the language, attention, memory and other cognitive problems that appear after acquired brain injury.

The meta-analysis examined 97 articles, comprising 115 studied treatment samples and 45 control samples. These samples collectively included 2,014 individuals who underwent cognitive rehabilitation after brain injury and 870 individuals in a variety of control conditions. The authors of the initial reviews had concluded there was enough evidence to generally support the use of a variety of rehabilitative treatments. To develop specific treatment guidelines, this new analysis documented the extent to which treatment type and timing, origin of the injury, recovery level, and participant age affected the odds of success.

Given the patterns they found, the authors offered initial treatment guidelines:

• Generally, it is better to start treating patients as early as possible, rather than waiting for a more complete neurological recovery.
• Even older patients (age 55 and up) may benefit from cognitive rehabilitation, particularly if the brain injury is due to stroke.
• Clinicians should focus their efforts on direct cognitive skills training in specific cognitive domains (such as attention or visuospatial processing). More holistic, non-targeted interventions appear to be less effective.

Especially if they were treated soon after the event, language training helped older people after stroke with aphasia, problems producing and/or comprehending language. However, language training was still effective, just not as much, when it started more than a year after the stroke.

Attention training helped people with acquired brain injury and seemed to work best with younger patients less than a year after injury. It was the most specific treatment, improving nothing but attention.

Visuospatial training helped stroke patients with visuospatial neglect, the inability to respond or orient to something shown on the side opposite to the site of the injury. Visuospatial training also tended to improve performance in other cognitive domains.

Memory treatment did not produce clear results. Nor did comprehensive treatments that attempted to treat cognitive problems holistically.

The authors also found that patients treated less than a year after injury did better than those treated more than a year later.

Brain Injury Association of America Teams Up With Journal of Head Trauma Rehabilitation