Craniocerebral Trauma

Overview of Topics

Divisions of Trauma

1. Divided into three groups based upon the nature of the injury.
   1. Closed head injuries
   2. Depressed fracture of the skull
   3. Compound fracture of the skull (direct contact with cerebral tissue)

2. Concussion -- loss of consciousness following head injury: may be momentary or prolonged and full recovery may or may not occur.
   1. Damage due to head movement swirling forces and shear forces.
   2. Damage begins at surface and progresses inward.
   3. If severe enough to reach brain stem on diencephalon, loss of consciousness will occur.
   4. Direct area damage also contrecoup injury w*hich is greater in closed head injury.

3. Contusion or lacerations -- bruising or tissue injury most common with Penetiating injuries where loss of consciousness is less likely to occur.

4. Recovery
   1. Coma
   2. Stupor
   3. PTA
   4. Confusion
   5. PCS

Complications of head injury

1. Subdural hemorrhage - arachnoid - normal

2. Extradural hemorrhage - due to tear in meningeal arteries or dural sinus 15%
   1. relatively rare (3%)
   2. usually pt. recovers consciousness and then suffers a relapse into coma with development of hemiplegia
   3. with more severe injuries - may not have lucid interval
   4. may develop after several weeks
   5. fixed - dilated pupil may be present
   6. most fatal complication - mortality 100% in untreated and over 50% in treated cases
   7. death usually occurs within 12 to 72 hours
   8. Rx - evacuation and repair

3. Subdural hemorrhage (1 to 10%)
   1. always secondary to head trauma
   2. blood not absorbed in CSF but is encapsulated by dura
   3. fibroblasts invade clot from dura
   4. newly formed capillaries enter the clot and absorb
   5. causes dural thickening - with large clot may cause subdural cyot with calcification
   6. clot may cause contralateral compression thus confusing effects
   7. symptoms develop within first few days
   8. frequently bilateral

4. Subdural Hygroma - excessive collection of subdural fluid

5. Intracerebral Hemorrhage

6. Infections
   1. extradural
   2. subdural abscess
   3. meningitis
   4. brain abscess

7. Rhinorrhea - cribraform plate injury

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Sequelae of head injuries

1. Seizures - develop several months later
   1. 2.5 to 40% incidence
   2. 5% with closed head injury
   3. 30 to 40% with penetrating head injury

2. Psychoses and mental disturbances

3. Intracerebral hemorrhage

4. Subarachnoid Hemorrhage
   1. blood in cerebral spinal fluid

5. Trauma consequences
   1. Concussion
   2. Contusions & lacerations
   3. Complications of skull fractures

Basic Information regarding TBI

• Statistics
  • In 1977, approximately 10 million head injuries
  • 1.5 million severe including concussions, intercranial injuries, and fractures.
  • 90% are less than 44 years old
  • Leading cause of death between 4 - 44 years.
• Type of injuries:
  • Work injuries - 3%;
  • Auto Accidents- 12%;
  • Play (kids) injuries - 42%;
  • Injuries at home - 44%;

Mechanics of Traumatic Brain Injury

• Contusion - bruise
  • effect of pressure

• Concussion
  • Transient loss of consciousness due to mechanical forces to the brain
  • Shear force
  • Centrifugal forces (Ommya and Gennerali)
  • Most severe at surface (Cortex) causing cognitive impairment.
  • If severe, damage may extent down into the midbrain, causing an acute memory deficit (post- traumatic amnesia).
  • If even more severe, extend down into brainstem - Coma.

• Initial hospital records very important
  • Clarify source of data

Neuropsych vs CT Scan and EEG

• Percent who appear impaired
  • EEG: 28% mild, 72% severe
  • CT Scan: 26% mild, 45% severe
  • Neuropsychological battery: 87% mild, 89% severe
• Neuropsychology is most important for the mild injury

Post-Concussion Symptoms

• Symptoms often confused with cognitive impairment
• Actually reflect interaction of cognitive and emotional factors
• Good guide to recovery
  • Number
  • Intensity
  • Change over time

Outcome Measures

• Pre-Injury Factors
  • Pre-injury level
  • Age
  • Education/Occupation
  • Personality
  • Emotional Adjustment

• Neurological Factors
  • Severity - Cognitive Impairment

• Post-Injury Factors
  • Post-Concussion Symptoms
  • Pain
  • Family Support
  • Compensation
  • Stress
  • Expectancy

Severity Determination

Post-Traumatic Amnesia

Minor Head Injury

• Definition
  • Coma < 20 minutes
  • Hospitalization < 72 hours
  • Glasgow Coma Scale > 12

• Problem with Definition
  • No Lower Limits
  • Leads to misclassification of individuals who sustain no neurological trauma

• Redefine - some PTA or neurological symptoms

Consequences of Mild Head Injury

• Cognitive Impairment
  • Recovery
    • Mild = 3 mo
    • Mod.= 1 yr

• Post-Concussion Symptoms
  • Minor = 78% of cases. Symptoms last approximately 3 months
  • Severe = 24% of cases. Symptoms last approximately 1 year.

• Percentage of patients who return to work by 1 year
  • Mild = 90%
  • Mod.= 80%

In recent years, health care professionals have made tremendous strides in understanding the effects of head injury. In spite of this understanding, it is often difficult to communicate this information to the survivors and their family; and, without effective communication, it is difficult to elicit their maximum effort during rehabilitation. The purpose of this article is to outline methods for enhancing this communication and, by outlining various models, to assist in improving the rehabilitation process. A further advantage of a model of recovery is to allow more effective communication with other health care professionals as well as to objectify one's own perception of the patient's progress.

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THE NATURE OF HEAD INJURY

Although these three systems function in many other ways and are highly interconnected in the way that they process information, this over-simplified view of brain function will provide a better understanding of changes in behavior following head injury.

CORTICAL SYSTEM
INFORMATION PROCESSING
MODALITY (Vision, Audition, Somatosensory)

MATERIAL (Verbal/Non-Verbal)

PREFRONTAL CORTEX (Planning and Regulation)

DIENCEPHALON (Limbic System)

AROUSAL

EMOTION

MOTIVATION

MEMORY CONSOLIDATION

BRAIN STEM

ACTIVATION (Cortical Desynchronization)

SHIFTING ATTENTION

HABITUATION

PERCEPTION

Brain Stem:

Dencephalon:

Memory consolidation, while appearing to be quite different from emotion and motivation, fits into the same process in that it is important for us to remember things that are significant for our survival (Long, 1984). Thus, we tend to remember things that allow us to get what we need to survive and to avoid things that are not helpful in this regard. Memory consolidation varies according to the importance of stimuli. We tend to remember very important or unusual things (whether they are positive or negative) and tend not to remember more neutral things. During recovery from head injury, some pieces of information will be recalled but others will not. These recollections are most likely related to the emotional significance of the stimuli.

Cortical System:

The most anterior region (the prefrontal cortex) is concerned with planning, formulating complex motor responses to the environment, and orienting the receptors to enhance sensory input. In addition to formulating plans, this system is important in directing the individual's behavior toward these plans or goals. Damage to this region impairs the individual's ability to sustain attention or to concentrate on a task. They have trouble with both developing a plan and with breaking down a problem into the necessary steps to carry out the plan. In addition, they lose the ability to monitor their activities. Thus, they are easily distracted from their pursuit of a goal and tend not to be aware of such problems.

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CONTUSION/CONCUSSION

If the forces are greater, the shear forces radiate down into the mid part of the brain (the diencephalon) and result is impaired memory consolidation, affecting the storage of new memories. If the shear forces are even greater, they radiate further down to the brain stem; damage to this region results in unconsciousness. These findings have been demonstrated in studies with both humans and animals (Gennarelli, Thibault, Adams, Graham, Thompson, & Marcincin 1982). Ommaya & Gennarelli's model is extremely helpful in understanding both the effects of head injury and the process of recovery.

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THE PROCESS OF RECOVERY

This, of course, is quite different from the typical television portrayal where the person has been unconscious for three weeks, wakes up, and says, "Gee, where have I been? I'd like to have ham and eggs for breakfast." Other than on TV, the only way that happens is with an injury that doesn't cause shear forces. For example, an impact may rupture a vessel and put pressure on the brain stem. In this case, the rest of the brain hasn't been affected to the extent outlined above, and the body may resolve the clot on the brain stem. When the brain stem regains function in this case, the rest of the brain, not being significantly damaged, is able to function normally.

Diencepalon:

The most common problem with memory following head injury does not involve retrograde amnesia but, rather, to impaired memory consolidation. This relates to the fact that, even after recovery of brain stem functions, the diencephalon (hippocampus, hypothalamus, etc.) remains impaired. Since this system is essential for storing new memories, the person may recall early experiences but not be able to retain current events or have memories of things since the accident. With recovery, therefore, patients first regain consciousness and then memory consolidation,which results in recovery from post-traumatic amnesia.

A frequent question relates to whether survivors will ever regain these lost memories. While they will regain their preciously stored memories, they will not regain any memory for the period of 5 to 15 minutes before the accident until they regain memory consolidation after their accident. This is due to the fact that the brain is not able to store information during this time; and, since the information is not stored, it is not available for later recall.

It is not anatomically possible to suffer severe damage to the brain that will destroy all personal memories and not destroy other memories as well. Head injury survivors who can walk, talk, and function without apparent impairment, but who cannot recall who they are, who their family is, or anything of their life from birth to the accident, most likely have emotional factors playing an important role. This is because the parts of the brain that remember how to move a hand or leg, the parts that remember what speech sounds mean, and the parts that can interpret visual images would also be damaged to some extent. While the period of memory loss before the accident (retrograde amnesia) may be very long at first, it shrinks over time and usually is no longer than 5 to 15 minutes in most cases. The time for which no memories are stored and, thus cannot be recalled, is the period from 5 minutes before the accident until the time the individual recovers memory consolidation.

Cortex:

In most cases there are more than shear forces operating. For example, people may strike their head on an object and receive a contusion; and this force may be great enough to cause the brain to fly toward the impact, leaving a vacuum on the opposite side. The effects of this type of injury are referred to as a contra cou injury (injury on the side opposite the primary impact). In addition, there are several predominant bony ridges in the skull which encases the brain. If the brain is suddenly thrown forward, it may be forced across these ridges, and frequently this results in direct injury to the temporal and frontal lobes. This type of injury will cause greater problems in functioning than would occur with only shear-force type injury. In specific cases, individuals might experience post-traumatic seizures with this type of injury and most certainly would have some areas of more specific deficits. In addition to these variations, small vessels may rupture and cause focal areas of damage.

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DEVELOPING AN AWARENESS OF THE CONSEQUENCES OF HEAD INJURY

Further research indicated that, of the majority of patients with mild and moderate injuries who were tested during the -early course of their recovery, only 28% showed impairment on the EEG and 26% on CAT scan. In contrast, on the neuropsychological assessments which were given at the same time, 87% of these patients demonstrated some form of cognitive impairment. As the severity of the injuries increased, the differences between these tests were less pronounced (Long & Gouvier, 1982). Despite these findings, neurosurgeons complain that, while insurance companies will allow numerous CAT or MRI scans, these same companies often won't approve a neuropsychological assessment. Unfortunately, this can create obstacles in providing a thorough and accurate treatment strategy for survivors of head injury.

Regardless of the assessment procedure, the major problem is one of clearly and successfully communicating to the survivor, family, and physician where the individual is in the course of recovery, the severity of the injury, and what to expect in terms of recovery.

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A MODEL OF RECOVERY

Figure 2. Diagrammatic representation of level of cortical functioning as a function of time since head trauma: (A) premorbid level, (B) retrograde amnesia, (C) coma, (D) post-traumatic amnesia, (E) recovery of cognitive functions, (F) final level of recovery (Long & Webb, 1983).

The effect of the trauma suddenly lowers the level of cognitive functioning from the pre-injury level. In cases of mild head injury, the cognitive functioning of the individual may not be reduced to the level of post-traumatic amnesia. However, as the severity of the forces increases, the degree of cognitive decline also increases. In cases of severe head injury, recovery progresses from a period of coma, stupor, and post-traumatic amnesia. Finally, they regain memory consolidation only to find themselves functioning at a level of impaired cognitive functioning.

It is clear from this figure that the period of recovery from impaired cognitive functioning is much longer than the period of coma and post traumatic amnesia. In many cases, it is this prolonged period of recovery of cognitive functioning that is most problematic. On the surface, the individuals appear to be functioning at their pre-injury level; however, they are not. They may be slower in their responses, more distractible, more irritable, prone to fatigue, and have headaches, dizziness, etc. Furthermore, the survivors and/or families may be unaware of the potential problems confronting them. They may be continually frustrated by their inability to perform at the level they expect and, as a result, may make poor decisions. They may go back to work or school too early or attempt to take on too much.

The role of the neuropsychologist is to help patients and their family understand the nature of the injury, where they are in the recovery process, what barriers are present to impede their recovery, and the time period that should elapse before they attempt to make important decisions (Long & Williams, 1988; Long & Schmitter, 1990a,b). This model aids this process in the following ways. First the survivor's level of cognitive functioning is assessed by neuropsychological and/or other testing. These test results need to be communicated to those involved.

When communicating to a family, a survivor, or to another professional, it is inadequate to merely relay test results, such as intellectual functioning, speed of processing, etc. No one is particularly interested in that. What attorneys want to know is how does the present level of functioning compare with abilities prior to the injury. In almost all cases, this has to be estimated. Likewise, what families and physicians want to know is how long will recovery take and how long will it take to reach some specified point in recovery. This also must be estimated from experience with similar individuals with head injury. What does become clear is that no matter how accurately cognitive functions are measured, they must invariably be compared with some estimated starting or end point to answer most questions. To do this, relatively accurate estimates of the pre-injury level of functioning must be made. In addition, to predict time to recovery to some specified level, one must also be able to estimate the severity of the injury. These points will be discussed below.

Pre-injury Level of Functioning:

In estimating pre-injury level of functioning, it is important to obtain as much information as possible from different sources. This estimation can be greatly enhanced if the neuropsychologist has access to school grades, work history, and information from family members. Typically, however, one does not have direct access to this information, or the access is limited, and they must exercise professional judgment based on past experience with similar individuals. Attempts at developing a more accurate predictive formula have met with little success (Bolter, Gouvier, Veneklasen, & Long, 1982).

Determination of Severity of Injury:

Mild Head Injury:

Moderate Head Injury:

Severe and Very Severe Head Injury:

Duration of post-traumatic amnesia helps the professional to get an idea of the time span needed for the head-injury patient to recover. The age of the individual as well must also be considered. The older one is at the time of injury, the longer the time required for recovery. Conversely, the younger one is, the more likely this process may be speeded up.

So, when does recovery time end? Technically, it may go on to infinity; but, as noted in Figure 2, it is rapid at first and gradually slows over time. Which things are likely to improve the most: Those things that are being slowed down or impaired by some barrier or some limitation. Once the professional understands the individual's pre-injury level of functioning, and obtains a measure of the severity of injury, treatment planning can be more effective. If an individual appears to be 30% below the pre-injury level, and it appears that is about where he or she should be on the recovery curve, it may be concluded that this individual does not have any significant emotional problems, probably has a good family support system, an not much can be done to speed recovery. On the other hand, if an individual is 30% below the pre-injury level, and this is much below what would be expected within these parameters, other factors should be taken into account. At this point, one should evaluate the individual's personality, talk to the family, and attempt to identify barriers to recovery. If the barriers are identified and strategies are developed to work around them, then recovery time should be reduced. Other things being equal, the extent of the final recovery decreases as a function of the severity of head injury. For survivors of mild and many survivors of moderate head injury, cognitive functions will recover to the level they were before the injury. Survivors of severe and very severe head injury are more likely to retain residual weaknesses or impairments, requiring them to learn compensatory strategies (Jones & Long, 1990).

Of course, things are never equal and, as you will learn, there are many barriers which can greatly limit the recovery of less severely injured survivors.

An example of potential barriers can be seen in the story of a young man with a moderate head injury who attempted to return to school. Before his injury, he was a B student. However, when he attempted to take 18 hours the semester after his head injury, he was making all Fs. His neurosurgeon couldn't understand the reason for such problems, because the young man's CAT scan appeared normal. His family thought he wasn't applying himself, and he was getting very depressed.

This young man had post-traumatic amnesia of 18 days, indicating a severe head injury; and his return to school was only 0- months since his injury. The results of a neuropsychological evaluation revealed that he was functioning at a level estimated to be 30% below his pre-injury level. The recovery curve outlined above was used to explain his estimated pre-injury level, his current level, and what this 30 % reduction in cognitive abilities meant in terms of his ability to function at that point in his recovery. It was explained that taking on too much too soon and working long hours inefficiently was delaying his recovery by increasing his frustration and leading to depression. He was advised to take only one course. This was not agreeable with him and it was concluded that he could function best if he attempted to take 2 or 3 courses and dropped one or two if the schedule proved to be too difficult. Following this advice, he registered for three courses, ended up dropping one, and received B and a C in his remaining two classes. He was off for the summer and by the fall semester was able to function near his pre-injury level.

Expectancy:

Further examples can be seen in the cases of two young ladies, both 25 years of age and both severely injured.

The mother of the first young woman reported frustration with the rehabilitative system. As a result, she traveled the country, talked to representatives of numerous rehabilitation programs both in the United States and in England, and finally put together a program for her daughter. Fourteen months after her accident, the daughter returned to work, and we had a chance to test her about 6 or 7 times during the rehabilitation period. She made an amazing recovery. She was exceptional before her head injury, and she also had an exceptional social support system.

The other girl's situation was totally different. There was turmoil in her home environment. There was no father in the home. She and her mother didn't agree on very much. And she didn't get along with her brothers and sisters. In addition, she didn't have the insurance or the finances to stay in a rehabilitation program, which she really needed. We tested this young woman over a period of four years and never observed any recovery in her.

Social Support Systems:

Many families need advice and counsel; they also need information as to what works and what doesn't. As was shown previously, this is something that they are not likely to develop on their own. The use of diagrams and demonstrations often helps these individuals better understand the recovery process and the time period involved. The time factor is especially significant.

Denial:

Eventually, with time and hard work, recovery stabilizes. Hopefully functioning reaches the same level it was before that injury. If it does, this generally reflects that the survivor is using a different part of the brain, accomplishing the same tasks in different ways. The most important thing about this process is not how much of the individual's brain was damaged but, rather, how well he or she learns to use what remains. As Symonds said in the early part of this century, " It is not only the kind of injury that matters, but the kind of head that is injured that determines recovery of function" (Symonds, 1939). In other words, all things being equal, the higher functioning the patient is before the injury, the better the recovery. Someone who could not play the piano well before a head injury will not be able to play it well afterwards.

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Pre-existing factors:

Mental Regression:

In many ways the process of recovery can be viewed as going through the whole process of development all over again, hopefully at a faster rate than before. Parents of young children and young adults can be aided by helping them determine at what mental age the survivor appears to be functioning and then advising the parent to treat the survivor as they would have at that age. For example, 18 year olds who sustain a severe head injury and return home after hospitalization and brief rehabilitation will not be able to drive. They will be dependent upon the family to transport them everywhere. They also will be more impulsive and may curse, without thinking, or say things to upset others. In short, the family concludes that these 18 year olds are functioning much like they were at 12 years of age. In this case, the family should be encouraged to treat these teenagers as if they really were 12; and hopefully, with time and effort, they will quickly progress to 13 or above.

One problem with this strategy is that the survivor may act 18 at one time and 6 at another. This variability relates to fatigue or stress. The family needs to be aware of the time of day or the period of time involved in an activity and understand how to modify their behavior appropriately. This approach works particularly well with young children (Long, 1987).

Invariably one family member becomes the primary caregiver. These individuals may find themselves caught in the middle; they must deal with the immaturity and frustration from the survivor, an they also are bombarded with advice and criticism from the rest of the family. In terms of priorities, the needs of the primary caregiver should come first. If they can't function effectively, then the whole system breaks down. They need support and understanding from the rest of the family; and, if they don't get it, they need to seek adequate professional help for the whole family.

Post-Concussion Symptoms:

Post-concussion symptoms can serve as a valuable guide to the overall functioning of the individual. If none are experienced, it is likely that the survivor is not doing much. On the other hand, if symptoms increase in number and/or frequency, then this usually indicates that he or she is taking on too much. Monitoring post concussion symptoms can provide valuable information as the effect that the injury and the situation is having on the survivor at any given time. Some symptoms are expected, but too many indicate that the individual needs to readjust their schedule.

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Future Research:

Early transportation and treatment in trauma centers continues to improve patient outcome. Certainly all of the effects that are due to secondary damage may be identified and corrected, and this alone appears to hold great promise.

Even so, there remain many concerns with regard to head injury. One of these relates to the families' early needs. The best resource for this are other survivors and their families. Hopefully trauma centers will become aware of this and have survivors and/or their families available to talk to families of new head injury survivors. This would provide a vital source of support because the neurosurgeon would not be able to provide much exact information at that point in their recovery anyway.

Another area that needs to be developed is the use of home health care to provide head trauma services. They have a very good model. They can train family members to do nursing and provide physical therapy. Having these needs met by family members would be cost effective; professional who would simply come back once every week or two to monitor the process. In cases where family members are unable to be trained or provide home care, then available inpatient resources become more desirable. This is especially true for stressful home environments such as those previously discussed.

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NON-ORGANIC FACTORS INFLUENCING RECOVERY

Finally, the kind of occupational status the individual has is important. Consider, for instance, a young 21 year old who works in a parts warehouse and part of his job requirements is to know every number for every part. After a severe head injury, he is unlikely to be able to function in that environment. If he's smart enough, he may do well in many other environments; but his prior job will add significant stress. The results is a reduction in his occupational status. Social, vocational, educational, and cognitive factors, plus the amount of stress and how the individual deals with it, all complicate the situation (Long & Webb, 198; Long, Gouvier, & Cole, 1984). Neurological factors are only part of the story.

Primary pre- and post-trauma factors that influence Post Trauma Behavior are:

Situational (perceived) Stress
Personality (Stress Management)
Organic Status
Occupational Status

The trauma often caused the following changes:

Increased Stress
Reduced Stress Management
Neurological Damage (Impaired Cognitive Functions_
Reduced Occupational Status

REFERENCES

Bond, M.R. (1 98 3). Standardized methods of assessing and predicting outcome. In M. Rosentahl, E. Griffith, M. Bond, & J. Miller (Eds.), Rehabilitation of the head injured adult, (pp 97-113). Philadelphia: Davis.

Gennarelli, T.A., Spielman, G.M., Thibault, L.E., Adams, J.H., Graham, D.I., Thompson, C.J., Marcincin, R.P. (1982). Diffuse axonal injury and traumatic coma in the primate. Annals of Neurology, 12, S64-574.

Jones, C.L., & Long, C.J., (1990).Outcome following headtrauma: A million dollar question. The Joumal of Head Injury; A Search for Understanding, 1, 12-15.

Long, C.J., (1984). Evaluating the memory correlates of hypothalamic dysfunction, in The Hypothalamus in Health and Disease, edited by J. G. Givens, Year Book Medical Publishers, Chicago, 303-320.

Long, C.J., (1987). Head Injury, in Encyclopedia of Special Education: A Reference for the Education of the Handicapped and Other Exceptional Children and Adults. Edited by Reynolds & Mann, Wiley-Interscience, Vol. 2, pp. 762-763.

Long, C.J., & Gouvier, WD., (1982). Neuropsychological assessment of outcome following closed head injury, In R.N. Malatesha & L.C. Hartlage (Eds.) Neuropsychology and Cognition, Volume II, The Hague: Martinus Nijhoff Publishers.

Long, C.J., Gouvier, WD., and Cole J.C. (1984). A Model of Recovery for the total rehabilitation of individuals with head trauma, journal of Rehabilitation, 39-70.

Long, C.J., & Haban, G., (1986). Strategies for developing a plan of intervention for head trauma patients, Psychotherapy in Private Practice, 4, 71-80.

Long, C.J., & Novack, T.A., (1986). Post-concussion symptoms after head trauma: Interpretation and Treatment, Southern Medical journal, 728-732.

Long, C.J., Ross, L. & Matchnick, M.E., (1990). The use of neuropsychological data in the development of a treatment plan for brain injured individuals, Psychotherapy in Private Practice, 8, 99-113.

Long, C.J., & Schmitter, M.E., (1990). Neuropsychological Evaluation: Evaluation of cognitive sequelae following head injury, in Long, C.J., Mutchnick, M., & Ross, L., I Head Trauma: Acute care to recovery, Plenum.

Long, C.J., & Webb, WL. (1983). Psychological sequelae of head trauma. In Hall, D., (Ed), Psychiatric Medicine, 1:1, 35-77.

Long, C.J., & Williams, J.M., (1988). Neuropsychological Assessment and Treatment of Head Trauma Patients, in Issues in Neuropsychology, Ed by Whitaker & Caramazza, Lawrence Eribaum Assoc.

Novack, T., Daniel, M., & Long, C.J. (1983). The relationship between MMPI scores, post-concussion symptoms, neuropsychological performance, and severity of head injury. Clinical Neuropsychology, 6, 139-142.

Novack, T.A., Daniel, M.S., & Long, C.J. (1985). Factors related to emotional adjustment following head lnj'ury. International joumal of Clinical Neuropsychology, 6, 139-142.

Ommaya, A., & Gennarelli, T. (1974). Cerebral concussion and traumatic unconsciousness. Brain, 97, 633-654.

Russell, WR. (1932). Cerebral involvement in head injury: A study based on the examination of 200 cases. Brain, 3S, 549-603.

Williams, J.M., & Long, C.J., (1987). Cognitive Rehabilitation in Neurologically Impaired and Learning Disabled, Plenum Press.

Symonds, C.P., (1939). Mental disorder following head injury. Proceedings of the Royan Society of Medicine, 30, 1081-1094.

Williams, J.M., & Long, C.J., (9188). Cognitive Approaches to Neuropsychology, Plenum Press.

Wood, E, Novack, T.A., and Long, C.J. (1984). Postconcussion symptoms: Cognitive, Emotional and Environmental aspects. journal of Psychiatry in Medicine, 14, 277-283.

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Case Studies

CASE 1:

This 26 year-old male was involved in a head-on collision 3 months ago. It was estimated that he was unconscious less than 10 minutes as he remembers being removed from the car. He was taken to the Hospital ER and released after 3 hours. Prior history reveals left-sided hemiparesis, since birth, as a result of cerebral palsy. He graduated from high school but had problems with attention and concentration which persist. Since the accident he reports problems with memory. He has attended college but presently works part-time in pizza delivery.

Test Findings: Low-average IQ (82), long-term memory(76%); high-average short-term memory (112). Cognitive functions are mildly impaired and strongly lateralized to the right hemisphere. No significant problems with emotional adjustment.

Conclusions: Patient suffered a minimal to very-mild TBI with recovery expected within 1 to 2 months. Present level of function appears to be at or near his premorbid level. Findings suggest recovery delayed somewhat due to interaction of TBI effects with pre-existing impairment.(26032)

CASE 2:

This 70 year-old lady was involved in a motor vehicle accident when her car was rear-ended by another driver two years ago. She experienced no coma or PTA and did not seek medical treatment for 2 weeks. She sought treatment at that time for impaired memory and concentration, headaches and dizziness, and loss of energy. She was diagnosed as suffering a concussion and was referred for further diagnostic studies.

Test Findings: Diagnostic tests reveal normal MRI. A neuropsychological evaluation, without age corrected norms, revealed mild generalized cerebral dysfunction thought to be secondary to her TBI. She was referred for a second opinion and again diagnosed as suffering from post-concussion syndrome. Test data also revealed moderate depression and anxiety.

Further investigation of this case revealed that since the accident, she continued to manage her business and that her mother had been killed in a similar MVA 1 week before. Age corrected norms revealed generally normal range of functioning.

Conclusions: This lady did not suffer from TBI. Weaknesses noted could have resulted from other factors.

CASE 3:

A 40-year-old man with 12 yrs education had trouble remembering daily events and has become highly distractible. Patient states that he experiences frequent occurrences where he "walks in their room and does not know why he was there" and forgets work activities from one day to the next. He denies sensory or motor problems but reports occasional pains in his neck, mild experiences with vertigo, hearing loss in his right ear, and occasional sleep disturbance.

Test Findings: Average IQ (112), superior short-term memory (143), and average long-term memory (86%). Performance on all tasks of higher cortical function fell within the normal range. In contrast, the results of personality assessment revealed marked depression and anxiety.

Treatment recommendation: Appropriate chemotherapy and supportive counseling aimed at developing more effective coping strategies.