Overview of Topics

Lesson Objectives

Functional Systems

Functional Unit

Cognitive Functions

Cognitive vs Emotional Factors

Data Interpretation

Traumatic Brain Injury

Neuropsychological Exams vs CT Scans & EEG

Post-Concussion Symptoms

Outcome Measures

Severity Determination

Minor Head Injury

Case Studies

Lesson Objectives

1. Describe how an understanding of the 3 basic functional systems in the brain assist in neuropsychological assessment.

2. Describe the use of the concept of the functional unit to understand human brain-behavior relationships.

3. Outline and discuss the basic cognitive functions evaluated in a neuropsychological assessment.

4. Why has neuropsychological assessment remained the preferred method in evaluating the consequences of traumatic brain injury?

5. What is minor head injury?

Brain-Behavior Relationships

Functional Systems

• Brain Stem Activation
  • Cortical desynchronization ARAS-DPTS
  • Necessary for perception
  • Attention/Habituation

• Limbic System
  • Behavioral Arousal
  • Emotion (Preparation - reinforcing value)
  • Motivation
  • Memory Consolidation

• Cortical System
  • Information Processing
  • Provides a distribution of information according to:
    • Modality (visual, auditory, somatosensory.)
    • Material (i.e., verbal versus non-verbal)

Functional Unit

Cognitive Functions

• Psychosensory
  • Suppression
  • Simple to complex
• Psychomotor
  • Strength
  • Stamina
  • Fine motor movements
  • Motor sequencing
• Perceptual motor
• Integrative Functions
• Language
  • Receptive and expressive
• Attention/Concentration.
• Intelligence
• Memory

Cognitive vs Emotional Factors

• Symptoms may be augmented due to an emotional disorder
• Symptoms must be distinguished from psychological problems.
  • Example case: A patient had at first appeared to be self-inflicting injuries when she walked into doors at work. Thought it was an emotional problem, but it turned out to be a brain tumor.
• NOTE: Don't make assumptions in the absence of data.
• At the same time, don't let an emotional problem be diagnosed as a brain disorder.

Data Interpretation

• Primary Areas
  • Cognitive
  • Emotional
  • Situational
• Prioritize across cognitive, emotional, situational areas.
• Prioritize within an area
• Cognitive Data Analysis
  • Dysfunction
  • Lateralization
  • Localization

Traumatic Brain Injury

Basic Information

• 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

Length PTA	Russell 35	Alternate	Cognitive Recovery	Full Recovery
< 5 min	-	Minim	1 mo	1 mo
5-60 min	Mild	V mild	1-3 mo	3 mo
1-24 hrs	Mod	Mild	3-6 mo	1 yr
1-7 days	Severe	Mod	6-12 mo	1-2 yrs
8-28 days	V Sev	Severe	12-24 mo	Residual
> 28 days	V Sev	V Sev	+24 mo	Residual

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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%

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.

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Terms to know