What determines recovery time for a child after a traumatic brain injury?

This article explains why it takes children different amounts of time to recover from traumatic brain injury.

Why do some youngsters bounce back quickly from a traumatic brain injury, while others suffer devastating side effects for years?

New UCLA/USC research suggests that damage to the fatty sheaths around the brain's nerve fibers--not injury severity-- may explain the difference. Published in the July 15 edition of the Journal of Neuroscience, the finding identifies possible biomarkers that physicians could use to predict higher-risk patients who require closer monitoring.

The study is the first to combine imaging scans with recording of the brain's electrical activity to reveal how damage to the protective coating around the brain's circuitry affects how quickly children and teens can process and recall information after a concussion or other head trauma.

"Just as electricians insulate electrical wires to shield their connections, the brain's nerve fibers are encased in a fatty tissue called myelin that protects signals as they travel across the brain," explained Dr. Christopher Giza, director of the UCLA Steve Tisch BrainSPORT Program and a professor of pediatrics and neurosurgery at UCLA's David Geffen School of Medicine and Mattel Children's Hospital. "We suspected that trauma was damaging the myelin and slowing the brain's ability to transmit information, interfering with patients' capacity to learn."

To test their hypothesis, the scientists assigned a series of mental tasks to 32 youngsters ages 8 to 19. Each had suffered a moderate to severe brain injury in the past five months. The tests evaluated the children's processing speed, short-term memory, verbal learning and cognitive flexibility.

The UCLA team recorded the kids' brains' electrical activity to test how quickly their nerve fibers could transmit information, and then imaged the wiring to assess its structural soundness.

When the scientists compared the patients' results to those of a matched control group of 31 healthy children, they discovered dramatic differences.

Half of the brain-injury group showed widespread damage to the myelin insulating their brain's circuitry. These patients performed 14 percent more poorly on the cognitive tests and their wiring worked three times slower than healthy children's.

Scans of the other 16 patients in the brain-injury group showed their myelin was nearly intact; and their brains were able to process information as quickly as healthy children's. They performed 9 percent better on the cognitive tasks than the youngsters with more myelin damage, though not as well as the uninjured kids.

"Our research suggests that imaging the brain's wiring to evaluate both its structure and function could help predict a patient's prognosis after a traumatic brain injury," said first author Emily Dennis, a postdoctoral researcher at USC's Keck School of Medicine.

"Our next step will be to explore how brain biomarkers change during a patient's first year of recovery when most people recapture some cognitive function," said principal investigator Robert Asarnow, a professor of psychiatry and psychology at UCLA's Semel Institute for Neuroscience and Human Behavior and College of Letters and Science.

Traumatic brain injury is the single most common cause of death and disability in children and teens, according to the U.S. Centers for Disease Control.

The research was supported by funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institute of Biomedical Imaging and Bioengineering, and the National Cancer Institute.

Read more here

Reducing severity of brain injury in children - Recreational Safety

A study of brain injury in children indicated that education and attempts at prevention can reduce the severity of a brain injury.

An exhaustive analysis of data from more than 40,000 cases of brain trauma in children -- published by the New England Journal of Medicine -- provides convincing evidence that protecting children in advance from head injuries is the key to reducing their severity.

The new findings, obtained during one of the largest multi-center prospective studies of its kind ever conducted in the United States, show that the most common cause of brain injury among children younger than 12 is falling -- typically from a moving bicycle, scooter or other wheeled device. Among U.S. adolescents, the three major causes of brain trauma are automobile accidents, assaults and sports-related injuries. Based on a previous study of pediatric brain trauma that studied children's medical histories at 25 sites in the Pediatric Emergency Care Applied Research Network (PECARN), the newly-released findings send a clear safety message to parents and caregivers alike, said Children's Hospital of Michigan Division Chief and Research Director of Emergency Medicine Prashant V. Mahajan, M.D., one of the authors.

"We studied a very large cohort of patients in our secondary analysis of this previously collected data," said Dr. Mahajan, professor of pediatrics and emergency medicine at the Wayne State University School of Medicine, "and the good news for all of us is that they demonstrate clearly the importance of prevention in protecting children from brain trauma. The bottom line on this prospective study of more than 43,000 pediatric brain injuries is that it identifies falls -- often from bicycles -- as the major cause of trauma in children under age 12. Knowing that, we're now better able to help educate parents and policymakers alike about the great value of safety helmets for this population of kids."

Dr. Mahajan said the data on adolescent brain trauma similarly underlines the vital importance of providing sports safety equipment and automobile seatbelts for teenagers.

"Once again, the implications of this very large study are crystal clear," said Dr. Mahajan, who has spent the past 18 years treating injured tots and teenagers at the Children's Hospital of Michigan, part of the Detroit Medical Center. "Our study really emphasizes the importance for pediatricians of educating parents as a key strategy for reducing the severity of such brain injuries among children everywhere."

Dr. Mahajan said his 18 years in pediatric emergency rooms have shown him the importance of prevention, and sometimes in very dramatic fashion. "As a specialist in emergency medicine, I've seen how important such preventive measures as bike safety helmets and automobile seatbelts truly are."

"On several occasions," he added, "I've treated injured children who had been protected by safety equipment and also injured children who have not been protected, during the same eight-hour shift in the emergency room. In most cases, the children who had benefited from wearing the helmets or seatbelts sustained less severe injuries.

"That's the lifesaving message contained in this study -- and it's the message I want to convey to parents and pediatricians everywhere, as a doctor who cares passionately about preventing fatal or disabling brain trauma in children."

Dr. Steven E. Lipshultz, pediatrician-in-chief at the Children's Hospital of Michigan and chair of pediatrics for the Wayne State University School of Medicine, noted, "Dr. Mahajan has long been a dedicated researcher with a great passion for conducting clinical studies that help improve patient care. As his new study reveals in compelling detail, the knowledge that our Children's Hospital of Michigan researchers gain every day is extremely important in improving the quality of the health care we provide to children day in and day out."

Read more here

CDC's Heads Up app helps to spot symptoms of concussions in children

Summer concussions are from falls and accidents. I see many water sport induced brain injuries.

 If your child is not right, trust your instincts. Trust your child if they feel they are not right. See a physician! - JR

An app created by the CDC helps to spot symptoms of concussions in children.

Need a primer on how to spot the signs of a concussion for your child? The Centers For Disease Control and Prevention's Heads Up app will help you learn how to recognize the signs and symptoms, and what to do if you think a child has a concussion or other serious brain injury.

This is crucial information that you can find easily in the app to act quickly if needed. Children and teen athletes are more susceptible to concussion than older athletes, and they have an increased risk compared to adults for traumatic brain injury with greater severity and prolonged recovery due to their developing brains.

The app says that signs and symptoms generally appear soon after an injury, but the seriousness of the injury and some symptoms may not appear for hours or days. In rare cases of a hematoma (a collection of blood in the brain), you would need to take your child immediately to the emergency room. If a child does suffer from a concussion, there is information on recovery, such as when to return to school and sports.

This app can also help you pick the right helmet for your child's activity, including what to look for and what to avoid. For example, you can choose hockey to find out about the correct size and fit, tips for finding a good helmet, and how long it should last.

Besides sports, there are safety tips to prevent brain injuries at home, playground, cars, homes, and bikes.

Lastly, the CDC encourages to share information on concussions with others. In May, President Obama at the Healthy Kids and Safe Sports Concussion Summit called for the end of the culture in youth sports where kids are encouraged to “suck it up” after sustaining head injuries.

“We have to change a culture that says you suck it up,” said President. “Identifying a concussion and being able to self-diagnose that this is something that I need to take care of doesn’t make you weak - it means you’re strong.”

Read more here

White House plans to educate the public on youth concussions

The White House and President Obama plan to gather experts to help educate the public on youth concussions.

Concerned that too little is known about the effects of head injuries in young athletes, President Barack Obama is bringing representatives of professional sports leagues, coaches, parents, youth sports players, researchers and others to the White House to help educate the public about youth sports concussions.

Tackling the issue at a White House summit Thursday, Obama also will highlight pledges of money and other support from the NFL, the National Institutes of Health, the Pop Warner Little Scholars and others to do the research, promote safety and speed development of materials designed to provide better protection.

Obama comes to the issue through his well-documented love of sports, and as the father of two daughters active in sports. The president thinks sports are also a good way to keep kids healthy and out of trouble, but he raised some eyebrows last year by saying he would "have to think long and hard" before letting a son, if he had one, play football because of the risk of head injuries.

"He, as a parent, is concerned about the safety of his own daughters," said White House communications director Jennifer Palmieri, who was among officials who previewed the White House Healthy Kids & Safe Sports Concussion Summit for reporters.

In a report last fall, the Institute of Medicine and the National Research Council called for a national system to track sports-related concussions and begin answering questions about the risks of youth sports, such as how often do the youngest athletes suffer concussions or which sports have the highest rates.

Nearly 250,000 kids visit hospital emergency rooms each year with brain injuries caused by sports or other recreational activity, the White House said.

The National Football League is committing $25 million over the next three years on promoting youth sports safety.

Read more here

Study: Concussion can mean depression years later

A study done in mice shows that concussions can lead to the development of depression later in life.

A head injury can lead immune-system brain cells to go on "high alert" and overreact to later immune challenges by becoming excessively inflammatory -- a condition linked with depressive complications, a new animal study suggests.

The findings could help explain some of the midlife mental-health issues suffered by individuals who experience multiple concussions as young adults, researchers say. And these depressive symptoms are likely inflammation-related, which means they may not respond to common antidepressants.

An added complication is that aging already increases brain inflammation. So on top of normal aging concerns, people who have had a traumatic brain injury (TBI) experience added inflammation caused by magnified immune responses to so-called "secondary challenges," such as a second head injury, infections or other stressors.

In mice, these high-alert cells in the brain -- called microglia -- had an exaggerated response to an immune challenge one month after a moderate brain injury. This increased brain inflammation corresponded with the development of depressive behaviors that were not observed in uninjured mice.

"If we had waited three, six or nine months, the symptoms probably would have gotten even worse," said lead author Jonathan Godbout, associate professor of neuroscience at The Ohio State University and a researcher in the Institute for Behavioral Medicine Research.

"A lot of people with a history of head injury don't develop mental-health problems until they're in their 40s, 50s or 60s. That suggests there are other factors involved, and that's why we're looking at this two-hit idea -- the brain injury being the first and then an immune challenge. It's as if one plus one plus one equals 15. There can be a multiplier effect."

The research is published online in the journal Biological Psychiatry.

This work applies to concussive brain injuries that result in a diffuse -- or spread out -- trauma to the brain. These are also concussive injuries from which people and animals recover fairly quickly, typically showing no problems with thinking or moving about a week after the injury to the brain.

In the study, researchers compared uninjured mice with mice that had experienced a moderate TBI. Injured mice showed some initial coordination problems, but those resolved within a week.

The injured mice also showed signs of depressive symptoms that improved within one month. Godbout and colleagues attributed those symptoms to the expected neuroinflammation that occurs after a traumatic brain injury. In these mice, most of the inflammation had cleared within seven days.

Thirty days after injury, researchers examined the brains of the injured mice to determine whether immune cells had remained on high alert since the injury. As expected, the injured brains contained microglia that had stayed in a "primed" state -- meaning they were on standby to respond to a challenge to the immune system. The cells in the brains of uninjured mice did not have the same characteristics.

Under normal circumstances, microglia are the first line of defense and help protect the brain after injury or infection by making proteins and other chemicals that generate just enough inflammation to repair the problem. When they are primed, however, these cells are in a higher state of alert and when they are activated, they generate an amplified immune response that lasts longer than necessary. When these systems are activated with nothing to fight, the circulating chemicals and proteins generate excessive inflammation.

"The young adult mice that have a diffuse head injury basically recover to normal, but not everything is normal. The brain still has a more inflammatory makeup that is permissive to hyperactivation of an immune response," Godbout said.

At 30 days after TBI, the mice were injected with lipopolysaccharide (LPS) -- the dead, outer cell wall of bacteria that stimulates an immune reaction in animals. Tests showed that over the course of 24 hours after the injection, TBI mice were much less social than uninjured mice -- one type of depressive symptom in these animals. The brains of the TBI mice also had dramatically higher levels of two inflammation-related proteins than did brains from normal mice.

Seventy-two hours after the LPS challenge, injured mice showed additional depressive symptoms, including minimal interest in sugar water -- a sign that they avoided what is typically a pleasurable activity. They also showed increased resignation, or a sign of "giving up."

Uninjured mice behaved normally and the levels of inflammatory proteins in their brains had returned to baseline over the same time period.

"These results tell us the TBI mice are having an amplified and prolonged activation of microglia, and that was associated with development of depressive symptoms in the mice," Godbout said.

His lab is now investigating potential treatments that could either prevent the priming of microglia immediately after injury or later reverse the high-alert characteristics of these cells.

Read more here

Children with concussions more likely to be depressed

A study claims that children with head injuries or those who have had a concussion are significantly more likely to have depression.

Children who've suffered a concussion or other head injury seem to have a much higher-than-average rate of depression, a new study finds.

Using data from a U.S. health survey, researchers found that children and teenagers who'd ever sustained a brain injury were much more likely to have ever been diagnosed with depression.

Overall, 15 percent had received that diagnosis, while the national prevalence was less than 4 percent, the investigators noted.

The finding does not prove that kids' head injuries caused the depression, said Keith Yeates, a pediatric neuropsychologist who was not involved in the study.

But there is a "well-documented" connection between brain injury, particularly more severe ones, and depression in adults, said Yeates, who heads pediatric psychology and neuropsychology at Nationwide Children's Hospital in Columbus, Ohio.

There have been some small studies of children, but the findings have been more mixed, according to Yeates. While this latest study doesn't prove cause-and-effect, it does support an association between brain injury and depression in kids, he said.

It's not clear why the link exists, Yeates noted. Even so, he said doctors should assess children for behavioral problems and mood symptoms, including depression and anxiety, as part of their follow-up after a head injury.

Dr. Matthew Wylie, a pediatric emergency specialist who led the study, agreed. "It's helpful for pediatricians to recognize that there is this potential for depression, and to be attuned to it."

Wylie presented the findings Friday at the American Academy of Pediatrics national conference in Orlando, Fla.

The results are based on a 2007 nationally representative study covering nearly 82,000 children and teens younger than 18. Just over 2,000 parents said their child had ever been diagnosed with a "brain injury or concussion," and just over 3,100 said their child had ever been diagnosed with depression -- for a national rate of 3.7 percent.

Among kids with a past head injury, however, the rate of depression was about four times higher, at 15 percent, the investigators found.

The researchers then weighed other factors in children's depression risk, such as family income and mothers' mental health. In the end, kids with a history of head injury still had double the risk of depression as other kids.

The study had a number of limitations, both Wylie and Yeates pointed out.

One is that "brain injury" and "concussion" were lumped together into one question, Yeates noted. So it's not possible to tell whether kids who suffered mild concussions had the same depression risk as those with more serious brain injuries.

It's likely that more severe injuries would carry a greater risk, Wylie said. But that's a question for future studies, he added.

It's also unclear which came first, the brain injury or the depression. Yeates said it's possible that people with depression are at greater risk of accidents and injury -- because, for example, they have difficulty concentrating or are less aware of their surroundings.

On the other hand, there are reasons to believe that a blow to the head could contribute to depression. "One possibility is that there are alterations to the brain structure in areas associated with mood regulation," Yeates explained.

There could also be indirect links. If a brain injury is serious enough to hinder a child's functioning and ability to socialize with friends, that could lead to depression, Yeates said.

As for what parents can do, Wylie advised focusing on head injury prevention: Bike helmets, proper seat belt use and safety equipment for sports will all lower risk. If your child has already suffered a concussion or other brain injury, Wylie said, be on the lookout for potential depression symptoms.

At the same time, though, Yeates stressed that parents should not be unduly alarmed. The majority of childhood brain injuries are concussions or other milder forms, and while they should be taken seriously, most kids recover fully, he said.

The data and conclusions of research presented at medical meetings should be viewed as preliminary until published in a peer-reviewed journal.

Read more here

Biomarkers predict outcomes for children's brain injuries

Biomarkers found in cerebrospinal fluid can predict outcomes for pediatric traumatic brain injuries.

The study aims to systematically review the literature on brain injury biomarkers, defined as any injury biomarker detected in cerebrospinal fluid (CSF) or blood injury biomarkers primarily expressed in the brain parenchyma, to determine outcome prediction in pediatric severe traumatic brain injury (sTBI). Based on the status of current sTBI biomarker research, the authors recommend that future research should be directed at both novel biomarker discovery and validation of biomarker panels in large, well–designed longitudinal studies.

Methods

• A search of MEDLINE, EMBASE, PsycINFO, Pubmed, and the Cochrane Database, as well as grey literature sources, personal contacts, hand searches, and reference lists.
• The search terms used were traumatic brain injury, biomarkers, prognosis, and children.
• No language, publication type, or publication date restrictions were imposed.
• All articles were critically reviewed by two clinicians independently.

Results

• A total of 7,150 articles were identified initially with 16 studies identified for review.
• Eighteen different biomarkers were examined; 11 in CSF and 7 in blood.
• Outcomes assessed included either in–hospital mortality or functional state (hospital discharge, 3–months or 6–months; Glasgow Outcome Scale or Pediatric Cerebral Performance Category).
• Significant correlations were established between sTBI outcomes and various biomarkers in CSF (IL–6, IL–8, IL–1β, S100β, NGF, NSE, DCX, ET–1, HMGB–1, cytochrome C) and blood (GFAP, NF–H, UCH–L1, SBDP–145, leptin).
• Mixed results were obtained for blood S100β.
• Outcome did not correlate with several biomarkers in either CSF (BDNF, GDNF, α–Syn) or blood (NSE, MBP).
• The Class of Evidence was considered II in 1 study and III in the remaining 15 studies.

Read more here

Heading Soccer Balls and Brain Injury

A study shows that heading a soccer ball can result in brain injury resembling a concussion.

Researchers at Albert Einstein College of Medicine of Yeshiva University have shown that soccer players who frequently head the ball have brain abnormalities resembling those found in patients with concussion (mild traumatic brain injury). The study, which used advanced imaging techniques and cognitive tests that assessed memory, published online today in the journalRadiology.

"We studied soccer players because soccer is the world's most popular sport," said Michael L. Lipton, M.D., Ph.D., associate director of Einstein's Gruss Magnetic Resonance Research Center and medical director of MRI services at Montefiore, the University Hospital and academic medical center for Einstein. "Soccer is widely played by people of all ages and there is concern that heading the ball -- a key component of the sport -- might damage the brain." Dr. Lipton is also associate professor of radiology, of psychiatry and behavioral sciences and in the Dominick P. Purpura Department of Neuroscience at Einstein.

On average, soccer players head the ball six to 12 times during games, where balls can travel at speeds of more than 50 miles per hour. During practice drills, players commonly head the ball 30 or more times. The impact from a single heading is unlikely to cause traumatic brain damage such as laceration of nerve fibers. But scientists have worried that cumulative damage from heading's repeated subconcussive impacts might be clinically significant. "Repetitive heading could set off a cascade of responses that leads to degeneration of brain cells over time," noted Dr. Lipton.

To study possible brain injury from heading, the researchers used diffusion tensor imaging (DTI), an advanced MRI-based imaging technique, on 37 amateur adult soccer players (median age 31 years) who had all played the sport since childhood. Participants reported playing soccer for an average of 22 years and had played an average of 10 months over the previous year. Researchers ranked the players based on heading frequency and then compared the DTI brain images of the most frequent headers with those of the remaining players. All participants also underwent cognitive testing.

DTI "sees" the movement of water molecules within and along axons, the nerve fibers that constitute the brain's white matter. This imaging technique allows researchers to measure the uniformity of water movement (called fractional anisotropy, or FA) throughout the brain. Abnormally low FA within white matter indicates axon damage and has previously been associated with cognitive impairment in patients with traumatic brain injury.

"The DTI findings pertaining to the most frequent headers in our study showed white-matter abnormalities similar to what we've seen in patients with concussion," said Dr. Lipton. "Soccer players who headed the ball above a threshold between 885 to 1,550 times a year had significantly lower FA in three areas of the temporal-occipital white matter." Dr. Lipton noted that players with more than 1,800 headings per year were also more likely to demonstrate poorer memory scores compared to participants with fewer yearly headings.

"Our study provides compelling preliminary evidence that brain changes resembling mild traumatic brain injury are associated with frequently heading a soccer ball over many years," said Dr. Lipton. "While further research is clearly needed, our findings suggest that controlling the amount of heading that people do may help prevent brain injury that frequent heading appears to cause."

Read more here

MRIs Show Signs of Brain Injuries Missed in CT Scans

MRIs can show signs of traumatic brain injuries that cannot be seen in CT scans. 

The second best test is a history and exam by a specialist. 

The most sensitive test is a parent saying that their child is not right. JR

Hospital MRIs may be better at predicting long-term outcomes for people with mild traumatic brain injuries than CT scans, the standard technique for evaluating such injuries in the emergency room, according to a clinical trial led by researchers at the University of California, San Francisco (UCSF) and the San Francisco General Hospital and Trauma Center (SFGH).

Published this month in the journalAnnals of Neurology, the study was led by UCSF neuroradiologist Esther Yuh, MD, PhD and followed 135 people treated for mild traumatic brain injuries over the past two years at one of three urban hospitals with level-one trauma centers: SFGH, the University of Pittsburgh Medical Center and University Medical Center Brackenridge in Austin, Texas as part of a study called NIH-funded TRACK-TBI (Transforming Research and Clinical Knowledge in Traumatic Brain Injury).

All 135 patients with mild traumatic brain injuries received CT scans when they were first admitted, and all were given MRIs about a week later. Most of them (99) had no detectable signs of injury on a CT scan, but more than a quarter (27/99) who had a "normal" CT scans also had detectable spots on their MRI scans called "focal lesions," which are signs of microscopic bleeding in the brain.

Spotting these focal lesions helped the doctors predict whether the patients were likely to suffer persistent neurological problems. About 15 percent of people who have mild traumatic brain injuries do suffer long-term neurological consequences, but doctors currently have no definitive way of predicting whether any one patient will or not.

"This work raises questions of how we're currently managing patients via CT scan," said senior author on the study Geoff Manley, MD, PhD, the chief of neurosurgery at SFGH and vice-chair of the Department of Neurological Surgery at UCSF. "Having a normal CT scan doesn't, in fact, say you're normal," he added.

Better Precision Tools Needed for Head Injuries, Doctors Say

At least 1.7 million Americans seek medical attention every year for acute head injuries, and three quarters of them have mild traumatic brain injuries -- which generally do not involve skull fractures, comas or severe bleeding in the brain but have a variety of more mild symptoms, such as temporary loss of consciousness, vomiting or amnesia.

The U.S. Centers for Disease Control and Prevention (CDC) estimates that far more mild traumatic brain injuries may occur each year in the United States but the true number is unknown because only injuries severe enough to bring someone to an emergency room are counted.

Most of those who do show up at emergency rooms are treated and released without being admitted to the hospital. In general, most people with mild traumatic brain injuries recover fully, but about one in six go on to develop persistent, sometimes permanent disability.

The problem, Manley said, is that there is no way to tell which patients are going to have the poor long-term outcomes. Some socioeconomic indicators can help predict prolonged disability, but until now there have been no proven imaging features, or blood tests for predicting how well or how fast a patient will recover. Nor is there a consensus on how to treat mild traumatic brain injuries.

"The treatment's all over the place -- if you're getting treatment at all," Manley said.

The new work is an important step towards defining a more quantitative way of assessing patients with mild traumatic brain injuries and developing more precision medical tools to detect, monitor and treat them, he added.

If doctors knew which patients were at risk of greater disabilities, they could be followed more closely. Being able to identify patients at risk of long-term consequences would also speed the development of new therapeutics because it would allow doctors to identify patients who would benefit the most from treatment and improve their ability to test potential new drugs in clinical trials.

Read more here