Brain damage from mild concussions

This article explains how football players can have brain damage from milder concussions.

A new, enhanced MRI diagnostic approach was, for the first time, able to identify significant damage to the blood-brain barrier (BBB) of professional football players following "unreported" trauma or mild concussions. Published in the current issue of JAMA Neurology, this study could improve decision making on when an athlete should "return to play."

According to Prof. Alon Friedman, from the Ben-Gurion University Brain Imaging Research Center and discoverer of the new diagnostic, "until now, there wasn't a diagnostic capability to identify mild brain injury early after the trauma. In the NFL, other professional sports and especially school sports, concern has grown about the long-term neuropsychiatric consequences of repeated mild Traumatic Brain Injury (mTBI) and specifically sports-related concussive and sub-concussive head impacts."

The paper, published by researchers at Ben-Gurion University of the Negev (BGU) and Soroka University Medical Center, describes a new diagnostic approach using Magnetic Resonance Imaging (MRI) for detection and localization of vascular pathology and blood-brain barrier breakdown in football players.

The images from the Ben-Gurion University of the Negev JAMA Neurology study represent Blood-Brain Barrier (BBB) Permeability in Football Players (A) vs. a control group (B). The players in the pathological-BBB group (B) presented focal BBB lesions in different cortical regions including the temporal (player 4), frontal (player 5), and parietal (player 6) lobes. Both gray and white matter were involved.

"The goal of our study was to use our new method to visualize the extent and location of BBB dysfunction in football players using Dynamic Contrast-Enhanced Magnetic Resonance Imaging (DCE-MRI) on a Phillips 3-T Ingenia. Specifically, it generates more detailed brain maps showing brain regions with abnormal vasculature, or a 'leaky BBB.' "

Study participants included 16 football players from Israel's professional football team, Black Swarm, as well as 13 track and field athletes from Ben-Gurion University who served as controls. All underwent the newly developed MRI-based diagnostic.

The DCE-MRIs were given between games during the season and revealed significant damage.

Forty percent of the examined football players with unreported concussions had evidence of "leaky BBB" compared to 8.3 percent of the control athletes.

"The group of 29 volunteers was clearly differentiated into an intact-BBB group and a pathological-BBB group," Friedman explains. "This showed a clear association between football and increased risk for BBB pathology that we couldn't see before. In addition, high-BBB permeability was found in six players and in only one athlete from the control group."

Friedman also explains that not all the players showed pathology. This indicates that repeated, mild concussive events might impact some players differently than others. This level of diagnosis of individual players can provide the basis of more rational decision making on "return to play" for professionals as well amateurs of any age.

"Generally, players return to the game long before the brain's physical healing is complete, which could exacerbate the possibility of brain damage later in life," says Friedman.

A decade of research in the BGU Laboratory for Experimental Neurosurgery has shown that vascular pathology, and specifically dysfunction of the blood-brain barrier (BBB), plays a key role in brain dysfunction and degeneration, and may be an underlying cause of neurodegenerative complications after brain injuries.

The BBB is a highly selective permeable membrane that separates circulating blood from extracellular fluid. It protects the brain by preventing many dangerous substances from penetrating, and therefore is not meant to be damaged.

Medical researchers, including Friedman's group at BGU, are working to find ways to find drugs that will target the BBB and facilitate its repair, allowing for the prevention of Alzheimer's disease and other brain-related disease.

"Prof. Friedman has been able to conduct this breakthrough brain research using the state-of-the-art MRI machine donated as a result of contributions from American Associates, Ben-Gurion University of the Negev (AABGU)," explains Doron Krakow, AABGU executive vice president. "We believe that with continued support, Prof. Friedman and the DCE-MRI can help render more accurate and informed decisions by athletes and others exposed to mild concussions about when to resume activities."

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MRI may help prevent ADHD misdiagnosis

MRI scans may help prevent potential misdiagnosis of ADHD.

Brain iron levels offer a potential biomarker in the diagnosis of attention deficit hyperactivity disorder (ADHD) and may help physicians and parents make better informed treatment decisions, according to new research published online in the journalRadiology.

ADHD is a common disorder in children and adolescents that can continue into adulthood. Symptoms include hyperactivity and difficulty staying focused, paying attention and controlling behavior. The American Psychiatric Association reports that ADHD affects 3 to 7 percent of school-age children.

Psychostimulant medications such as Ritalin are among the drugs commonly used to reduce ADHD symptoms. Psychostimulants affect levels of dopamine, a neurotransmitter in the brain associated with addiction.

"Much debate and concern has emerged regarding the continual rise of ADHD diagnosis in the U.S. given that two-thirds of those diagnosed receive psychostimulant medications," said Vitria Adisetiyo, Ph.D., postdoctoral research fellow at the Medical University of South Carolina in Charleston, S.C. "We wanted to see if we could identify brain iron as a potential noninvasive biomarker for medication-naïve ADHD to prevent misdiagnosis."

For the study, the research team measured brain iron levels in 22 children and adolescents with ADHD, 12 of whom had never been on medication for their condition (medication naïve), and 27 healthy control children and adolescents using a magnetic resonance imaging (MRI) technique called magnetic field correlation imaging. The technique was introduced in 2006 by study co-authors and faculty members Joseph A. Helpernadhd di, Ph.D., and Jens H. Jensen, Ph.D. No contrast agents were used, and blood iron levels in the body were measured using a blood draw.

The results showed that the 12 ADHD medication-naïve patients had significantly lower brain iron levels than the 10 ADHD patients who had been on psychostimulant medication and the 27 children and adolescents in the control group. In contrast, ADHD patients with a history of psychostimulant medication treatment had brain iron levels comparable to controls, suggesting that brain iron may increase to normal levels with psychostimulant treatment.

"Our research suggests that iron absorption into the brain may be abnormal in ADHD given that atypical brain iron levels are found even when blood iron levels in the body are normal," Dr. Adisetiyo said. "We found no differences in blood iron measures between controls, medication-naïve ADHD patients or pscyhostimulant-medicated ADHD patients."

Magnetic field correlation imaging's ability to noninvasively detect the low iron levels may help improve ADHD diagnosis and guide optimal treatment. Currently, ADHD diagnosis is based only on subjective clinical interviews and questionnaires. Having a biological biomarker may help inform clinical diagnosis, particularly in borderline cases, Dr. Adisetiyo noted.

If the results can be replicated in larger studies, magnetic field correlation might have a future role in determining which patients would benefit from psychostimulants -- an important consideration because the drugs can become addictive if taken inappropriately and lead to abuse of other drugs like cocaine.

"We want the public to know that progress is being made in identifying potential noninvasive biological biomarkers of ADHD which may help to prevent misdiagnosis," Dr. Adisetiyo said. "We are currently testing our findings in a larger cohort to confirm that measuring brain iron levels in ADHD is indeed a reliable and clinically feasible biomarker."

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Study: Brain scans show difference between those who have recovered from ADHD and those who have not

Very interesting news about ADD!! We have observed that half of kids grow out it.- JR

A study looked into brain scans from adults who recovered from ADHD versus those who have not recovered from ADHD and noted differences in the brain scan results.

About 11 percent of school-age children in the United States have been diagnosed with attention deficit hyperactivity disorder (ADHD). While many of these children eventually "outgrow" the disorder, some carry their difficulties into adulthood: About 10 million American adults are currently diagnosed with ADHD.

In the first study to compare patterns of brain activity in adults who recovered from childhood ADHD and those who did not, MIT neuroscientists have discovered key differences in a brain communication network that is active when the brain is at wakeful rest and not focused on a particular task. The findings offer evidence of a biological basis for adult ADHD and should help to validate the criteria used to diagnose the disorder, according to the researchers.

Diagnoses of adult ADHD have risen dramatically in the past several years, with symptoms similar to those of childhood ADHD: a general inability to focus, reflected in difficulty completing tasks, listening to instructions, or remembering details.

"The psychiatric guidelines for whether a person's ADHD is persistent or remitted are based on lots of clinical studies and impressions. This new study suggests that there is a real biological boundary between those two sets of patients," says MIT's John Gabrieli, the Grover M. Hermann Professor of Health Sciences and Technology, professor of brain and cognitive sciences, and an author of the study, which appears in the June 10 issue of the journal Brain.

Shifting brain patterns

This study focused on 35 adults who were diagnosed with ADHD as children; 13 of them still have the disorder, while the rest have recovered. "This sample really gave us a unique opportunity to ask questions about whether or not the brain basis of ADHD is similar in the remitted-ADHD and persistent-ADHD cohorts," says Aaron Mattfeld, a postdoc at MIT's McGovern Institute for Brain Research and the paper's lead author.

The researchers used a technique called resting-state functional magnetic resonance imaging (fMRI) to study what the brain is doing when a person is not engaged in any particular activity. These patterns reveal which parts of the brain communicate with each other during this type of wakeful rest.

"It's a different way of using functional brain imaging to investigate brain networks," says Susan Whitfield-Gabrieli, a research scientist at the McGovern Institute and the senior author of the paper. "Here we have subjects just lying in the scanner. This method reveals the intrinsic functional architecture of the human brain without invoking any specific task."

In people without ADHD, when the mind is unfocused, there is a distinctive synchrony of activity in brain regions known as the default mode network. Previous studies have shown that in children and adults with ADHD, two major hubs of this network -- the posterior cingulate cortex and the medial prefrontal cortex -- no longer synchronize.

In the new study, the MIT team showed for the first time that in adults who had been diagnosed with ADHD as children but no longer have it, this normal synchrony pattern is restored. "Their brains now look like those of people who never had ADHD," Mattfeld says.

"This finding is quite intriguing," says Francisco Xavier Castellanos, a professor of child and adolescent psychiatry at New York University who was not involved in the research. "If it can be confirmed, this pattern could become a target for potential modification to help patients learn to compensate for the disorder without changing their genetic makeup."

Lingering problems

However, in another measure of brain synchrony, the researchers found much more similarity between both groups of ADHD patients.

In people without ADHD, when the default mode network is active, another network, called the task positive network, is suppressed. When the brain is performing tasks that require focus, the task positive network takes over and suppresses the default mode network. If this reciprocal relationship degrades, the ability to focus declines.

Both groups of adult ADHD patients, including those who had recovered, showed patterns of simultaneous activation of both networks. This is thought to be a sign of impairment in executive function -- the management of cognitive tasks -- that is separate from ADHD, but occurs in about half of ADHD patients. All of the ADHD patients in this study performed poorly on tests of executive function. "Once you have executive function problems, they seem to hang in there," says Gabrieli, who is a member of the McGovern Institute.

The researchers now plan to investigate how ADHD medications influence the brain's default mode network, in hopes that this might allow them to predict which drugs will work best for individual patients. Currently, about 60 percent of patients respond well to the first drug they receive.

"It's unknown what's different about the other 40 percent or so who don't respond very much," Gabrieli says. "We're pretty excited about the possibility that some brain measurement would tell us which child or adult is most likely to benefit from a treatment."

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Brain abnormalities seen in late pre-term infants

A study looked into MRI scans of late pre-term infant and found that they have brain abnormalities.

Babies born 32 to 36 weeks into gestation may have smaller brains and other brain abnormalities that could lead to long-term developmental problems, according to a new study published online in the journal Radiology.

Much of the existing knowledge on preterm birth and brain development has been drawn from studies of individuals born very preterm, or less than 32 weeks into gestation at birth.

For the new study, researchers in Australia focused on moderate and late preterm (MLPT) babies -- those born between 32 weeks, zero days, and 36 weeks, six days, into gestation. MLPT babies account for approximately 80 percent of all preterm births and are responsible for much of the rise in the rates of preterm birth over the last 20 years. Despite this, to date there have been no large-scale studies published on brain alterations associated with MLPT birth that may provide insight into brain-behavior relationships in this group of children.

"In those very preterm babies, brain injury from bleeding into the brain or a lack of blood flow, oxygen or nutrition to the brain may explain some of the abnormal brain development that occurs," said the study's lead author, Jennifer M. Walsh,M.B.B.Ch., B.A.O., M.R.C.P.I., from the Royal Women's Hospital in Melbourne, Australia. "However, in some preterm babies, there may be no obvious explanation for why their brain development appears slow compared with babies born on time."

To learn more, the researchers performed magnetic resonance imaging (MRI) exams on 199 MLPT and 50 term-born infants (greater than 37 weeks gestation) between 38 to 44 weeks of gestation. They looked for signs of brain injury and compared the size and maturation of multiple brain structures in the two groups.

While injury rates were similar between the two groups, MLPT birth was associated with smaller brain size at term-equivalent age. In addition, MLPT infants had less developed myelination in one part of the brain and more immature gyral folding compared with term-born controls. Myelination -- the formation of a fatty insulating sheath around some nerve fibers -- and gyral folding -- the folding of the cerebral cortex to increase the brain's surface area -- are important processes in early brain development.

The findings suggest that MLPT birth may disrupt the expected trajectory of brain growth that would normally occur in the last two or so months in utero, according to Dr. Walsh.

"Given that brain growth is very rapid in the last one-third of pregnancy, it is perhaps not surprising that being born during this potentially vulnerable period may disrupt brain development," she said. "Brain growth is very complex, involving not only the neurons with which we think and do things, but also the other brain cells that support the neurons and are vital for normal brain function."

The researchers are hoping to learn in greater depth the impact that moderate to late preterm birth has on the brain, so that they can then begin to try different treatments designed to improve brain function and long-term outcome in these infants.

"Medications, along with early intervention to help parents understand their baby's needs, have been effective in helping very preterm babies catch up to their term-born peers," Dr. Walsh said. "However, whether any of the existing treatments will help babies born between 32 and 36 weeks is unknown, as they have not been studied very much at all."

The researchers plan to follow the infants in the study group through childhood to learn more about the relationship between brain abnormalities and later outcomes. They also are assessing additional MRI information about brain structure and function in these children.

"Understanding what problems they have and what might be causing them is the first step in trying to improve their long-term outcome," Dr. Walsh said.

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Children with ADHD show specific MRI Patterns

Children with ADHD show specific MRI patterns indicating that ADHD may be diagnosable though MRI scans.

A new study has found that children and adolescents with attention deficit hyperactivity disorder (ADHD) have disrupted connections between different areas of the brain that are evident on resting-state functional magnetic resonance imaging (rfMRI). The results of this research are published online in the journal Radiology.

The findings point to the potential of rfMRI to help provide objectively accurate, early diagnosis of a disorder that affects approximately 5 percent of children and adolescents worldwide.

ADHD is a disorder characterized by age-inappropriate degrees of inattention, hyperactivity and impulsivity. Functional MRI studies, which measure brain activity when a person is focused on a particular task, have implicated the brain's frontostriatal circuit, a collection of neural pathways in the frontal lobe of the brain that helps control behavior. However, the specific brain physiology underlying ADHD remains poorly understood.

For the new study, researchers used rfMRI, a relatively new technique that assesses neural function when the brain is not focused on a specific task. The technique is useful for exploring the brain's functional organization independent of task performance.

The researchers compared rfMRI results in 33 boys with ADHD, ages 6 to 16, with those of 32 similarly aged, healthy controls. They correlated the MRI findings with results from tests of executive function, a term for the set of mental processes involved in planning, organizing, time management and regulating emotions, among other things. People with ADHD often have abnormal executive function.

The results showed that the patients with ADHD had altered structure and function located in areas of the brain like the orbitofrontal cortex, which is primarily involved in the cognitive processing of strategic planning, and the globus pallidus, which is involved in executive inhibitory control.

"Our study suggests that the structural and functional abnormalities in these brain regions might cause the inattention and hyperactivity of the patients with ADHD, and we are doing further analysis on their correlation with the clinical symptoms," said Qiyong Gong, M.D., Ph.D., a neuroradiologist from the Department of Radiology at West China Hospital of Sichuan University in Sichuan, China. "Our preliminary results show the association between imaging findings and symptoms."

The researchers also found abnormalities in the connections between resting-state brain networks associated with executive dysfunction. These abnormalities indicate more widespread brain alterations in ADHD than previously had been shown, Dr. Gong said.

Exploration of the association between brain activity and executive function might be useful in better characterizing patients with ADHD and in understanding the pathophysiology underlying the condition, according to Dr. Gong.

"Our results suggest the potential clinical utility of the rfMRI changes as a useful marker, which may help in diagnosis and in monitoring disease progression and, consequently, may inform timely clinical intervention in the future," he said.

Dr. Gong indicated that larger studies are needed to validate the results. The researchers also plan to study changes in connectivity over time in ADHD patients and explore the potential differences of functional connectivity between the clinical subtypes of ADHD, such as inattentiveness and hyperactivity.

The ADHD study is part of a larger project from Dr. Gong's group at Huaxi MR Research Center of the West China Hospital to explore MRI's diagnostic and prognostic potential in psychiatric disorders.

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$1 billion spent on brain scans each year for headache sufferers

A study shows that $1 billion is spent each year on brain scans for those who suffer from headaches when most of the scans may be unnecessary.

One in eight visits to a a doctor for a headache or migraine end up with the patient going for a brain scan, at a total cost of about $1 billion a year, a new study finds. 

And many of those MRI and CT scans -- and costs -- are probably unnecessary, given the very low odds that serious issues lurk in the patients' brains.

In fact, several national guidelines for doctors specifically discourage scanning the brains of patients who complain of headache and migraine. But the new study shows the rate of brain scans for headache has risen, not fallen, since guidelines for doctors came out. This may mean that patient demand for scans drives much of the cost.

The researchers suggest that better education of the public, and insurance plan designs that ask patients to pay part of the cost based on the likely value of the scan for them, may be needed to reduce unnecessary use and spending.

The research, published in JAMA Internal Medicine by a team from the U-M Department of Neurology, uses national data on headache-related doctor visits and neuroimaging scans by people over age 18, and calculates estimated total costs across multiple years.

In all, 51.1 million headache-related patient visits occurred between 2007 and 2010 -- nearly half of them related to migraine. The vast majority were by people under the age of 65, and more than three-quarters of the patients were women. In those same four years, 12.4 percent of these visits resulted in a brain MRI or CT.

The researchers estimated the total cost of the four years' worth of scans at $3.9 billion, based on typical Medicare payments to doctors for imaging.

"This is a conservative cost estimate based on what Medicare would pay for these tests. CTs and MRIs are commonly ordered for headache and migraine, and increasing over time, despite the fact that there are rare circumstances where imaging should be used," says Brian Callaghan, M.D., M.S., the U-M neurologist who led the team performing the study.

"Lots of guidelines say we shouldn't do this -- including ones from neurology and radiology groups -- but yet we still do it a lot. This is a source of tremendous cost in health care without a lot of evidence to justify the cost," he notes.

A billion dollars' worth of reassurance?

Doctors might order a CT or MRI scan for a headache or migraine to put patients' minds at ease about fears that a malignant brain tumor, aneurysm, arteriovenous malformation or other issue might be causing their symptoms.

And even if the patient doesn't meet the conditions that guidelines say can benefit most from brain imaging -- for instance, someone with an abnormal neurological exam or a known cancer -- doctors might order a scan at a patient's request to protect themselves legally.

But past research shows that only 1 percent to 3 percent of scans of patients with repeated headaches find that a growth or blood vessel problem in the brain is to blame. And many of the issues that scans spot turn out not to pose a serious threat -- or may not require treatment right away.

"There's solid research showing that the number of times you find serious issues on these scans in headache patients is about the same as that for a randomly chosen group of non-headache patients," he says. "And a lot of the things we find on such scans aren't necessarily something we will do something about."

Callaghan notes that the current study, based on data from the Centers for Disease Control & Prevention's National Ambulatory Care Medical Survey, couldn't detect which scans met guidelines and which didn't.

But the fact that 14.7 percent of people who saw a doctor for headache or migraine in 2010 went on to have a brain scan would not be expected if guidelines were being followed, he says. The team is working on further research into the appropriateness of the scans ordered for patients.

He also notes that the $1 billion a year estimate doesn't include other costs, including follow-up tests and any treatment that might be ordered if a scan finds something. And, CT imaging comes with a radiation exposure that itself carries risks, while MRI scans are more costly and have a higher chance of finding things that turn out to be of no concern.

"But doctors typically don't consider costs, and patients usually aren't paying directly for these scans," he notes. "Insurers may require prior authorizations but still cover the scans if they are ordered." In fact, he and his colleagues last year published a study showing that the cost of medical imaging ordered by neurologists cost more than the cost of all visits to neurologists added together.

The bottom line for headache patients who think they might want to have a brain scan, says Callaghan: if the doctor treating your headache doesn't think you need a scan, don't push them.

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Head impacts lead to lower test scores

A new study shows that non-concussion head impacts can result in lower test scores and brain changes over time.

Repeated blows to the head during a season of contact sports may cause changes in the brain's white matter and affect cognitive abilities even if none of the impacts resulted in a concussion, according to a study published today in the journalNeurology.

Using a form of magnetic resonance imaging, or MRI, researchers at the Indiana University School of Medicine and the Geisel School of Medicine at Dartmouth College found significant differences in brain white matter of varsity football and hockey players compared with a group of noncontact-sport athletes following one season of competition. White matter is composed primarily of axons, the long fibers that transmit signals between neurons.

"The contact sports and noncontact-sports groups differed, and the number of times the contact sports participants were hit, and the magnitude of the hits they sustained, were correlated with changes in the white matter measures," said Thomas W. McAllister, M.D., chair of the IU Department of Psychiatry.

"In addition, there was a group of contact sports athletes who didn't do as well as predicted on tests of learning and memory at the end of the season, and we found that the amount of change in the white matter measures was greater in this group," Dr. McAllister said.

The study was conducted while Dr. McAllister was Millennium Professor of Psychiatry at Dartmouth.

"This study raises the question of whether we should look not only at concussions but also the number of times athletes receive blows to the head and the magnitude of those blows, whether or not they are diagnosed with a concussion," Dr. McAllister said.

Two groups of Dartmouth athletes were studied: 80 football and ice hockey players in the contact sports group, and 79 athletes drawn from such noncontact sports as track, crew and Nordic skiing. The football and hockey players wore helmets equipped with accelerometers, which enabled the researchers to compile the number and severity of impacts to their heads. Players who sustained a concussion during the season were not included in the analysis.

The athletes were administered a form of MRI test known as diffusion tensor imaging, which is used to measure the integrity of the white matter. They were also given the California Verbal Learning Test II, a measure of verbal learning and memory.

The study did not find "large-scale, systematic differences" in the brain scan measures at the end of the season, which the authors found "somewhat reassuring" and consistent with the fact that thousands of individuals have played contact sports for many years without developing progressive neurodegenerative disorders.

However, the results do suggest that some athletes may be more susceptible to repeated head impacts that do not involve concussions, although much more research would be necessary to determine how to identify those athletes.

More work would also be necessary to determine whether the effects of the head impacts are long-lasting or permanent, and whether they are cumulative.

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Brain scans can determine which letter a person is reading

fMRI brain scans can be used to determine which letter a person regarding. This technology may be the first step to determining what a person is thinking.

By analysing MRI images of the brain with an elegant mathematical model, it is possible to reconstruct thoughts more accurately than ever before. In this way, researchers from Radboud University Nijmegen have succeeded in determining which letter a test subject was looking at.

The journal Neuroimage has accepted the article, which will be published soon.

Functional MRI scanners have been used in cognition research primarily to determine which brain areas are active while test subjects perform a specific task. The question is simple: is a particular brain region on or off? A research group at the Donders Institute for Brain, Cognition and Behaviour at Radboud University has gone a step further: they have used data from the scanner to determine what a test subject is looking at.

The researchers 'taught' a model how small volumes of 2x2x2 mm from the brain scans -- known as voxels -- respond to individual pixels. By combining all the information about the pixels from the voxels, it became possible to reconstruct the image viewed by the subject. The result was not a clear image, but a somewhat fuzzy speckle pattern. In this study, the researchers used hand-written letters.

Prior knowledge improves model performance

'After this we did something new', says lead researcher Marcel van Gerven. 'We gave the model prior knowledge: we taught it what letters look like. This improved the recognition of the letters enormously. The model compares the letters to determine which one corresponds most exactly with the speckle image, and then pushes the results of the image towards that letter. The result was the actual letter, a true reconstruction.'

'Our approach is similar to how we believe the brain itself combines prior knowledge with sensory information. For example, you can recognise the lines and curves in this article as letters only after you have learned to read. And this is exactly what we are looking for: models that show what is happening in the brain in a realistic fashion. We hope to improve the models to such an extent that we can also apply them to the working memory or to subjective experiences such as dreams or visualisations. Reconstructions indicate whether the model you have created approaches reality.'

Improved resolution; more possibilities

'In our further research we will be working with a more powerful MRI scanner,' explains Sanne Schoenmakers, who is working on a thesis about decoding thoughts. 'Due to the higher resolution of the scanner, we hope to be able to link the model to more detailed images. We are currently linking images of letters to 1200 voxels in the brain; with the more powerful scanner we will link images of faces to 15,000 voxels.'

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Trouble concentrating in people with insomnia

A study using brain scans helps to explain why people with insomnia have 'wandering minds' and trouble concentrating.

A new brain imaging study may help explain why people with insomnia often complain that they struggle to concentrate during the day even when objective evidence of a cognitive problem is lacking.

"We found that insomnia subjects did not properly turn on brain regions critical to a working memory task and did not turn off 'mind-wandering' brain regions irrelevant to the task," said lead author Sean P.A. Drummond, PhD, associate professor in the department of psychiatry at the University of California, San Diego, and the VA San Diego Healthcare System, and Secretary/Treasurer of the Sleep Research Society. "Based on these results, it is not surprising that someone with insomnia would feel like they are working harder to do the same job as a healthy sleeper."

The research team led by Drummond and co-principal investigator Matthew Walker, PhD, studied 25 people with primary insomnia and 25 good sleepers. Participants had an average age of 32 years. The study subjects underwent a functional magnetic resonance imaging scan while performing a working memory task.

Results published in the September issue of the journal Sleepshow that participants with insomnia did not differ from good sleepers in objective cognitive performance on the working memory task. However, the MRI scans revealed that people with insomnia could not modulate activity in brain regions typically used to perform the task.

As the task got harder, good sleepers used more resources within the working memory network of the brain, especially the dorsolateral prefrontal cortex. Insomnia subjects, however, were unable to recruit more resources in these brain regions. Furthermore, as the task got harder, participants with insomnia did not dial down the "default mode" regions of the brain that are normally only active when our minds are wandering.

"The data help us understand that people with insomnia not only have trouble sleeping at night, but their brains are not functioning as efficiently during the day," said Drummond. "Some aspects of insomnia are as much of a daytime problem as a nighttime problem. These daytime problems are associated with organic, measurable abnormalities of brain activity, giving us a biological marker for treatment success."

According to the authors, the study is the largest to examine cerebral activation with functional MRI during cognitive performance in people with primary insomnia, relative to well-matched good sleepers. It also is the first to characterize functional MRI differences in working memory in people with primary insomnia.

The American Academy of Sleep Medicine reports that about 10 to 15 percent of adults have an insomnia disorder with distress or daytime impairment. Most often insomnia is a comorbid disorder occurring with another problem such as depression or chronic pain, or caused by a medication or substance. Fewer people suffering from insomnia are considered to have primary insomnia, which is defined as a difficulty falling asleep or maintaining sleep in the absence of a coexisting condition.

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Brain structure may be changed by migraines

A recent study shows that migraine headaches may permanently change the brain's structure.

Migraine may have long-lasting effects on the brain's structure, according to a study published in the August 28, 2013, online issue ofNeurology®, the medical journal of the American Academy of Neurology.

"Traditionally, migraine has been considered a benign disorder without long-term consequences for the brain," said study author Messoud Ashina, MD, PhD, with the University of Copenhagen in Denmark. "Our review and meta-analysis study suggests that the disorder may permanently alter brain structure in multiple ways."

The study found that migraine raised the risk of brain lesions, white matter abnormalities and altered brain volume compared to people without the disorder. The association was even stronger in those with migraine with aura.

For the meta-analysis, researchers reviewed six population-based studies and 13 clinic-based studies to see whether people who experienced migraine or migraine with aura had an increased risk of brain lesions, silent abnormalities or brain volume changes on MRI brain scans compared to those without the conditions.

The results showed that migraine with aura increased the risk of white matter brain lesions by 68 percent and migraine with no aura increased the risk by 34 percent, compared to those without migraine. The risk for infarct-like abnormalities increased by 44 percent for those with migraine with aura compared to those without aura. Brain volume changes were more common in people with migraine and migraine with aura than those with no migraines.

"Migraine affects about 10 to 15 percent of the general population and can cause a substantial personal, occupational and social burden," said Ashina. "We hope that through more study, we can clarify the association of brain structure changes to attack frequency and length of the disease. We also want to find out how these lesions may influence brain function."

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Concussion recovery requires the brain to compensate

A study claims that increased brain activity a few weeks after a concussion shows that the brain compensated to help recover.

Concussion patients have irregular brain activity within the first 24 hours after their injury but increased levels of brain activity a few weeks later, which suggests that the brain may compensate for the injury during recovery, a new study reports.

Researchers used functional MRI to study the recovery of 12 high school football players with concussion and compared them to 12 uninjured teammates. The concussed players underwent brain scans at 13 hours and again seven weeks after their head injury, and the uninjured players had brain scans at the same time.

At 13 hours, the concussed athletes had typical symptoms such as decreased reaction time and reduced mental abilities. Their brain scans revealed decreased activity in certain areas of the right hemisphere of the brain. This suggests that their reduced mental abilities may be related to underactivation of attentional brain circuits, according to the researchers.

At seven weeks, the concussed players showed improvement in their mental abilities and normal reaction time. Brain scans at that time revealed that the concussed athletes had more activation in the brain's attentional circuits than the uninjured players.

"This hyperactivation may represent a compensatory brain response that mediates recovery," study lead author Thomas Hammeke, a professor of psychiatry and behavioral medicine at the Medical College of Wisconsin, said in a college news release. "This is the first study to demonstrate that reversal in activation patterns, and that reversal matches the progression of symptoms from the time of the injury through clinical recovery."

The study appears in the September issue of the Journal of the International Neuropsychological Society.

"Deciding when a concussed player should return to the playing field is currently an inexact science," study senior author Dr. Stephen Rao, director of the Schey Center for Cognitive Neuroimaging at the Cleveland Clinic, said in the news release. "Measuring changes in brain activity during the acute recovery period can provide a scientific basis for making this critical decision."

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ALERT for anyone touched by epilepsy, neurologic illness. New Proposed Cuts in EEG, MRI Reimbursement Will Imperil Epilepsy Care

If you value private practice neurology, its ease of access, personal quality and its financial savings, contact congress today! 

If you have family or friends working in private practice or a business that depends on private practice, contact congress and CMS.

If you are a Tricare beneficiary, consider the effects of this rule.

Dont forget...Commercial Insurance is tied to Medicare.


 The overall plan is clear.  CMS is attacking outpatient practitioners to force them into big  hospital managed care.  

The government will cut costs by limiting access.

Think about how reduced access will affect people with limited ability to drive. 

Think about how decreased access will affect health care shortage areas.

Hospitals charge 5-9 times Medicare. Will it save you money? Absolutely not. You have less access and higher charges.

JR

Full article here

Federal register with link to comments here

Wednesday, August 07, 2013

New Proposed Cuts in EEG Reimbursement Imperil Epilepsy Care

BY ORLY AVITZUR, MD

 

Right on the heels of devastating nerve conduction study (NCS) cuts which crippled many neurology practices this year, the Centers for Medicare and Medicaid Services (CMS) has now released a proposed rule that would substantially reduce payments for electroencephalography (EEG) performed in the office. The proposed Medicare Physician Fee Schedule for 2014, announced on July 8 — http://go.cms.gov/12TOqIS — listed 200 services — including eight EEG codes — that would be affected by a cap to reduce non-facility practice expense values so that payment does not exceed the hospital outpatient payment rate, which uses the ambulatory payment classification system. The measure cuts physician office payment by about 50 percent for physicians who bill globally in the office — both technical and professional components.

THE FIGURES LOOK GRIM

One of the biggest drops in payment will be for the most common EEG code — CPT code 95819 for EEG awake and asleep. Using the current 2013 Medicare Fee Schedule, this procedure pays $421.34 for the technical payment in an office billing globally compared with the APC payment of $172.61 for provider-based billing that is used by hospitals. The payment for the physician's interpretation is the same regardless of which way the technical payment is billed: $56.14. 

“For most physician practices, not just neurologists, the technical payments for procedures have historically been adequate and served as the profit centers for the practice, underwriting the payments for patient care, which are break-even at best but are typically the loss leader in the business of running a medical office,” said Gregory L. Barkley, MD, clinical vice chair in the department of neurology at Henry Ford Hospital in Detroit. The proposed drop in payment will put a substantial dent in the economics of running a neurology practice, he added.

Moreover, the EEG test is not always predictable. “The current rates cover a two-hour test that could easily stretch to three hours given that patients are often disabled, have seizures during the test, are sometimes uncooperative due to their altered mental status, and may need sedation or time to fall asleep in the middle of the day,” said Marc R. Nuwer, MD, PhD, department head of clinical neurophysiology at the Ronald Reagan University of California, Los Angeles Medical Center and former chair of the AAN Medical Economics and Management (MEM) Committee.

“Reimbursement to provide the EEG test now will be less than it was in the year 2000," he continued, “yet, the costs for the technologist, equipment, and supplies continue to rise with inflation, as do the costs of office rent, staff, and other expenses of keeping the doors open.”

“If the practice has bought an EEG machine, those costs are still there, as is the office overhead. If a part-time tech is brought in, can the margin be sufficient to keep the trained tech?” Dr. Barkley asked.  He said the proposed rule raises these questions, as well:  Can the EEG machine be sold and the EEGs be performed at the hospital with the physician still getting the professional payment without the technical expenses?  If this path is taken, how does this affect the office overhead for everything else in the practice? This might trigger a move to a smaller, less expensive office. Alternatively, is there some other revenue stream that can be generated to replace this lost revenue? 

“These are the decisions that any small business makes when the paradigm shifts. For some neurologists, this may be the last straw that triggers a decision to sell the practice and become an employed physician or even to retire,” he said.

CMS is accepting comments until Sept. 6 and will publish the final rule by Nov.1, which will go into effect on Jan. 1, 2014. In the meantime, the AAN has been refining its response, enlisting the help of its members, consultants, other professional societies, and consumer groups.

“The AAN has retained a powerful Washington, DC-based consulting group to help us take the most effective action,” said AAN President Timothy A. Pedley, MD, former chair of the department of neurology at Columbia University Medical Center. “We also immediately reached out to partner societies and patient groups to develop a united response to this proposal.”

Dr. Pedley noted that private practice neurologists are still reeling from the recent EMG/NCS cuts, adding that AAN members should start preparing for these potential EEG cuts. “They may decide they can no longer perform the tests in their office,” he said, emphasizing, “There is little margin left for those in neurology private practices.” 

See the Sept. 5 issue of Neurology Today for more in-depth coverage on the proposed EEG cuts. For more on the issue of reimbursement cuts, seehttp://bit.ly/1bbOsyh andhttps://www.aan.com/public-policy.

Junk food cravings could be due to sleep deprivation

A study claims that sleep deprivation makes a person more likely to crave junk food which could explain the link between sleep deprivation and obesity.

A sleepless night makes us more likely to reach for doughnuts or pizza than for whole grains and leafy green vegetables, suggests a new study from UC Berkeley that examines the brain regions that control food choices. The findings shed new light on the link between poor sleep and obesity

Using functional magnetic resonance imaging (fMRI), UC Berkeley researchers scanned the brains of 23 healthy young adults, first after a normal night's sleep and next, after a sleepless night. They found impaired activity in the sleep-deprived brain's frontal lobe, which governs complex decision-making, but increased activity in deeper brain centers that respond to rewards. Moreover, the participants favored unhealthy snack and junk foods when they were sleep deprived.

"What we have discovered is that high-level brain regions required for complex judgments and decisions become blunted by a lack of sleep, while more primal brain structures that control motivation and desire are amplified," said Matthew Walker, a UC Berkeley professor of psychology and neuroscience and senior author of the study published Aug. 6 in the journal Nature Communications.

Moreover, he added, "high-calorie foods also became significantly more desirable when participants were sleep-deprived. This combination of altered brain activity and decision-making may help explain why people who sleep less also tend to be overweight or obese."

Previous studies have linked poor sleep to greater appetites, particularly for sweet and salty foods, but the latest findings provide a specific brain mechanism explaining why food choices change for the worse following a sleepless night, Walker said.

"These results shed light on how the brain becomes impaired by sleep deprivation, leading to the selection of more unhealthy foods and, ultimately, higher rates of obesity," said Stephanie Greer, a doctoral student in Walker's Sleep and Neuroimaging Laboratory and lead author of the paper. Another co-author of the study is Andrea Goldstein, also a doctoral student in Walker's lab.

In this newest study, researchers measured brain activity as participants viewed a series of 80 food images that ranged from high-to low-calorie and healthy and unhealthy, and rated their desire for each of the items. As an incentive, they were given the food they most craved after the MRI scan.

Food choices presented in the experiment ranged from fruits and vegetables, such as strawberries, apples and carrots, to high-calorie burgers, pizza and doughnuts. The latter are examples of the more popular choices following a sleepless night.

On a positive note, Walker said, the findings indicate that "getting enough sleep is one factor that can help promote weight control by priming the brain mechanisms governing appropriate food choices."

Read more here

Causes of headaches in children

This article discusses the many possible causes of headaches in children ranging from normal to serious causes.

Children’s headaches can be related to ailments, from allergies to ear infections to sinus problems, and most of the time they don’t indicate a dangerous illness.

But for many parents, the shadow of a terrible diagnosis lurks in the corner of the darkened room where a headachy child is lying with a cool cloth on her brow.

Sometimes, children with headaches need neuroimaging — brain CTs or MRIs. But recently several large studies have raised concerns about CT scans done on children because the radiation from these scans can increase the risk of eventually developing cancer, though that overall risk is still very small.

Doctors are being asked to follow guidelines for judicious use of these scans, but many parents remain unaware of the risks and guidelines. A study in the journal Pediatrics looked at a huge group of children who each saw a doctor at least twice with headaches but had no injury or trauma. More than 25 percent of those children got CT scans, the researchers found.

Children who brought their aching heads into emergency rooms were more likely to get scans than children visiting their regular doctors or neurology clinics.

“However, even outside the emergency room, the use of CT scans was quite high,” said Andrea DeVries, a director of research at HealthCore, a subsidiary of the insurer WellPoint, and the lead author of the study. About two-thirds of the children who received CT scans did not visit an emergency room, she noted.

Who does need neuroimaging? Doctors worry about a severe headache that gets worse, and about any abnormalities on the physical exam or changes that suggest a pathology in the brain. These changes can range from disturbances in gait or eye movements to confusion and lethargy.

Though nausea and vomiting commonly go along with migraines, vomiting can also indicate increased pressure in the brain. It can be a danger sign in a child who has recently had a concussion.

Symptoms like these quickly push a headache into the realm of a neurological emergency. Headaches that wake children from sleep or occur on just one side also may be cause for concern.

For children whose headaches don’t fit a clear migraine pattern, an eye exam is an important diagnostic step, said Dr. Andrew Lee, a neuro-ophthalmologist at the Methodist Hospital in Houston. An exam is also critical if parents have noticed any crossing of the eyes.

In serious situations, the eye exam may reveal signs of increased pressure in the brain. On a more mundane level, an exam may find that a child’s headache is caused by eye strain.

“The mother and father might not notice till reading age, third grade or fourth grade,” Lee said. Headaches that come on at that age, and are made worse by homework or reading, can be treated with glasses to correct poor vision and exercises to strengthen the eye movements.

And then there’s concussion. A 2012 study that looked at children who had head trauma found that three months after their injuries, many reported headaches. Most of the time, these children improve, but some will have headaches for months, and a very small percentage may have them for more than a year.

Heidi Blume, a pediatric neurologist at Seattle Children’s Hospital and lead author of the study, invoked a “SMART” mnemonic for helping children deal with their recurrent headaches. S is for sleep, she said, and getting enough of it. M is for not skipping meals and drinking enough to be properly hydrated. A is for physical activity, because too much or too little can lead to headaches, and R is for relaxation. T is for triggers to avoid, like cigarette smoke or particular foods.

Children can take painkillers (acetaminophen, ibuprofen and others; children should not take aspirin). Those with migraines may also benefit from preventive medicines. Counseling and biofeedback are important: Headaches can be triggered by stress, and living with chronic pain can cause depression. One goal in headache clinics is getting children back to school and helping them navigate regular activities while still avoiding their triggers.

“Many, many kids will outgrow their bad headaches,” said Dr. Daniel Bonthius, professor of pediatrics and neurology at the University of Iowa. “Exactly why they got the headaches and exactly why they go away, modern medicine doesn’t really understand.”

Read more here

Study: Brain Abnormalities in Migraine Patients

Brain abnormalities are present in people who have migraines. Some are present at birth while others progress over time.

A new study suggests that migraines are related to brain abnormalities present at birth and others that develop over time.

The research is published online in the journal Radiology.

Migraines are intense, throbbing headaches, sometimes accompanied by nausea, vomiting and sensitivity to light. Some patients experience auras, a change in visual or sensory function that precedes or occurs during the migraine. More than 300 million people suffer from migraines worldwide, according to the World Health Organization.

Previous research on migraine patients has shown atrophy of cortical regions in the brain related to pain processing, possibly due to chronic stimulation of those areas. Cortical refers to the cortex, or outer layer of the brain.

Much of that research has relied on voxel-based morphometry, which provides estimates of the brain's cortical volume. In the new study, Italian researchers used a different approach: a surface-based MRI method to measure cortical thickness.

"For the first time, we assessed cortical thickness and surface area abnormalities in patients with migraine, which are two components of cortical volume that provide different and complementary pieces of information," said Massimo Filippi, M.D., director of the Neuroimaging Research Unit at the University Ospedale San Raffaele and professor of neurology at the University Vita-Salute's San Raffaele Scientific Institute in Milan. "Indeed, cortical surface area increases dramatically during late fetal development as a consequence of cortical folding, while cortical thickness changes dynamically throughout the entire life span as a consequence of development and disease."

Dr. Filippi and colleagues used magnetic resonance imaging (MRI) to acquire T2-weighted and 3-D T1-weighted brain images from 63 migraine patients and 18 healthy controls. Using special software and statistical analysis, they estimated cortical thickness and surface area and correlated it with the patients' clinical and radiologic characteristics.

Compared to controls, migraine patients showed reduced cortical thickness and surface area in regions related to pain processing. There was only minimal anatomical overlap of cortical thickness and cortical surface area abnormalities, with cortical surface area abnormalities being more pronounced and distributed than cortical thickness abnormalities. The presence of aura and white matter hyperintensities -- areas of high intensity on MRI that appear to be more common in people with migraine -- was related to the regional distribution of cortical thickness and surface area abnormalities, but not to disease duration and attack frequency.

"The most important finding of our study was that cortical abnormalities that occur in patients with migraine are a result of the balance between an intrinsic predisposition, as suggested by cortical surface area modification, and disease-related processes, as indicated by cortical thickness abnormalities," Dr. Filippi said. "Accurate measurements of cortical abnormalities could help characterize migraine patients better and improve understanding of the pathophysiological processes underlying the condition."

Additional research is needed to fully understand the meaning of cortical abnormalities in the pain processing areas of migraine patients, according to Dr. Filippi.

"Whether the abnormalities are a consequence of the repetition of migraine attacks or represent an anatomical signature that predisposes to the development of the disease is still debated," he said. "In my opinion, they might contribute to make migraine patients more susceptible to pain and to an abnormal processing of painful conditions and stimuli."

The researchers are conducting a longitudinal study of the patient group to see if their cortical abnormalities are stable or tend to worsen over the course of the disease. They are also studying the effects of treatments on the observed modifications of cortical folding and looking at pediatric patients with migraine to assess whether the abnormalities represent a biomarker of the disease.

Read more here

Differences in brains of people with migraines

A new study shows there are differences in the brains of people who have migraine headaches and the brains of people who do not.

People who suffer migraines may have certain structural differences in pain-related areas of the brain, a new study suggests.

Using MRI scans, researchers found that in specific brain regions related to pain processing, migraine sufferers showed a thinner and smaller cortex compared to headache-free adults. The cortex refers to the outer layer of the brain.

It's not clear what it all means. But the researchers suspect that certain aspects of brain development may make some people more vulnerable to developing migraines -- and that migraine attacks create further changes in the brain.

The surface area of the brain "increases dramatically" during fetal development, while the thickness of the cortex changes throughout life, explained senior researcher Dr. Massimo Filippi.

"We speculate that migraine patients might have a sort of cortical 'signature' -- abnormal cortical surface area -- which could make them more susceptible to pain and abnormal processing of painful stimuli," said Filippi, a professor of neurology at the University Vita-Salute's San Raffaele Scientific Institute in Milan.

Once migraines develop, they may alter the thickness of the brain's cortex, Filippi explained.

A neurologist who was not involved in the study said it "adds to the growing body of knowledge that patients with migraine have brains that not only function differently, but may actually look different structurally as well."

That's important because it helps "legitimize" migraine as a neurological disorder associated with "real structural changes in the brain," said Dr. Matthew Robbins, of the Albert Einstein College of Medicine and Montefiore Headache Center, in New York City.

Worldwide, an estimated 11 percent of people have had a migraine in the past year. Migraines typically cause intense, throbbing pain on one side of the head, along with sensitivity to light and sound, and sometimes nausea and vomiting.

About 30 percent of people with recurrent migraines also have sensory disturbances right before their head pain hits. Those disturbances, known as "aura," are usually visual -- like seeing flashes of light or blind spots.

No one knows precisely what causes migraines, but they do seem to involve abnormal brain activity and -- like the new study suggests -- abnormal brain structure.

The findings, published online March 26 in Radiology, come from MRI scans of 63 adults with migraines, and 18 migraine-free men and women.

Filippi's team found that the migraine brain was complicated. In some areas, the cortex was thicker, but in others -- including pain-processing areas -- the cortex was thinner, versus migraine-free adults.

And there were also differences among migraine sufferers. The exact location of the cortex abnormalities tended to differ between the half of patients who had aura and the half who did not.

According to the researchers, those structural differences might help explain why the two forms of migraine manifest differently.

Filippi said it's important to understand the structural brain changes linked to migraines because that could give insight into the cause of people's pain and other symptoms.

But whether any of this will help in managing migraines remains to be seen. According to Filippi, it's possible that doctors could eventually monitor structural changes in the brain's cortex to gauge migraine patients' response to treatment, for example.

Robbins, of Montefiore Headache Center, said that right now, it's "very hard to say" whether that will happen.

He pointed out that the study participants had one MRI scan, so it's not known what happens later on. "It is unclear if these changes in the brain are dynamic -- meaning, do they change over time?" Robbins said.

Filippi said his team is now following these patients to see whether the structural patterns in their brains are "stable" or tend to shift. They are also doing a similar study of children with migraines.

Read more here