Faculty Bibliography

BACKGROUND:While the cognitive sequelae of traumatic brain injury (TBI) are well known, emotional impairments after TBI are suboptimally characterized. Lack of awareness of emotional difficulties can make self-report unreliable. However, individuals with TBI demonstrate involuntary changes in heart rate variability which may enable objective quantification of emotional dysfunction. METHODS:Sixteen subjects with chronic TBI and 10 age-matched controls were tested on an emotional function battery during which they watched a series of film clips normed to elicit specific positively and negatively valenced emotions: amusement, sexual amusement, sadness, fear and disgust. Subjective responses to the emotional stimuli were also obtained. Additionally, surface electrodes measured cardiac and respiratory signals to compute heart rate variability (HRV), from which measures of parasympathetic activity, the respiratory frequency area (RFA) and sympathetic activity, the low frequency area (LFA), of the HRV frequency spectrum were derived. The Neurobehavioral Rating Scale-Revised (NRS-R) and the King-Devick (KD) test were administered to assess neurobehavioral dysfunction. RESULTS:The two groups showed no differences in subjective ratings of emotional intensity. Subjects with TBI showed significantly decreased sympathetic activity when viewing amusing stimuli and significantly increased sympathetic activity when viewing sad stimuli compared to controls. Most of the subjects did not show agitation, anxiety, depression, blunted affect, emotional withdrawal, decreased motivation or mental fatiguability on the NRS-R. However, 13/16 subjects with TBI demonstrated attention difficulty on the NRS-R which was positively correlated with the increased sympathetic activity during sad stimuli. Both attention difficulty and abnormal autonomic responses to sad stimuli were correlated with the timing on the KD test, which reflected difficulty with visual attention shifting. CONCLUSIONS:The HRV spectrum may be useful to identify subclinical emotional dysfunction in individuals with TBI. Attention difficulites, specifically impairment in visual attention shifting, may contribute to abnormal reactivity to sad stimuli that may be detected and potentially treated to improve emotional function.

Introduction/Rational A 66 year old female with history of Fuchs' dystrophy presented to an outpatient traumatic brain injury (TBI) office visit one year after sustaining a concussion during a fall. Her complaints at the visit included fatigue, decreased attention, decreased workplace productivity and feeling overwhelmed with basic activities of daily living (ADL). Method/Approach The patient complained of persistent fatigue, neurocognitive deficits and neurological fatigue, at which time she was trialed on twice daily dosing of amantadine and instructed to follow up in the outpatient setting in one month. Shortly after initiating amantadine, the patient developed acute left eye blindness. She saw her ophthalmologist who instructed her that amantadine has been shown to aggravate Fuchs' dystrophy, causing corneal edema. Amantadine was discontinued and steroid eye drops were prescribed with rapid improvement in her vision upon cessation of the medication. Results/Effects The patient reported an overall improvement in her cognitive functioning and fatigue while taking amantadine. However, while amantadine has demonstrated positive outcomes in persistent executive functioning deficits following TBI, several case reports have reported acute visual loss and exacerbation of ocular symptoms in the setting of Fuchs' dystrophy. Fuchs' Dystrophy, also known as Fuchs' corneal endothelial dystrophy (FCED) is an autosomal dominant, slowly progressing degenerative disease leading to corneal edema and vision loss, eventually requiring corneal transplant. The mechanism of action by which amantadine causes corneal edema is currently unknown. Conclusions/Limitations Persistent deficits in higher executive functioning and workplace performance are common following concussion. However, although improvements in these domains are noted following initiation of neurostimulants such as amantadine, this case outlines the importance of weighing the risks and benefits of symptomatic management in TBI

Case Description: A 66-year-old woman with history of Fuchs' dystrophy presented to an outpatient traumatic brain injury (TBI) office visit one year after sustaining a concussion during a fall. Her complaints at the visit included fatigue, decreased attention, decreased workplace productivity and feeling overwhelmed with basic activities of daily living (ADL). Given her persistent deficits and symptoms, she was trialed on amantadine and instructed to follow up in one month. Setting: Outpatient office. Results or Clinical Course: The patient reported an overall improvement in her cognitive functioning and fatigue on twice daily dosing of amantadine. However, she developed acute left eye blindness, prompting a visit to her ophthalmologist, who instructed her that amantadine has been shown to aggravate Fuchs' dystrophy, causing corneal edema. Amantadine was discontinued and steroid eye drops were prescribed with rapid improvement in her vision upon cessation of the medication. Discussion: While amantadine has demonstrated positive outcomes in persistent executive functioning deficits following TBI, several case reports have reported acute visual loss and exacerbation of ocular symptoms in the setting of Fuchs' dystrophy. Fuchs' Dystrophy, also known as Fuchs' corneal endothelial dystrophy (FCED) is an autosomal dominant, slowly progressing degenerative disease leading to corneal edema and vision loss, eventually requiring corneal transplant. The mechanism of action by which amantadine causes corneal edema is currently unknown, though review of the literature suggests a causal relationship between the two and does not appear to be dose dependent. Conclusion: Persistent deficits in higher executive functioning and workplace performance are common following concussion. However, although improvements in these domains are noted following initiation of neurostimulants such as amantadine, this case outlines the importance of weighing the risks and benefits of symptomatic management in TBI

OBJECTIVE:: To examine the prevalence of self-reported head injury among treatment-seeking refugee survivors of torture, a population at high risk for such injuries. PARTICIPANTS:: A total of 488 survivors of torture accepted at a torture treatment clinic between January 1, 2008, and December 31, 2011. MAIN MEASURES:: Harvard Trauma Questionnaire, incidence of head injury and resulting loss of consciousness (LOC), chief physical complaints, general health scale, indicators of torture severity (length of detention, sexual assault, and number of different persecution types). RESULTS:: Of the 488 cases reviewed, 335 (69%) patients reported sustaining a blow to the head. Of the 335 with head injury, 185 (55%) reported LOC following the injury. Those who reported sustaining a head injury were significantly more likely to be men, to have a greater number of types of torture experiences, and report sleep disturbances and headaches as their primary medical complaints. CONCLUSIONS:: The high rates of head injury and head injury followed by LOC among treatment-seeking survivors of torture indicates the need for torture treatment centers to assess for possible brain injury. Our findings suggest that patients with possible traumatic brain injury (TBI) may be at a higher risk of negative physical outcomes than those without possible TBI.