Cases reported "Brain Injuries"

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1/68. Benign idiopathic partial epilepsy and brain lesion.

    A 14-year-old girl had severe head trauma from a dog bite at the age of 9 days. This resulted in extensive brain damage, tetraplegia, mental retardation, and epilepsy. The seizures were of rolandic type, and the EEG showed multifocal sharp waves. The course was benign. The initial diagnosis of a pure symptomatic epilepsy was revised after demonstrating typical benign focal sharp waves in the EEG of the healthy sister. Thus a phenocopy of a benign partial epilepsy by the brain lesion could be excluded with sufficient certainty. This observation allows the conclusion that the genetic disposition underlying the sharp-wave trait characteristic of benign partial epilepsies can be involved also in the pathogenesis of seemingly pure symptomatic epilepsies. EEG studies on siblings of such patients are needed to exclude possible phenocopies.
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2/68. Workers Compensation cases with traumatic brain injury: an insurance carrier's analysis of care, costs, and outcomes.

    The purpose of this survey was to review the medical care, medical costs, and outcomes of 86 Workers Compensation cases involving traumatic brain injury. An analysis of ICD-9 diagnoses, Rancho Los Amigos Cognitive Levels, age, sex, accident description, management techniques, costs, outcomes, and many other factors was conducted. The total indemnity (wage loss) and medical payments amounted to $27.1 million. For example, one case with temporal lobe hematoma, due to a fall in 1972, has had $1.1 million in medical payments since the injury occurred. The current average age is 40 years with 71% still residing at home. Only 10% are currently employed and 40% are known to be receiving other benefits. The increasing frequency and severity of these cases, as well as the extension of survival due to improved care and technology, highlight the need to address the question, "Who will be the caretakers, and what will be the associated costs?" Actuarial projections into the 21st century are given. It is concluded that, while further long-term studies are needed, Workers Compensation carrier representatives and health care providers must continue to work together on the interdisciplinary rehabilitation team.
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3/68. Assessment of command-following in minimally conscious brain injured patients.

    OBJECTIVE: To develop a method for establishing the presence of command-following in individuals with traumatic brain injury, based on the principles of single-subject experimental design. DESIGN: A series of single-subject experiments, individualized to the particular command-following question about a particular patient. SETTING: An inpatient rehabilitation hospital with a specialized program for vegetative and minimally conscious brain injured patients. patients: Eight individuals with serious brain injury of traumatic or nontraumatic origin, presenting in vegetative or minimally conscious states. INTERVENTIONS: The frequency of performance of the behavior in question was assessed in response to commands and in relation to appropriate control conditions. Data were analyzed with chi2 or Fisher's exact test, as well as measures derived from signal detection theory. MAIN OUTCOME MEASURES: The frequency of performance of a specific behavior in the presence of a command and in relevant contrasting conditions. RESULTS: This method identified whether a specific behavior was being performed in response to command and whether the reliability of this behavior was changing over time either spontaneously or in response to treatment. CONCLUSIONS: Quantitative assessment of command-following based on principles of single-subject experimental design can determine whether patients are capable of following commands and whether this ability changes over time or in response to treatment.
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4/68. Relations between traumatic brain injury and the environment: feedback reduces maladaptive behaviour exhibited by three persons with traumatic brain injury.

    feedback is a commonly used technique in neurorehabilitation. It functions to strengthen or weaken select relations between individuals' behaviour and their environment. The study of behaviour-environment relations is a focus of operant psychology, commonly referred to as behaviour analysis. Central to behaviour analysis is the analysis of interrelations among stimuli, behaviour, and consequences. The focus on behaviour-environment relations may have considerable benefits for designing clinical treatments and accounting for successful and unsuccessful treatments, especially psychological interventions for maladaptive behaviour. In the present investigation, three persons with traumatic brain injuries, diagnosed with depression and presenting mild cognitive impairments, received feedback about their maladaptive behaviour. Weekly feedback resulted in general reductions in the variability and frequency of maladaptive behaviour. The results support the utility of giving equal consideration to relations between persons with traumatic brain injury and their environment, despite existing psychological or cognitive impairments. Future research on variables that influence the development and maintenance of behaviour-environment relations, and more generally operant behaviour, may provide a unique perspective on the effects of traumatic brain injury.
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5/68. Differential reinforcement of other behavior (DRO) to reduce aggressive behavior following traumatic brain injury.

    Severe brain injury can result in significant neurobehavioral and social functioning impairment. In rehabilitation settings, behavioral problems of aggression and nonadherence to therapeutic activities can pose barriers to maximal recovery of function. Behavioral interventions seem to be effective in reducing problem behavior among individuals recovering from severe brain trauma, but well-controlled studies examining the efficacy of such interventions are sparse. This article presents a single-case, multiple-baseline study of a differential reinforcement of other behavior (DRO) procedure in a 28-year-old, brain-injured male with aggressive behavior problems. The procedure successfully reduced the frequency of problem behavior by up to 74%, maintained at 1-month follow-up. Implications of this intervention for individuals with brain injury are discussed, and testing of this procedure using a between-group design seems indicated.
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6/68. head trauma and mid-frequency hearing loss.

    Numerous reports in the literature associate head trauma with high-frequency hearing losses, often mimicking "4K notches" attributed to noise exposure. We have observed that some patients with a positive history for head trauma may show midfrequency notches in their audiometric configurations.
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7/68. A 12-year ophthalmologic experience with the shaken baby syndrome at a regional children's hospital.

    PURPOSE: To examine the ophthalmologic experience with the shaken baby syndrome (SBS) at one medical center, including clinical findings, autopsy findings, and the visual outcome of survivors. methods: One hundred sixteen patients admitted from 1987 to 1998 for subdural hematomas of the brain secondary to abuse were included. RESULTS: Retinal hemorrhages were detected in 84% of the children, but this important finding had been missed often by nonophthalmologists. Poor visual response, poor pupillary response, and retinal hemorrhage correlated strongly with demise of the child. One child who died had pigmented retinal scars from previous abuse, a condition not previously observed histopathologically. The clinical and autopsy findings varied somewhat, probably because of the differing conditions for examination. No correlation could be made between computerized tomography scans done during life and the subdural hemorrhage of the optic nerve found on autopsy. Half of the surviving patients were known to have good vision. One fourth of the patients had poor vision, largely due to cerebral visual impairment from bilateral injury posterior to the optic chiasm. Severe neurologic impairment correlated highly with loss of vision. CONCLUSION: This series provides information on the frequency of eye findings in SBS patients. No fundus finding is pathognomonic for SBS. When retinal hemorrhages are found in young children, the likelihood that abuse occurred is very high. The difficulty that nonophthalmologists have in detecting retinal hemorrhage may be an important limiting factor in finding these children so they may be protected from further abuse.
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8/68. Unique electroencephalographic change of acute encephalopathy in glutaric aciduria type 1.

    We report the peculiar serial electroencephalographic (EEG) findings in a 7-year-old boy with glutaric aciduria type 1 during an episode of acute encephalopathy. The patient developed Reye-like syndrome triggered by cellulitis. Cranial magnetic resonance imaging demonstrated diffuse softening of cerebral hemisphere. The EEG on the day following onset of acute encephalopathy showed suppression burst pattern including continuous 14-15 Hz rhythmic waves at first. Then, periodic synchronous discharge appeared and lasted for about 40 minutes. Periodic synchronous discharge finally disappeared and nearly total electrocerebral silence continued. There have been no reports indicating such a change of EEG in a short period. The serial EEG changes probably reflect the process of electrical death of neurons in cerebral hemispheres.
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9/68. Brain injury after survived gunshot to the head: reactive alterations at sites remote from the missile track.

    Gunshot wounds to the brain usually lead to acute respiratory arrest or death after a brief survival period, even in cases involving only slight direct tissue damage. It can be assumed therefore that the damage extends beyond the zone of recognizable destruction and hemorrhages. To determine the true extent of the tissue injury resulting from gunshot wounds to the brain, we carried out microscopic investigations for reactive changes (emigration of leukocytes and macrophages, axonal expression of beta-amyloid precursor protein (beta-APP) in 10 cases of gunshot wound to the narrow channel of the brain with survival times >2h. Demonstration of leukocytes expressing naphthol AS-D chloroacetate esterase activity in the brain tissue at the border of the missile track established the vitality of the gunshot effect. The presence of macrophages (CD68-epitope) allowed demarcation of a 1-2mm wide necrotic zone around the permanent cavity. Within this zone and beyond, beta-APP showed an initial increase followed by a decline in the number of injured axons. Three types of beta-APP positive staining could be differentiated. In the immediate vicinity of the missile track beta-APP positive neurons were present at a distance of 2-4mm from the margin of the permanent cavity (type 1) as a result of primary injured neuronal tissue by the gunshot itself. At longer distances from the narrow channel and the permanent cavity single beta-APP positive axons or axon fragments and two additional types were found; type 2 shows a parallel, wave-like arrangement of the damaged fibers, which suggests that the injury was produced by mechanical acceleration of the brain tissue created by the energy the projectile expended within the brain; irregular aggregation of beta-APP positive axons or axon fragments within a local edema represents type 3, which may be attributed to secondary ischemia or edema.
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10/68. Effect of training frequency on face-name recall by adults with traumatic brain injury.

    Many TBI survivors have difficulty recalling the names of people with whom they frequently interact. Researchers have established that mnemonics and visual imagery strategies are often effective in facilitating encoding and recall of such information; however, no research exists pertaining to the frequency that such training should occur. The purpose of this study was to assess the relative effectiveness of three frequencies of intervention sessions--once per day, two times per week, and five times per day--on TBI survivors' ability to recall face-name associations. Results showed that sessions held daily and twice a week were more effective than sessions held five times per day. Mnemonics and visual imagery strategies were effective for four of the seven participants, regardless of frequency of intervention sessions. Implications for treatment and future research are discussed.
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