TBI, and one organizing theme to these studies is that they address the issue of neu-, ropsychological heterogeneity. Severe Traumatic Brain Injury . the three-cluster solution were differentiated primarily by level of performance. xref S. (1997). Primary and secondary injuries If that was the case, then the group might be most accurately characterized as, clusters and the GCS. ... Hierarchical cluster analysis was used with raw total seconds of the TMT A and B tests serving as attributes. There was clear sepa-, ration between the mild GCS group and the moderate and severe groups, although, these differences did not achieve statistical signiﬁ, small number of cases in the mild GCS group. It was hypothesized that if the TMT, clusters represented a reliable method of classifying the sample, those with more, severe injuries would demonstrate greater impairment on these other indicators of, outcome. Accordingly, despite its simplicity. A traumatic brain injury (TBI), also known as an intracranial injury, is an injury to the brain caused by an external force. VA/DoD Clinical Practice Guideline for the Management of Concussion -mild Traumatic Brain Injury . Nonetheless, the results clearly demonstrate a lack of correspondence between, severity ratings made at the time of injury using the GCS and later classiﬁ, the low correspondence between GCS scores and TMT may be largely accounted, for by this factor since the GCS is typically administered during the acute phase of, was the case for the children in this study, while the TMT is generally administered during a follow-up exam some weeks after, tions are limited with regard to predicting post acute recovery of neurocognitiv, They found that while the moderate group had fewer children with no neuropsycho-, tion of unconsciousness but not lowest GCS score predicted neuropsychological, outcomes. These results are discussed in the context of current classification methods, limitations of the current findings are discussed, and directions for future research are suggested. Figure, larly with the Digit Span subtest in which all three groups converged in le, performance. Loss of consciousness of ≥30 min. 0000011253 00000 n A moderate cluster is also present (C2), as well as a more, the TBI sample that resulted from the GCS scores and the TMT clusters. The lowest postresuscitation Glasgow Coma Scale (GCS) score and the presence of intracranial pathology are more strongly associated with outcome than the durations of posttraumatic amnesia and impaired consciousness, possibly reflecting measurement issues in older persons who are likely to be injured in low velocity falls and to suffer delayed complications. This paper discusses the Mayo Classification System for Traumatic Brain Injury Severity. (8.6 %), skiing accident (5.9 %), gunshot wound (3.3 %), bicycle accident (3.3 %), falls (1.3 %), and other causes (6.0 %). Sixty-one children and adolescents with moderate to severe brain injuries completed the TMT-C and performed a battery of neuropsychological tests. WISC-III cluster analysis results from Donders & Warschausky ( 1997 ) and Thaler et al. The cluster that performed the best obtained scores that were in the average range, all, obtaining scores in the impaired range on both TMT, cluster solution, the impaired cluster (C3) was divided into two clusters with the, fourth cluster (C4) exhibiting marked impairment on TMT, impaired cluster (C3) was divided again to form a ﬁ, scores were used to predict cluster membership, there was a negligible difference in. The GCS (T, been completed for 97 of the children, either by ﬁ, were transported to the hospital, and indicated that overall they had sustained mod-, two parts, A and B, and both parts include 25 circles that are distributed across an, subject is given a pencil and instructed to draw a line as quickly as possible that con-, nects the 25 numbered circles in order. Some recommend a combination of these, cation system that expands upon current qualitative observations, ndings indicate that unique patterns of neurocognitive impairment are observed in, ed using cluster analysis may prove useful for identifying homo-, between 3 and 15, with scores of 3–8 indicating severe injury, cating moderate injury, and scores of 13–15 indicating mild injury, objective and simple to complete. The predictive validity of a brief inpatient neuropsychologic battery for persons with, (2008). poses, such as to predict educational and vocational outcomes, troubled by heterogeneity. although the best performing cluster obtained scores that were in the average range. Clinicians and researchers have proposed classification systems based on lesion location and causative processes, physical mechanisms that cause TBI, distinctions between primary vs. secondary injuries, and clinical signs such as coma duration or post-traumatic amnesia, among others. between 5 and 19 years of age. However, classification of TBI severity has presented a number of unique challenges owing largely to the heterogeneity in neuropathology that can result from the injury and associated heterogeneity in clinical, cognitive, and behavioral disturbances. typically used when interpreting test performance. When the WISC-III scores, were subjected to cluster analysis, four clusters were identiﬁ, Three of the clusters were characterized by either above average, a, average index scores and in this way were dif, and attention indexes and impaired scores on the nonv, indexes. Thus, the, children with TBI that distinguish them from non-brain-injured children, these, patterns of impairment are not accounted for by expected variation in test perfor-, mance observed in normal populations, and cluster membership is associated with, patterns of outcome on some important clinical variables. in Traumatic Brain Injury; prognosis; traumatic brain injury Prognosis in Severe Brain Injury Robert D. Stevens, MD1-4; Raoul Sutter, MD1-3 1Division of Neurosciences Critical Care, Department of Anesthesiol-ogy and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. During 2013, TBIs were diagnosed in nearly 2.8 million of the 26 million injury-related emergency department visits, hospitalizations, and deaths that occurred in the U.S. 1 TMT clusters differed on all intellectual, academic, and, memory variables, with the severe cluster consistently performing belo, moderate and mild clusters, and these differences appeared unrelated to demo-, graphic or clinical variables such as age, time since injury, results provide strong evidence that children who perform in the “sev, impairment across a number of domains that have implications for real-world, outcomes. The TMT was not able to correctly classify Slow Learners among the Kindergarten children. tion was optimal for the control group (Fig. Cluster analysis of IQ and memory scores indicated that a four-cluster solution was optimal for the IQ scores and a five-cluster solution was optimal for the memory scores. MB Potts, SE Koh, WD Whetstone, et al.Traumatic injury to the immature brain: inflammation, oxidative injury, and iron-mediated damage as potential therapeutic targets NeuroRx, 3 (2006), pp. 926 0 obj <> endobj Traumatic brain injuries are usually emergencies and consequences can worsen rapidly without treatment. In this regard, neuropsycho-. predict long-term productivity outcome from traumatic brain injury, Predictive utility of weekly post-traumatic amnesia assessments after brain injury: A multicen-, and research recommendations for mild traumatic brain injury: the WHO Collaborating centre. The current study examined the validity of scores from a newer version of the Trail Making Test, the Comprehensive Trail Making Test (CTMT), in children and adolescents with traumatic brain injury (TBI). tal. Plots of achievement variables are present on Fig. This goal, was addressed in two ways, including a direct comparison of agreement between, the two different approaches to severity classiﬁ. making test performance in children and adolescents with traumatic brain injury. Traumatic brain injury can be broadly categorized as penetrating or non-penetrating, and as focal or diffuse. Three clusters on each battery differed primarily by level of performance, while the others had pattern variations. By, graphing the clusters in discriminant function space, the overlap between each clus-, ter was inspected (as suggested by Aldenderfer & Blashﬁ. These indexes were compared across TMT clusters and GCS groups. Differences between the TBI and control groups remained stable across age. Clusters did not differ on demographic or psychiatric variables. The present study describes the ability of the TMT to discriminate between normal and slow learners among a group of 122 young children (ages 6 to 8, grades K through 2). Receiver operating characteristic analysis indicated that the CTMT composite index provided the best overall classification, with a correct classification rate of 79%. Cluster Analysis in Neuropsychological Research: Recent Applications (pp.95-123), Heterogeneity in Trail Making Test performance in OEF/OIF/OND veterans with mild traumatic brain injury, Patterns in Cognitive Rehabilitation of Traumatic Brain Injury Patients: A Text Mining Approach, A Comparison of IQ and Memory Cluster Solutions in Moderate and Severe Pediatric Traumatic Brain Injury. The severity classification is determined based on characteristics of the initial injury. Panel ( a ): GCS groups. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. working memory, inhibition/interference control, and visuomotor abilities. including TBI in children and adults (Armitage, approximately 84 % when normal controls are compared to mixed neurological. MAAS,4 ALEX VALADKA,5 and GEOFFREY T. MANLEY,6* and WORKSHOP SCIENTIFIC TEAM AND ADVISORY PANEL MEMBERS* ABSTRACT The heterogeneity of traumatic brain injury (TBI) is considered one of the most significant barri- These findings indicate that the CTMT is sensitive to TBI and overall demonstrates classification rates that are comparable with some other versions of the Trail Making Test. However, most research on the TMT has been limited to older children (ages 9 to 14). (PsycINFO Database Record (c) 2012 APA, all rights reserved). In terms of the classification of severity, historically TBI was classified as mild, moderate or severe by using the Glasgow Coma Scale, a system used to assess coma and impaired consciousness. This heterogeneity can be seen in Fig. (2009). Journal of the International Neuropsychological Society, Archives of Physical Medicine and Rehabilitation, 83, Journal of the International Neuropsycholo, viduals sustaining paediatric traumatic brain injury. Used with permission. 133. 0000001497 00000 n The Halstead-Reitan neuropsychological test battery: cation of traumatic brain injury for targeted therapies. time of injury or soon thereafter in order to predict injury severity, signs often include length of unconsciousness and post-traumatic amnesia (PT. The TMT clusters could, psychological and academic outcomes for the moderate and severe clusters and so, and academic domains. pants and are generally consistent across the two versions of the test. II. Tirapu, J., et al. These results provide some support for the stability of previously identified memory and IQ clusters and provide information about the relationship between IQ and memory in children with TBI. For example, Partington and Leiter. raphy scans (CTs) of six individuals who sustained a severe TBI. This system is viewed as an innovative system which distinguishes between different severities of traumatic brain injury in keeping with the general outcome literature regarding traumatic brain injury. These level of per, formance differences range from mild to severe impairment and may correspond to, injuries also ranging from mild to severe. 5.1 Head Injury: Assessment and Early Management (2014) 5.2 Guidelines for the Management of Severe Traumatic Brain Injury (2016) 5.3 Management of Concussion-mild Traumatic Brain Injury (2016) 5.4 Rehabilitation Following Acquired Brain Injury (2003) injury or dysfunction has been particularly challenging. In I. Classifi cation of traumatic brain injury for targeted therapies. Additionally, moderate group consistently performed below the mild group on many of the, outcomes that were examined. children with mild injuries were distinct from children with moderate and severe inju-, ries when grouped into GCS scores, while children with severe injuries were distinct, from children with mild and moderate injuries when grouped into TMT clusters. startxref 2012, 102(11):2074-9. doi: 10.2105/AJPH.2012.300696. Multivariate analysis of variance showed that the Normal Learner group completed both parts of the TMT more rapidly than did the Slow Learner group. However, these patients continue to report significant anxiety, depression, and, The Comprehensive Trail Making Test (CTMT) is a relatively new version of the Trail Making Test that has a number of appealing features, including a large normative sample that allows raw scores to be converted to standard T scores adjusted for age. While we considered the other clusters (particularly C5) theoretically interesting, given what appears to be somewhat unique impairment on TMT, B, we decided that grouping these more severely impaired clusters into one “sev, cluster (C3) would provide a better approach with regard to cluster stability, alizability to other samples, and power to make comparisons between the clusters, on external validity variables. This is not totally unexpected, as the TMT was adminis-, tered at the same time as the tests of intelligence, achievement, and memory, higher correspondence would be anticipated between the TMT clusters and these, measures than would be expected for the GCS groups and neuropsychological mea-, sures. Comparison of the GCS and Trail Making Test severity groups on selected subtests from the Wechsler Intelligence Scales. 0000000016 00000 n 0000001607 00000 n Changes in GCS scores from one assessment to the next suggest a corre-, sponding change in level of consciousness (, Part B raw scores (time in seconds) were submitted to hierarchical cluster analysis, cluster analytic methodology of previous studies of neuropsychological variables in, those produced by other agglomerative clustering methods, and compared to these, other methods, it is less affected by outliers (Morris, Blashﬁ, measure of distance between objects in Euclidean space and is sensitive to both pat-, tern and level of performance differences (Ev, into their cluster solutions as well as to determine the overlap between clusters. x�b```b``~������� ̀ �l@��������;�ex�@h� lI'71(~`^%����X�`��mPJqsC�����9 <>�o,w̎. This chapter reviews issues relevant to TBI severity classification and cluster analysis of neuropsychological test scores and then goes on to present results of a study of children with TBI wherein the Trail Making Test (TMT) is subjected to cluster analysis in order to derive brain injury severity groups. The current study addressed this by comparing IQ and memory profiles of 137 children who sustained moderate-to-severe TBI. The main purpose of this book is to present emerging neuroimaging data in order to define the role of primary and secondary structural and hemodynamic disturbances in different phases of traumatic brain injury (TBI) and to analyze the potential of diffusion tensor MRI, tractography and CT perfusion imaging in evaluating the dynamics of TBI. For TMT, connect the circles by alternating between the numerical and alphabetical sequences, Performance is timed on both sections and the score is the amount of time (in sec-, onds) taken to complete each part. The sub-classification of TBI might be further refined if additional information … It may also be informativ, of the TMT when it is administered closer to the acute phase of injury, as it may, which may help explain differences in TMT performance following injury and be, useful in understanding the recovery process (T, ings do provide evidence that the TMT can serve as a brief classiﬁ, though continued research is necessary to replicate these ﬁ. ples with differing demographic and clinical characteristics. outcomes such as functional independence and disability (Hanks et al., pathophysiological changes that occur post-injury through the repeated measure-, ment of cognition and behavior over time (Goethe & Le, are therefore useful for broadly classifying injury severity, ture the heterogeneity of neurocognitive deﬁ, cluster analysis may provide a unique approach to reﬂ. 1-12. Results indicated that processing speed predicted Trails A performance while backwards span tasks predicted Trails B performance. Am J Public. clusters should be fairly well separated when plotted in discriminant function space, though there will often be some overlap. Results, of the cluster analyses for the TBI and control groups. In contrast, the GCS is more appropriate for classiﬁ, the acute stage of injury, as it loses its ef, ness. Cluster analyses indicated, Studies have found that processing speed and working memory influence performance on the Trail Making Test (TMT), though little research is available in this regard for the TMT for Children (TMT-C), particularly in clinical populations. Panel ( a ): normal controls. For example, when severity classiﬁ, using the GCS or other similar procedures, some children initially classiﬁ, and premorbid functioning may account for more variance in neurocognitive out-, Indeed, the GCS has been described as only a gross predictor of TBI severity and, the GCS relies primarily on acute behavioral responses post-injury including best, eye, verbal, and motor response, but provides little information about the patho-, physiologic mechanisms underlying injury, which may pro, of behavior may be useful for future TBI clinical trials. Studies should also further establish appropriate cut-, should be compared across behavioral variables and other outcome measures that, are relevant for TBI rehabilitation. Journal of Neurotrauma, 25 (7), 719–738. The Above Average cluster had better performance on measures of processing speed, working memory, and phonemic fluency compared with the Low B cluster. 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