214The Association of Early Computed Tomography ScanFindings and Ambulation, Self-Care, and Supervision Needsat Rehabilita...
EARLY CT SCAN FINDINGS, Englander                                                 215computed tomography (CT) scans of the...
216                                             EARLY CT SCAN FINDINGS, Englander       Table 1: Demographics of Study Sam...
EARLY CT SCAN FINDINGS, Englander                                                                          217       Table...
218                                                 EARLY CT SCAN FINDINGS, Englander         Table 4: Midline Shift and P...
EARLY CT SCAN FINDINGS, Englander                                                  219in the early postinjury phase of key...
220                                              EARLY CT SCAN FINDINGS, Englanderrehabilitation were not in this sample b...
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Ct scan , self care, rehab after traumatic brain injury


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Ct scan , self care, rehab after traumatic brain injury

  1. 1. 214The Association of Early Computed Tomography ScanFindings and Ambulation, Self-Care, and Supervision Needsat Rehabilitation Discharge and at 1 YearAfter Traumatic Brain InjuryJeffrey Englander, MD, David X. Cifu, MD, Jerry M. Wright, BA, Kertia Black, MD ABSTRACT. Englander J, Cifu DX, Wright JM, Black K. ADLs. The association of subdural hematoma with ambulation,The association of early computed tomography scan find- self-care, and supervision needs was related to the degree ofings and ambulation, self-care, and supervision needs at midline shift but not to the presence of subdural hematoma.rehabilitation discharge and at 1 year after traumatic brain Individuals with subcortical contusions were more likely toinjury. Arch Phys Med Rehabil 2003;84:214-20. require assistance at rehabilitation discharge for ambulation Objective: To ascertain the association between early com- (32% vs 18%, P .0001), lower-body dressing (61% vs 44%),puted tomography (CT) scan findings and the need for assis- toileting (52% vs 35%), bladder continence (34% vs 22%), andtance with ambulation, activities of daily living (ADLs), and overall supervision (61% vs 44%) than those without subcor-supervision at rehabilitation discharge and at 1 year after trau- tical contusions (P .0001). At 1 year, individuals with acutematic brain injury (TBI). subcortical contusions were more likely to need assistance with Design: Prospective longitudinal design. ambulation (15% vs 8%, P .004) and stair climbing (15% vs Setting: Seventeen Traumatic Brain Injury Model Systems 9%, P .03). Those with bilateral frontal (54% vs 46%,(TBIMS) centers. P .009) or bilateral temporal (58% vs 46%, P .03) contu- Participants: A total of 1839 adults with TBI admitted to sions were more likely to need assistance with overall super-TBIMS trauma centers with subsequent acute rehabilitation; vision at rehabilitation discharge, compared with those with849 were followed to 1 year after injury. unilateral or no cortical contusions. Interventions: Not applicable. Conclusions: The presence of either a midline shift greater Main Outcome Measures: Accumulated CT scan pathol- than 5mm or a subcortical contusion on acute CT scans isogy from the first week after injury; FIM™ instrument and associated with a greater need of assistance with ambulation,Disability Rating Scale at rehabilitation discharge and 1 year ADLs, and global supervision at rehabilitation discharge. Pa-after injury; and Supervision Rating Scale at 1 year. tients with bilateral cortical contusions require more global Results: Chi-square analyses showed that individuals with a supervision at rehabilitation discharge but no more supervisionmidline shift greater than 5mm (lateral compression) were for ambulation and ADLs. These findings may aid health caremore likely to require the assistance of another person at professionals and potential caregivers in planning for rehabil-discharge from acute rehabilitation with ambulation (29% vs itation and supervision needs after rehabilitation discharge and,17%–19%, P .02), toileting (47% vs 33%–38%, P .05), low- to a lesser extent, at 1 year after TBI.er-body dressing (57% vs 39%– 46%, P .015), bladder conti- Key Words: Activities of daily living; Brain injuries; Lo-nence (32% vs 19%–23%, P .03), and overall supervision comotion; Rehabilitation; Tomography, x-ray computed.(53% vs 44%, P .0006) than patients with a midline shift of © 2003 by the American Congress of Rehabilitation Medi-lesser degree. At 1 year, 57% of patients with a midline shift cine and the American Academy of Physical Medicine andgreater than 5mm on acute CT scans were being supervised in Rehabilitationthe home versus 30% to 39% of those with a shift of lesserdegree (P .003); there were no significant differences in thepercentages of those needing assistance for ambulation or P ATIENTS WITHevaluation andphase of treatment(TBI) un- dergo intensive TRAUMATIC brain injury teams in trauma centers. The initial treatment by the trauma involves maintenance of optimal oxygenation, ventilation, and cerebral perfusion pressure; the management of intracranial pressure; From the Department of Physical Medicine and Rehabilitation (Englander) and detection and treatment of surgically correctable cerebral andRehabilitation Research Center (Wright), Santa Clara Valley Medical Center, SanJose, CA; Stanford University School of Medicine, Stanford, CA (Englander); De- bodily injuries; initiation of nutritional support; and prophy-partment of Physical Medicine and Rehabilitation, Virginia Commonwealth Univer- laxis for prevention of early posttraumatic seizures.1 If thesity, Medical College of Virginia Campus, Richmond, VA (Cifu); Department of patient survives, questions regarding the prognosis for partic-Physical Medicine and Rehabilitation, Wayne State University, Detroit, MI (Black); ipating in various activities of daily living (ADLs) arise. Theand Rehabilitation Institute of Michigan, Detroit, MI (Black). Supported in part by the National Institute on Disability and Rehabilitation Re- most common questions concern whether the injured individualsearch, US Department of Education (grant nos. H133A70018, H133A980026, will be able to walk, to care for personal needs, to be safe in theH133A970021). home environment, and to return to productive activity. Health Presented at the American Congress of Rehabilitation Medicine’s 78th Annual care practitioners are often asked to predict outcome before theMeeting, October 26, 2001, Tucson, AZ. No commercial party having a direct financial interest in the results of the research patient has started to follow commands or interact in a mean-supporting this article has or will confer a benefit upon the author(s) or upon any ingful way with the environment. Although prognostic indica-organization with which the author(s) is/are associated. tors such as age, mechanism of injury, and medical history can Reprint requests to Jeffrey Englander, MD, Dept of Physical Medicine and Reha- be helpful, the only hard data available are typically limited tobilitation, Santa Clara Valley Medical Center, 751 S Bascom Ave, San Jose, CA95128, e-mail: Jeffrey.Englander@hhs.co.santa-clara.ca.us. the initial severity of injury, types and extent of surgical 0003-9993/03/8402-7443$35.00/0 interventions, early course of recovery, and a series of labora- doi:10.1053/apmr.2003.50094 tory and radiologic evaluations. It is important to note thatArch Phys Med Rehabil Vol 84, February 2003
  2. 2. EARLY CT SCAN FINDINGS, Englander 215computed tomography (CT) scans of the brain can help to intellectual skills; 80% to 90% of those with single-hemisphereguide acute treatment and interventions, but they are not typ- lesions (n 10) were independent with transfers, but only 50%ically relied on to predict long-term outcomes. The purpose of were independent with intellectual skills; 50% to 65% of thoseour study was to characterize the association of CT scans with bilateral lesions (n 17) were independent with transfersduring the first week after TBI with the need for another person and dressing, and only 12% were independent with intellectualto assist the patient with mobility and ADL tasks, and to skills. Rao suggested that “early CT data be given strongermonitor overall safety at discharge from rehabilitation and at 1 consideration in deciding whether admission to a rehabilitationyear after injury. program is appropriate”6(p20) and that those data may help in The Traumatic Coma Data Bank (TCDB) using initial CT setting appropriate goals and realistic expectations.scans, categorized CT scan pathology on the basis of the status Outcomes commonly desired by TBI patients and their fam- ilies include the ability to walk, to be left safely alone forof mesencephalic cisterns, degree of midline shift, and pres- periods of time, and to resume productive activity. Ambulationence of surgical masses, which helped to predict mortality in ability is difficult to predict from any neuroradiologic test. Inpeople with severe closed brain injury.2 The TCDB findings an earlier analysis7 of Traumatic Brain Injury Model Systemsshowed that individuals with mass lesions measuring greater (TBIMS) data of 637 patients, physical assistance with ambu-than 15cm3 or diffuse swelling with shift greater than 3mm lation at acute rehabilitation discharge was required more fre-have greater than 50% mortality rates. Subarachnoid hemor- quently (15% vs 4%) by patients with less than antigravityrhage with any of the above or with compressed cisterns was strength in the lower extremities when admitted to rehabilita-associated with greater than 60% mortality. Functional out- tion compared with those who had at least antigravity strength.come beyond that described by the Glasgow Outcome Scale The association persisted at 1 year, although 88% of patients(GOS) was not measured. The Westmead Head Injury Project3 with initially impaired strength required no assistance. Stair-found that cerebral edema, effaced mesencephalic cisterns, climbing, lower-body dressing, and transfer capabilities at re-midline shift, and intraventricular hemorrhage were all associ- habilitation discharge and 1 year after TBI were more stronglyated with increased mortality, whereas subarachnoid hemor- associated with rehabilitation admission motor strength, withrhage, intracerebral contusions, and hematomas were associ- 20% to 30% of individuals needing physical assistance at 1ated with disability as measured by the GOS. Quattrocchi et al4 year if their lower-extremity strength at admission was lessretrospectively studied 75 consecutive individuals with TBI than antigravity.who were admitted to a level I trauma center. They measured This study was undertaken to ascertain the associationsmidline shift and intracranial lesions from CT scans performed between CT scan findings during the first postinjury week andwithin 1 hour of injury. Logistic regression analysis showed ambulation, self-care, and safety at acute rehabilitation dis-that significant predictors for poor outcome were intracranial charge and at 1 year after TBI. Although previous studies havehemorrhage (34%), intracranial hemorrhage with midline shift addressed the relation between intracerebral lesions and func-(61%), and midline shift out of proportion to intracranial hem- tional outcome, they did so in only a cursory manner, usingorrhage (88%). Outcomes were broadly defined in these stud- relatively insensitive measures (eg, GOS), and characterizedies, from death to 1 of 4 levels of disability as measured by the radiologic findings in a fairly nonspecific manner (eg, focalGOS. cortical contusions) rather than in a manner that precisely The predictive value of CT scans in patients who undergo describes the nature of the lesions. This study more clearlyrehabilitation has also been evaluated, mostly in a preliminary describes the anatomy, size, and location of the injuries andfashion. Katz and Alexander5 evaluated 243 consecutive indi- suggests that there are unexplored relationships between brainviduals who were in rehabilitation for TBI. Diffuse axonal topography and functional outcome. This investigation alsoinjury (DAI) was found most often in patients who were less improves on the technical limitations of research—includingthan 40 years old, focal cortical contusions were found in those small sample sizes, single centers, or global functional mea-more than 40 years old, and subdural hematomas (SDHs) were sures— by using a large, prospective, multicenter database withfound in those more than 60 years old; epidural hematomas had specific, well-accepted functional outcome measures. The 3no age predilection. Within the DAI category, defined as injury study hypotheses were (1) the degree of midline shift (intra-from significant acceleration or deceleration force and imme- cranial compression) on CT scan during the first week afterdiate loss of consciousness (LOC), GOS scores at 6 and 12 TBI would be associated with the need for another person tomonths were somewhat predictable by using age, length of assist with ambulation, ADLs, and overall supervision at acutecoma, and posttraumatic amnesia (PTA). In patients with just rehabilitation discharge, but would be less so at 1 year afterfocal cortical contusions, defined as localized hemorrhage and injury; (2) the number and location of intracranial lesions onedema in cortical and subjacent subcortical areas seen on CT scan would be associated with the need for another personneuroimaging studies after TBI, the only statistically signifi- to assist with ADLs at acute rehabilitation discharge, but wouldcant relationship existed between PTA and GOS at 6 months; be less so at 1 year after injury; and (3) patients with bilateralthere was no relationship at 12 months. Because of the com- frontal or temporal lesions would be more likely to needplexity of lesion size and analysis, CT diagnosis was deferred supervision at acute rehabilitation discharge and at 1 year afteras an outcome predictor.5 injury. Rao et al6 performed a retrospective analysis of 30 TBIpatients who were admitted to a rehabilitation unit. They used METHODSCT scan reports performed within 10 days of injury to attemptoutcome prediction for self-care, mobility, and language and Participantsintellectual capabilities. CT scan classification was “normal,” Subjects were 1839 patients prospectively enrolled in the“one hemisphere” involved with intracerebral or extra-axial National Institute on Disability and Rehabilitation Researchhemorrhage, or “bilateral” involvement. Using the Patient TBIMS program between January 1989 and July 2000. Sub-Evaluation Conference System at discharge from acute reha- jects were recruited from 17 medical centers representing geo-bilitation, Rao found that patients with normal scans (n 3) graphically diverse regions of the United States. Each centerwere independent in transfers, dressing, language, and basic included emergency medical services, intensive and acute med- Arch Phys Med Rehabil Vol 84, February 2003
  3. 3. 216 EARLY CT SCAN FINDINGS, Englander Table 1: Demographics of Study Sample (N 1839) ganglia, and internal capsule. Petechial hemorrhages were re- Variable n (%) corded as present or absent. Extra-axial collections were noted as epidural, subdural, or not specified. Intraparenchymal bone Gender or metal fragments were noted as present or absent. Male 1361 (74) FIM™ instrument. The FIM instrument9 is an 18-item, Female 478 (26) 7-level scale denoting functional mobility, self-care, commu- Race/ethnicity nication, and cognitive status. Subscale scores were used in a White 1147 (62) dichotomous fashion for the help of another person to complete Black 438 (24) Hispanic 156 (8) the functional task. For bathing, lower-body dressing, toileting, Other 98 (6) and bowel and bladder continence, scores of 6 or 7 were Age (y) considered independent; scores of 5 indicated the need for 16–25 602 (33) help from another person. For ambulation and stair-climbing, a 26–35 366 (20) score of 4 definitively indicated the need for another person, 36–45 386 (21) whereas scores of 5 might indicate the need for another 46–55 218 (12) person for longer distances ( 4 – 6 stairs) but possibly not for 55 264 (14) shorter distances (4 – 6 stairs; household ambulation excep- Etiology tion). Therefore, for ambulation and stairs, scores of 5 to 7 MVC 1053 (58) indicated independence, and scores of 4 indicated the need Violence 280 (15) for help from another person. FIM data were collected at Falls 299 (16) inpatient rehabilitation discharge and at the 1-year follow-up. Other 197 (11) FIM raters at the centers had passed either the Uniform Data History of TBI System FIM certification testing or a similar vignette exercise Prior TBI 163 (9) administered by personnel at the Rehabilitation Research Cen- No history 1671 (91) ter, Santa Clara Valley Medical Center.Abbreviation: MVC, motor vehicle crash. Disability Rating Scale. The Disability Rating Scale10 (DRS) was performed on rehabilitation discharge and at the 1-year follow-up. Only the level of functioning subscale was used because it indicates the degree of supervision needed forical care, inpatient rehabilitation, and a spectrum of community physical and/or cognitive activities. It was interpreted in arehabilitation services. The procedures followed were in accord dichotomous fashion, with a cutoff of 3 indicating a need forwith the ethical standards of the responsible institutional re- supervision by another person. All DRS raters had passed aview boards. Inclusion criteria in the database8 were (1) TBI as reliability rating exercise by rating 3 case studies at 80%defined by an external force causing damage to brain tissue as correct.evidenced by LOC or PTA or objective neurologic findings that Supervision Rating Scale. The Supervision Rating Scale11are reasonably attributed to TBI on physical or mental status (SRS) is a 13-point scale that describes the level of supervisionexamination, with or without a skull fracture; (2) at least 16 actually received by the individual with TBI. The SRS wasyears of age; (3) presentation to the emergency department of performed at 1-year follow-up and was used in a dichotomousa TBIMS trauma center within 24 hours of injury; (4) receipt of fashion, by collapsing ratings of 1 or 2 (independence) versusacute care followed by inpatient rehabilitation at a participating 3 (supervision needed by another person, at least overnight).center; and (5) consent to participate. Individuals with previous Discharge FIM and DRS ratings were obtained by the reha-TBI were included. Table 1 shows the gender, race and eth- bilitation team within 72 hours of patients’ discharge fromnicity, age distribution, and etiology of injury for the study acute inpatient rehabilitation. One-year follow-up data werepopulation. collected in person or by telephone from the patient or his/her caretaker at 10 to 14 months after injury.Measures Measurement categories and evaluation protocols are de- Statistical Analysisscribed below. CT scan evaluation. CT diagnoses were based on a com- The outcome variables were dichotomized to lessen thepilation of all dictated radiographic reports in the medical potential ceiling effects of the FIM and DRS being adminis-record covering the first 7 days after injury. Dictated radio- tered at 1 year after injury. Because of the categorical nature ofgraphic reports of 20 representative patients were used to the variables examined and the dichotomous nature of theperform interrater reliability testing. There was greater than outcome variables chosen, chi-square analyses were per-80% interrater reliability for coding the dictated reports among formed. Cramer’s V or was used to measure effect size. Withthe physician coders at the 17 TBIMS centers. regard to demographic characteristics, the smaller sample size The extent of midline shift was indicated as none; cisterns used for 1-year analyses was not significantly different frompresent, midline shift 1 to 5mm; cisterns compressed or absent, the larger sample observed until rehabilitation discharge. Themidline shift 0 to 5mm; midline shift greater than 5mm; and number of subjects in various analyses was affected by missingcompression not specified. Contusions could be with or without data. For instance, if the degree of shift on a patient’s CT scanfocal hemorrhage. Focal cortical contusions were noted for was not specified, that subject’s data could not be used for thateach location. For adjacent overlapping areas—for example, analysis, whereas information on contusions may have beenfrontotemporal— both areas were indicated as contused but not available. Some analyses were conducted on smaller samplenoted as multiple unless present bilaterally or in nonadjacent sizes because of the outcome measures used. The SRS wasanatomic locations (eg, frontal and occipital). Subcortical con- added to the database in 1998; the DRS has been in thetusions included cerebellum, brainstem, pons, thalamus, basal database since its inception in 1989.Arch Phys Med Rehabil Vol 84, February 2003
  4. 4. EARLY CT SCAN FINDINGS, Englander 217 Table 2: Early Midline and Percentage Requiring Another Person for ADLs at Rehabilitation Discharge and 1 Year After TBI Cistern Compression No Midline Midline Shift and Cisterns Compressed, 5-mm Midline Shift 1–5-mm Midline Shift 0–5-mm Midline Shift Shift 2 Discharge ADL (n 1600) (n 1096) (n 146) (n 213) (n 145) Cramer’s V Bathing 55% 51% 51% 64% 7.3, P .06 .07 Dressing lower body 46% 39% 44% 57% 10.5, P .015 .08 Toileting 38% 33% 33% 47% 8.1, P .05 .07 Bladder 23% 19% 21% 32% 9.0, P .03 .08 Bowel 22% 18% 19% 25% 3.4, NS .05 Ambulation 19% 18% 17% 29% 9.8, P .02 .08 Stairs 40% 29% 32% 39% 10.3, P .02 .08 Cistern Compression No Midline Midline Shift and Cisterns Compressed, 5-mm Midline Shift 1–5mm Midline Shift 0–5-mm Midline Shift Shift 2 1-y ADL (n 735) (n 483) (n 74) (n 107) (n 71) Cramer’s V Bathing 14% 18% 17% 10% 2.4, NS .06 Dressing lower body 11% 16% 13% 9% 2.4, NS .06 Toileting 7% 8% 10% 9% 1.4, NS .04 Bladder 8% 7% 11% 9% 1.3, NS .04 Bowel 6% 7% 9% 6% 1.9, NS .05 Ambulation 8% 9% 8% 9% 0.2, NS .02 Stairs 9% 11% 10% 13% 0.8, NS .04Abbreviation: NS, not significant. RESULTS Contusion Location Subcortical contusions. The presence of a subcortical con-Midline Shift tusion was significantly associated with the need for assistance At inpatient rehabilitation discharge, a larger proportion of with all ADLs at inpatient rehabilitation discharge (table 3).those with greater than 5mm of midline shift required another Nearly twice the number of those with a subcortical contusionperson for ambulation, compared with those with a midline required another person for ambulation compared with thoseshift of 5mm. For self-care skills such as dressing, bathing, without subcortical contusion. For ADLs, those with a subcor-toileting, and bladder continence, a higher percentage of pa- tical contusion had a higher rate of assistance from anothertients with greater than 5mm of midline shift needed another person compared with those without.person to perform these activities than did those with a shift of At 1 year after TBI, a higher proportion of patients with a 5mm. Those with cisternal compression but a midline shift of subcortical contusion still needed another person for assistance 5mm had no increased need for another person’s assistancecompared with those without compression. At 1 year after TBI, Table 3: Subcortical Contusion and Percentage Requiring Anotherthere were no differences in the need of another person’s Person for Ambulation and ADLs at Rehabilitation Dischargeassistance for ambulation or ADLs between groups (table 2). and 1 Year After TBI Subcortical ContusionEarly SDH None Present 2 At inpatient rehabilitation discharge, 31% of patients with ADL (%) (%)SDH and a midline shift of greater than 5mm required another Discharge (n 1835)person for ambulation, compared with 18% of the patients with Bathing 53 67 22.3, P .0001 .11 2no SDH ( 2,n 1729 10.4, P .01, Cramer’s V .08). For self- Dressing lower body 44 61 28.0, P .0001 .12 2care skills such as toileting ( 2,n 1718 6.2, P .05, Cramer’s Toileting 35 52 30.4, P .0001 .13 2V .06) and bladder continence ( 2,n 1717 8.2, P .02, Cram- Bladder 22 34 19.7, P .0001 .10er’s V .07), a higher percentage of patients with SDH and a Bowel 21 33 20.8, P .0001 .11midline shift greater than 5mm required another person to Ambulation 18 32 30.5, P .0001 .13perform these activities. Patients with SDH and a shift of fewer Stairs 36 49 14.3, P .0002 .10millimeters or no SDH did not need another person. There were 1y (n 849)no statistically significant differences in the need for another Bathing 14 20 3.2, NS .06person to perform ambulation or self-care activities between Dressing lower body 12 15 1.3, NS .04patients with SDH and a midline shift of 5mm and those Toileting 8 11 1.6, NS .04without SDH. The need for another person was more closely Bladder 9 11 0.9, NS .03associated with the degree of midline shift than with the pres- Bowel 6 10 2.4, NS .05ence of an SDH. At 1 year after TBI, there were no differences Ambulation 8 15 8.4, P .004 .10in the need for another person for ambulation or ADLs between Stairs 9 15 4.4, P .03 .08those with and without an SDH. Arch Phys Med Rehabil Vol 84, February 2003
  5. 5. 218 EARLY CT SCAN FINDINGS, Englander Table 4: Midline Shift and Percentage Requiring Supervision at Inpatient Rehabilitation Discharge and 1 Year After TBI Midline Shift No Midline 1–5-mm Midline Cisterns Compressed, 5-mm Midline Shift Shift 0–5-mm Midline Shift Shift 2 Supervision Measure (%) (%) (%) (%) Cramer’s V DRS LOF at discharge (n 1606) 44 39 57 53 17.4, P .0006 .10 DRS LOF at 1y (n 732) 12 18 11 21 6.9, NS .10 SRS at 1y (n 527) 30 39 38 57 13.8, P .003 .16Abbreviation: LOF, level of functioning subscale.with ambulation and stair-climbing, compared with those with- supervision at 1 year with the DRS level of functioning mea-out. The differences in the need for another person’s assistance sure or the SRS was not significant.for self-care activities were not significant at 1 year. Cortical contusions. At inpatient rehabilitation discharge, DISCUSSION28% of patients with occipital contusions needed assistance This study is the first multicenter, prospective evaluation ofwith ambulation, compared with 20% of those with no occipital the relationship of early CT scans after TBI to key functional 2contusion ( 1,n 1819 4.5, P .03, .04). Those with unilat- outcomes. The large sample, diversity of subjects, and wideeral or bilateral frontal, temporal, or parietal contusions had no geographic representation of the 17 TBIMS sites contribute togreater likelihood for needing another person’s help for ambu- the generalizability of the data. Although several statisticallylation than did those without those lesions. At 1 year after TBI, significant associations between specific acute CT scan find-there were no statistically significant differences between any ings and short- and long-term functional outcomes were found,of the groups. the direct clinical applicability of many of these associations At inpatient rehabilitation discharge, 23% of individuals may be less significant. The associations that showed largewith multiple contusions required another person for ambula- increases (ie, 10%) in the percentage of increased functionaltion assistance, versus 19% of those without multiple contu- independence will be discussed because they are most likely to 2sions ( 2,n 1811 3.7, not significant). At 1 year after TBI, there have direct clinical relevance. A multifactorial model of thesewere no differences in the ambulation category. and other data is needed to account for all of the clinical significance of this research and will be the focus of futureCT Scan, Midline Shift, and Supervision Needs at analyses.Rehabilitation Discharge and 1 Year After TBI The ability to perform instrumental ADL tasks, ambulate, At inpatient rehabilitation discharge, a larger proportion of and achieve safety in the home is a key milestone in thepatients with a midline shift greater than 5mm or any cisternal recovery process after TBI. Although numerous factors may becompression required another person for overall supervision, associated with independence in these tasks, the identificationcompared with those with no cisternal compression and/or amidline shift 5mm. Using the same DRS level of functioningmeasure at 1 year after TBI, nearly twice as many individuals Table 5: Contusions and Percentage Requiring Supervision atwith a midline shift greater than 5mm required supervision than Rehabilitation Discharge and 1 Year After TBIdid patients with cisternal compression and midline shifts of Frontal Contusionslesser degree. Using the SRS at 1 year after TBI, most of those None Unilateral Bilateral Cramer’swith a midline shift greater than 5mm (were supervised at least Supervision Measure (%) (%) (%) 2 Vovernight) compared with individuals with cistern compressionor those without cisternal compression and a midline shift DRS LOF at discharge 5mm (table 4). (n 1834) 45 47 54 9.4, P .009 .07 DRS LOF at 1yEarly SDH, Midline Shift, and Supervision Needs at (n 845) 14 13 13 0.9, NS .01Rehabilitation Discharge and 1 Year After TBI SRS at 1y (n 622) 36 32 38 1.3, NS .04 Using the DRS level of functioning measure, there were no Temporal Contusionsstatistically significant differences in the global supervisionneeds between patients with SDH and any degree of midline None Unilateral Bilateral 2 Supervision Measure (%) (%) (%) Cramer’s Vshift and those without SDH at rehabilitation discharge and 1year after TBI. Using the SRS at 1 year after TBI, 56% of DRS LOF at dischargepatients with SDH and a midline shift greater than 5mm, (n 1831) 46 47 58 6.8, P .03 .0633% of those with SDH and cisterns compressed or a midline DRS LOF at 1y (n 845) 13 13 22 4.6, NS .07 2shift 5mm, and 34% of those with no SDH ( 2,n 586 6.7, SRS at 1y (n 622) 35 37 35 0.2, NS .02P .04, Cramer’s V .11). Subcortical ContusionsAcute Cerebral Contusions and Supervision Needs at None PresentRehabilitation Discharge and 1 Year After TBI Supervision Measure (%) (%) 2 Table 5 indicates that individuals with bilateral frontal con- DRS LOF at dischargetusions, bilateral temporal contusions, or subcortical contusions (n 1831) 44 61 27.1, P .0001 .12were more likely to require supervision at rehabilitation dis- DRS LOF at 1y (n 845) 12 19 4.6, NS .07charge, as measured by the DRS level of functioning variable. SRS at 1y (n 622) 34 41 1.8, NS .05The association between bilateral or subcortical contusions andArch Phys Med Rehabil Vol 84, February 2003
  6. 6. EARLY CT SCAN FINDINGS, Englander 219in the early postinjury phase of key variables with significant functional performance were small. The possibility that theassociations to independence may assist in planning the reha- accompanying visual and visuoperceptual deficits associatedbilitation process and in giving family members some guide- with occipital lobe injury would predispose an individual tolines for the patient’s recovery. This study used specific radio- increased functional dependency is intriguing but warrantsgraphic data, obtained in the first week after TBI, which more detailed analysis.showed relationships to functional independence. Patients with bilateral frontal or temporal contusions also Previous research has also identified associations between have very high needs for supervision at rehabilitation dis-several CT scan findings and global outcome measures. Spe- charge. Although bilateral cortical contusions were not associ-cifically, cisternal effacement, midline shift, cerebral edema, ated with increased need for supervision to ambulate or per-intraventricular hemorrhage, DAI, and focal cortical contusions form ADLs, these types of injuries are often associated withhave all been shown on the GOS to have some effect on poorer poor awareness of one’s safety, thus putting people with suchfunctional outcome.3 In this study, we identified a more fo-cused subset of radiographic findings that correlate with overall injuries at overall risk for harm if they are not closely super-supervision needs and the need for assistance with ADLs and vised. In addition, many third-party payers do not approveambulation. ongoing inpatient rehabilitation services for patients who re- Not surprisingly, evidence of substantial midline shift was quire supervision but who are physically capable of performingfound to be a prominent factor associated with the need for mobility and self-care tasks. This results in earlier rehabilita-assistance in ADLs at the time of discharge from acute reha- tion discharge of individuals still requiring supervision, if notbilitation. Most patients with either cisternal compression or physical assistance.high degrees of midline shift as seen on acute CT scans needed Finally, our study demonstrated that subcortical contusions,another person for overall supervision at acute rehabilitation likely caused by acceleration-deceleration forces that are asso-discharge, whereas less than 50% of those with lesser degrees ciated with DAI, were associated with greatest disability forof shift needed that level of supervision. The degree of midline ADLs and ambulation, both at rehabilitation discharge and at 1shift is often related to the degree of brain injury; thus, there are year after TBI. In fact, the presence of just a single subcorticalmultiple capabilities, both physical and cognitive, that could be contusion was associated with the highest need for globalso affected that a person would be more likely to require supervision. Subcortical contusions accompany high-speed in-supervision. Importantly, and in contrast to earlier studies, juries, such as motor vehicle crashes, and their appearance onneither lesser degrees of midline shift, nor general cerebral a CT scan probably represents only a small amount of theedema, nor focal evidence of cisternal compression showed an actual damage to these structures. Thus, the presence of aassociation with poorer outcomes at 1 year after injury. These subcortical contusion is likely a marker for overall increaseddifferences from previous research highlight the value of using parenchymal injury, because the force necessary to cause amore function-focused outcome measures, such as the FIM and deep contusion is greater than that for more superficial corticalDRS subscales and the SRS. contusions. The clinical abnormalities commonly associated The finding that there was an association between midline with these injuries would be expected to affect a wide varietyshift and the need for supervision at 1 year after TBI, but no of functional skills, including ambulation and ADLs. Althoughassociation with ambulation or ADL dependence, may reflect the need for increased functional assistance for these individ-several factors. These findings show the ability of persons with uals remained statistically significant at 1 year, the actualTBI to recover from many of their initial insults over a longer clinical relevance of this association is limited.period of time. As one might expect, the physical ability to The improvement noted between rehabilitation dischargeperform many familiar functional tasks may return with time, and 1 year after TBI was just as apparent with regard to overallwhereas more advanced cognitive skills that are necessary for supervision needs as it was with ADLs. However, the discrep-complete independence are not recovered as completely. Ad- ancy between the ratings on the level of functioning variable ofditionally, functional adaptations can occur with or without the DRS and the SRS is striking. Even individuals with exten-central nervous system recovery, which might help compensate sive midline shift or subcortical or bilateral temporal lobefor physical limitations to a greater extent than advanced safety contusions improved to the point where less than 25% requiredjudgment. another person at 1 year after TBI as rated by the DRS, whereas Individuals with limitations in mobility and self-care skills 35% to 57% of those were being supervised, according to thewould be likely to receive continued rehabilitation services SRS rating. Ratings for the DRS, generally done by the ratersafter inpatient discharge that may contribute to this adaptation, together with the patients or their caretakers, indicate the levelwhereas therapy for cognitive issues related solely to supervi- of supervision needed; however, SRS ratings typically reflectsion needs are less likely to be funded or may be less effective. the supervision being provided. Neither of these scales indi-Naturally, even in the face of permanent deficits in the brain, cates why that supervision is required. The reasons tend to beindividuals can develop compensatory strategies over time. multifactorial, not the least of which may be force of habit.Thus, a midline shift greater than 5mm in the acute post-TBI Other reasons might include medical complications, such asperiod should alert a clinician to the high likelihood of persis- posttraumatic seizures, or the fact that the patient may have losttent deficits in essential functional skills and the need for income and cannot afford the cost of living alone.ongoing supervision, which can facilitate appropriate rehabil- The effect size in these analyses was not large. Many of theitation program planning. These patients are more likely than statistically significant differences between groups were relatednot to need further rehabilitation services and another person to to the large sample size. Although there is some variability inhelp with basic mobility and ADL skills at rehabilitation dis- the study population, each subject was sufficiently disabled bycharge. his/her injuries to require inpatient rehabilitation. Thus, there Whereas previous studies have shown a relation between are individuals with TBI and intracranial lesions who are notfocal cortical contusions and poorer global outcome,5 we could included in the database because their mobility, ADLs, andnot show a clinically relevant association with a focal area of supervision needs are manageable without inpatient rehabilita-injury. Although there was statistical significance with CT scan tion. In addition, some individuals who were too severelyfindings of occipital lobe contusion, the differences in actual injured to transition directly from acute trauma care to acute Arch Phys Med Rehabil Vol 84, February 2003
  7. 7. 220 EARLY CT SCAN FINDINGS, Englanderrehabilitation were not in this sample because of the inclusion Referencescriteria. As with most longitudinal studies, the population that 1. Brain Trauma Foundation and American Association of Neuro-can be observed over time is biased for “followability.” In logical Surgeons. Management and prognosis of severe traumatic brain injury. New York: Brain Trauma Foundation; 2000.addition, although we used measures that indicate supervision 2. Eisenberg HM, Gary HE, Aldrich EF, et al. Initial CT findings inor assistance for individual mobility or self-care skills and for 753 patients with severe head injury: report from the NIH Trau-living in general, we did not assess why assistance was being matic Coma Data Bank. J Neurosurg 1990;73:688-98.provided. 3. Fearnside MR, Cook RJ, McDougall P, McNeil RJ. The West- Future studies may include a multifactorial analysis of the mead Head Injury Project outcome in severe head injury. Aimportance of various elements in predicting the need for comparative analysis of pre-hospital, clinical and CT variables. Br J Neurosurg 1993;7:267-79.assistance in ADLs or for supervision. Other measures of 4. Quattrocchi KB, Prasad P, Willits NH, Wagner FC. Quantificationinjury severity, as well as psychosocial factors, are likely to be of midline shift as a predictor of poor outcome following headinfluential in any prediction model. We did not describe the injury. Surg Neurol 1991;35:183-8.effect of age, education, social support, or other injuries in this 5. Katz DI, Alexander MP. Traumatic brain injury: predicting coursestudy. of recovery and outcome for patients admitted to rehabilitation. Arch Neurol 1994;51:661-70. 6. Rao N, Jellinek HM, Harvey RF, Flynn MM. Computerized CONCLUSIONS tomography head scans as predictors of rehabilitation outcome. Findings on early CT scans were more highly associated Arch Phys Med Rehabil 1984;65:18-20. 7. Englander JS, Cifu DX, Wright JM, Zafonte R, Mann N, Yablonwith functional outcomes at rehabilitation discharge than at 1 S. The impact of acute complications, fractures, and motor deficitsyear after TBI. A midline shift of greater than 5mm or subcor- of functional outcome and length of stay after traumatic braintical contusions were the most strongly associated CT scan injury: a multicenter analysis. J Head Trauma Rehabil 1996;1(5):findings with regard to ambulation, ADLs, and global super- 15-26.vision needs at rehabilitation discharge and, to a lesser extent, 8. Harrison C, Newton LN, Hall K, Kreutzer JS. Descriptive findingsat 1 year after TBI. The presence of bilateral frontal or tem- from the Traumatic Brain Injury Model Systems National Data-poral contusions was associated with very high rates of global base. J Head Trauma Rehabil 1996;11(5):1-14.supervision at the time of rehabilitation discharge but was not 9. Guide for the Uniform Data Set for Medical Rehabilitation (in-highly associated with the need for assistance in ambulation cluding the FIM™ instrument), version 5.1. Buffalo (NY): State Univ New York; 1997.and ADLs. These associations were no longer significant at 1 10. Rappaport M, Hall KM, Hopkins K, Belleza T, Cope DN. Dis-year after TBI. These findings may help guide rehabilitation ability Rating Scale for severe head trauma patients. Arch Physprofessionals, patients with TBI, and their potential caregivers Med Rehabil 1982;63:118-23.in planning and allocating resources for rehabilitation services 11. Boake C. Supervision rating scale: a measure of functional out-and supervision. come from brain injury. Arch Phys Med Rehabil 1996;77:765-72.Arch Phys Med Rehabil Vol 84, February 2003