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Management of Adults with Traumatic Brain Injury

Alexander, Michael P. MD

Cognitive And Behavioral Neurology: September 2013 - Volume 26 - Issue 3 - p 168–169
doi: 10.1097/WNN.0000000000000005
Book Reviews
Free Department of Neurology Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA

The reviewer declares no conflicts of interest.

Being asked to review this book as a neurologist for a neurologic journal illuminated a minor irony: Traumatic brain injury (TBI) is not a disorder treated by neurologists. The care of mild injuries and concussions proceeds from emergency department physicians (CT or no CT; admit or no admit) to primary care physicians (MRI or no MRI; referral or no referral) to either recovery or various forms of concussion specialists—physiatry, neuropsychology, neuropsychiatry—but rarely to neurology.

The care of severe TBI proceeds in similar fashion: emergency department to neurosurgery to, in most places, inpatient rehabilitation and inpatient physiatry to outpatient specialty programs in physiatry, neuropsychology, neuropsychiatry, and various multidisciplinary therapy groups. Some of the sequelae find their way to neurologists: headaches, dizziness, the occasional seizure, and perhaps late spasticity management or cognitive evaluation. But the understanding of injuries and their overall management has largely escaped neurology.

There are, to be sure, publications on TBI management in neurology journals. Recently, they have been focusing on advanced imaging techniques that might clarify the nature of TBI, especially mild TBI. There are American Academy of Neurology annual meeting sessions on TBI. Neurologists seem to play a larger role in the military care of TBI, if not so much in the Veterans Affairs health care system. The editors of major multi-authored texts, such as this one, usually include a neurologist, as does this one, but it is not a disorder that has demanded much attention in our field.

There are strengths to this book. The description of the stages of recovery from more severe TBI (Chapter 5; Table 5-2) is very helpful. Chapter 3 on neuropsychological assessment is thorough, recognizing specific issues of different epochs of recovery; the text might suggest more testing than is really necessary for monitoring recovery, but makes a case for it.

Chapter 4 on consciousness is quite good. The authors dismiss the possible value of detailing the anatomy of lesions, based on a single study (Whyte et al, 2005) that used imaging technology more than 10 years out of date. Chapter 8 on posttraumatic stress disorder is good. Chapter 17 on TBI in the elderly is a goldmine of common sense.

Chapter 18’s review of concussion in athletes is reasonable, though failing to truly note the uncertainties of management beyond a nearly religious faith in rest, and not returning to the claim made in the first chapter that concussion in athletes is somehow different from other concussions and cannot inform us about them.

Chapter 20 on persistent symptoms after mild TBI is generally good before it slips into an idiosyncratic psychotherapy model. (And I, like the authors, will miss the occasional discussion and consultation with Tom Kay, an excellent neuropsychologist, instrumental in establishing services for patients with TBI, who died much too young in 2012.)

Tables are used successfully throughout the book to present multiple dimensions—mechanisms, side effects, interactions—of all classes of medications that might be needed in post-acute TBI care. There are comprehensive tabulations of differential diagnoses of problems that occur after TBI but that might not be caused by the TBI. Throughout the book, the authors are diligent about recognizing the importance of pre-injury psychology and of post-injury situational factors in the management of the patients. Almost every chapter (for instance, pages 150 to 151) has an important reminder about attention to basic health—sleep, activities, and how to use everyday interventions to assist performance. Chapter by chapter, the authors acknowledge the overlap of symptoms and signs of different posttraumatic problems like sleep, mood, anxiety, and pain. The overall organization of the book is very transparent, making it easy to use for quick reference for a specific problem. It is inexpensive at $67 on, with a rave review from a hospitalist in inpatient rehabilitation—on reflection, perhaps the ideal candidate for this book.

Despite its strengths, this may not be a very satisfactory text for neurologists. I recommend looking through it before purchase. Some examples of what I found problematic:

The introduction to Chapter 2, on “Medical Evaluation,” indicates that the chapter will focus on evaluations “performed by physicians in subacute inpatient rehabilitation settings or outpatient clinics” (page 35). There are, however, sections that are unnecessary, even cringe-inducing for physicians: how to introduce yourself to a patient, summaries of how to obtain family histories, etc. The chapter also has a list of every element of the neurologic examination. Most of the audience will never perform it nor care about how it is performed; the rest will have been doing it for years.

Throughout the text are references to the superiority of neuropsychological testing over other tools for diagnosing mild TBI, without mentioning that no gold standard exists for comparison. If there were a gold standard, then there would be no need to compare modalities. What the claim of superiority actually means is that neuropsychological testing is better than other approaches at identifying a cluster of deficits compatible with mild TBI; however, these deficits are in no way pathognomonic.

Brief summaries of pathology are serial topic sentences, plunging from casual descriptions of contusion locations down to a sample of micropathologies and channelopathies induced by trauma—the latter entirely opaque to all but neuroscientists. There are many undigested differential diagnosis discussions, with proportionality and probabilities not made clear.

Throughout the book, the authors emphasize using structured interviews and standardized questionnaires and examinations—essentially none of them designed for TBI. To characterize “neuropsychiatric disturbances” after TBI, Table 2-3 lists 12 (!) suitable scales. To characterize cognitive symptoms, Table 5-3 suggests 6 scales, and, to examine cognition, Table 5-4 suggests 10 tests—even the MMSE—arrayed across various epochs of recovery.

The book runs a risk of “neophrenology” with its confident claims that this brain region performs that brain function or that a lesion in that area will cause this problem. Perhaps the statement that damage to the anterior cingulate region causes “decreased goal-directed cognition, emotion and behavior” seems a little reductionist to me, given the anterior cingulate gyrus’ wiring and its neighbors. More seriously, I guarantee that the neurologically naive will assume that the correlation works in the other direction: If A=B, then surely B=A.

But in the other direction, the book creates too many casual networks without clear cross reference, so that, for instance, the network of fatigue looks a lot like the network of apathy. Although the authors give intermittent descriptions of the different epochs of recovery and the different questions that arise in mild versus severe TBI, these distinctions too often get hazy: Recommendations come with a broad brush when a fine one for one specific epoch or one level of severity would be more appropriate. I think that the book would have been much stronger if it had proceeded on all fronts across the time course of recovery, keeping mild and severe TBI separate.

Although the interaction of different post-TBI problems is often mentioned, there is no single place to turn for help for a severely injured patient transferred to rehabilitation in a confusional state (encephalopathy, in Chapter 5), agitated (Chapter 10), tearful and frightened (Chapter 7), not sleeping (Chapter 15), on levetiracetam for a single seizure 10 days after trauma. The authors provide a better summary of these multifactorial problems for patients with mild TBI (Chapter 20).

The book is not intended as an encyclopedia of TBI, but the authors’ method of citing references will leave many readers stranded. The authors generally do not line up citations with claims. A table listing many cognitive interventions lacks a single reference for the reader to turn to for guidance about implementation or validity. In many places in the text, a list of symptoms or complications is followed by a series of references, with no indication of which goes with which.

Ah, deadlines. Even though they share authors, the excellent 2013 review by Theeler et al in Headache reaches different conclusions about headache from those of the chapter here. The very tight chapter on consciousness was not able to cite the authors’ own 2012 work on amantadine (Giacino et al, 2012).

But the main limitation for neurologists is the clear and unapologetic message that neuropsychiatrists should treat the sequelae of TBI. The page count for psychiatric issues equals the combined page count for pathology, imaging, natural history, and all somatic management issues. The claims for frequencies of neuropsychiatric disorders are so broad as to lose meaning: mood disorders in 6% to 77% of patients, and aggression in 5% to 70%. Much of the literature is out of date; eg, the references for aggression in epilepsy are more than 25 years old.

Each chapter with a “psychiatric” title (Chapters 6 to 12) labors to align disorders developing after TBI with a DSM-IV diagnosis. Working from an injury with a specifiable pathology to one without might be the wrong direction to go. Because of this approach, too much concern is given to diagnosis (yes or no; cutoff scores), when the issues, at least for patients recovering from TBI, might be more helpfully considered continuous (eg, the patient’s thoughts perhaps a little loose, apathy a portion of the problem). The treatment sections are peppered with “conflicting,” “emerging,” “beginning,” and “suggesting” because there is so little evidence for any specific interventions. The forensic chapter (21) has a very useful discussion of substituted judgments and competencies, but it is, not surprisingly, written as though only psychiatrists, not neurologists, could tackle this problem, whatever the legal requirements for psychiatry.

This book has many strengths, but as I noted at the outset, the understanding of injuries and their overall management has largely escaped neurology. I think that neurologists interested in TBI will probably prefer Zasler et al’s 2007Brain Injury Medicine: Principles and Practice (which shares one of the editors of the reviewed book), even though Zasler is more expensive, with a best price of $170 on

Michael P. Alexander, MD

Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA

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Giacino JT, Whyte J, Bagiella E, et al..Placebo-controlled trial of amantadine for severe traumatic brain injury.N Engl J Med.2012;366:819–826.
Theeler B, Lucas S, Riechers RG 2nd, et al..Post-traumatic headaches in civilians and military personnel: a comparative, clinical review.Headache.2013;53:881–900.
Whyte J, Katz D, Long D, et al..Predictors of outcome in prolonged posttraumatic disorders of consciousness and assessment of medication effects: a multicenter study.Arch Phys Med Rehabil.2005;86:453–462.
Zasler ND, Katz DI, Zafonte RD.Brain Injury Medicine: Principles and Practice.2007.New York:Demos Medical Publishing.
© 2013 by Lippincott Williams & Wilkins.