Jamshid Ghajar

All Publications

• Hypertonic Saline is Superior to Mannitol for the Combined Effect on Intracranial Pressure and Cerebral Perfusion Pressure Burdens in Patients With Severe Traumatic Brain Injury. Neurosurgery Mangat, H. S., Wu, X., Gerber, L. M., Schwarz, J. T., Fakhar, M., Murthy, S. B., Stieg, P. E., Ghajar, J., Hartl, R. 2019

  Abstract

  BACKGROUND: Hypertonic saline (HTS) and mannitol are effective in reducing intracranial pressure (ICP) after severe traumatic brain injury (TBI). However, their simultaneous effect on the cerebral perfusion pressure (CPP) and ICP has not been studied rigorously.OBJECTIVE: To determine the difference in effects of HTS and mannitol on the combined burden of high ICP and low CPP in patients with severe TBI.METHODS: We performed a case-control study using prospectively collected data from the New York State TBI-trac database (Brain Trauma Foundation, New York, New York). Patients who received only 1 hyperosmotic agent, either mannitol or HTS for raised ICP, were included. Patients in the 2 groups were matched (1:1 and 1:2) for factors associated with 2-wk mortality: age, Glasgow Coma Scale score, pupillary reactivity, hypotension, abnormal computed tomography scans, and craniotomy. Primary endpoint was the combined burden of ICPhigh (>25 mm Hg) and CPPlow (<60 mm Hg).RESULTS: There were 25 matched pairs for 1:1 comparison and 24 HTS patients matched to 48 mannitol patients in 1:2 comparisons. Cumulative median osmolar doses in the 2 groups were similar. In patients treated with HTS compared to mannitol, total number of days (0.6±0.8 vs 2.4±2.3 d, P<.01), percentage of days with (8.8±10.6 vs 28.1±26.9%, P<.01), and the total duration of ICPhigh+CPPlow (11.12±14.11 vs 30.56±31.89 h, P=.01) were significantly lower. These results were replicated in the 1:2 match comparisons.CONCLUSION: HTS bolus therapy appears to be superior to mannitol in reduction of the combined burden of intracranial hypertension and associated hypoperfusion in severe TBI patients.

  View details for DOI 10.1093/neuros/nyz046

  View details for PubMedID 30877299

• Concussion Subtype Identification With the Rivermead Post-concussion Symptoms Questionnaire FRONTIERS IN NEUROLOGY Maruta, J., Lumba-Brown, A., Ghajar, J. 2018; 9

  View details for DOI 10.3389/fneur.2018.01034

  View details for Web of Science ID 000451953400001

• Association of Visual Tracking Metrics With Post-concussion Symptomatology FRONTIERS IN NEUROLOGY Maruta, J., Spielman, L. A., Rajashekar, U., Ghajar, J. 2018; 9

  View details for DOI 10.3389/fneur.2018.00611

  View details for Web of Science ID 000439875000001

• Establishing Evidence for Concussion Subtypes Lumba-Brown, A., Lal, A., Collins, M., Kontos, A., Gioia, G., Bloom, J., Chesnutt, J., Clugston, J., Sills, A., Brody, D., Ghajar, J. LIPPINCOTT WILLIAMS & WILKINS. 2018: E106

  View details for Web of Science ID 000435555500091

• Mild traumatic brain injury and concussion: terminology and classification. Handbook of clinical neurology Sussman, E. S., Pendharkar, A. V., Ho, A. L., Ghajar, J. 2018; 158: 21–24

  Abstract

  Traumatic brain injury (TBI) is a major cause of morbidity and mortality throughout the world. Mild TBI, which is typically defined by Glasgow Coma Scale score ≥13, accounts for the vast majority of all TBIs, particularly in the setting of sports-related injuries. The terms concussion and TBI are often used interchangeably, both in the medical literature and in clinical care of this patient population. However, the lack of clearly defined definitions of these terms often leads to confusion, and this confusion may lead to delayed diagnosis and inconsistent management of affected patients. Here, we review the current terminology and classification of mild TBI and concussion. We will also discuss recent efforts to stratify these injuries into clinically relevant subtypes or profiles that are both diagnostic- and treatment-targeted.

  View details for DOI 10.1016/B978-0-444-63954-7.00003-3

  View details for PubMedID 30482349

• Visual Tracking in Development and Aging FRONTIERS IN NEUROLOGY Maruta, J., Spielman, L. A., Rajashekar, U., Ghajar, J. 2017; 8: 640

  Abstract

  A moving target is visually tracked with a combination of smooth pursuit and saccades. Human visual tracking eye movement develops through early childhood and adolescence, and declines in senescence. However, the knowledge regarding performance changes over the life course is based on data from distinct age groups in isolation using different procedures, and thus is fragmented. We sought to describe the age-dependence of visual tracking performance across a wide age range and compare it to that of simple visuo-manual reaction time. We studied a cross-sectional sample of 143 subjects aged 7-82 years old (37% male). Eye movements were recorded using video-oculography, while subjects viewed a computer screen and tracked a small target moving along a circular trajectory at a constant speed. For simple reaction time (SRT) measures, series of key presses that subjects made in reaction to cue presentation on a computer monitor were recorded using a standard software. The positional precision and smooth pursuit velocity gain of visual tracking followed a U-shaped trend over age, with best performances achieved between the ages of 20 and 50 years old. A U-shaped trend was also found for mean reaction time in agreement with the existing literature. Inter-individual variability was evident at any age in both visual tracking and reaction time metrics. Despite the similarity in the overall developmental and aging trend, correlations were not found between visual tracking and reaction time performances after subtracting the effects of age. Furthermore, while a statistically significant difference between the sexes was found for mean SRT in the sample, a similar difference was not found for any of the visual tracking metrics. Therefore, the cognitive constructs and their neural substrates supporting visual tracking and reaction time performances appear largely independent. In summary, age is an important covariate for visual tracking performance, especially for a pediatric population. Since visual tracking performance metrics may provide signatures of abnormal neurological or cognitive states independent of reaction time-based metrics, further understanding of age-dependent variations in normal visual tracking behavior is necessary.

  View details for DOI 10.3389/fneur.2017.00640

  View details for Web of Science ID 000416519300002

  View details for PubMedID 29250026

  View details for PubMedCentralID PMC5714854

• The Effect of Physical Exercise After a Concussion: A Systematic Review and Meta-analysis. American journal of sports medicine Lal, A., Kolakowsky-Hayner, S. A., Ghajar, J., Balamane, M. 2017: 363546517706137-?

  Abstract

  Data evaluating the role of exercise in patients with a concussion are contradictory. Studies have reported improvement in the Post-Concussion Symptom Scale (PCSS) score, whereas others showed no effect on the PCSS score.To conduct a systematic review and meta-analysis on the role of physical exercise on different outcomes in patients with a concussion.Systematic review and meta-analysis.A search of 5 databases from the earliest available date to September 30, 2016, and a hand search of a few articles were performed. Trial registries were reviewed, and authors of multiple studies were contacted to find additional published or unpublished studies. Randomized controlled trials (RCTs), cohort studies, and before and after (pre-post) studies evaluating the effect of physical exercise, compared with control, in patients with a concussion or mild traumatic brain injury were included.The search generated 1096 studies. Of these, 14 studies (5 RCTs, 1 propensity score matching study, 3 cohort studies, and 5 before and after studies) met our inclusion criteria. Exercise significantly decreased the PCSS score (mean difference, -13.06; 95% CI, -16.57 to -9.55; P < .00001; I(2) = 44%), percentage of patients with symptoms of a concussion (risk ratio, 0.74; 95% CI, 0.63 to 0.86; P = .0001; I(2) = 0%), and days off work (17.7 days vs 32.2 days, respectively; P < .05) compared with control. Exercise improved the reaction time (standard mean difference, -0.43; 95% CI, -0.80 to -0.06; P = .02) component of the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) score without affecting the Balance Error Scoring System (BESS) score and neuropsychological parameters. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) scores were moderate for the PCSS, symptoms, ImPACT, BESS, and neuropsychological tests.Physical exercise appears to improve the PCSS score and symptoms in patients with a concussion. A high-quality RCT evaluating different intensities of exercise at different time points, for different durations after a concussion, for different races/ethnicities, and for sex needs to be conducted to evaluate a clear effect of exercise in patients with a concussion.

  View details for DOI 10.1177/0363546517706137

  View details for PubMedID 28570092

• In Reply: Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery Hawryluk, G. W., Ullman, J. S., Totten, A. M., Ghajar, J. 2017

  View details for DOI 10.1093/neuros/nyx087

  View details for PubMedID 28402563

• Frequency Responses to Visual Tracking Stimuli May Be Affected by Concussion MILITARY MEDICINE Maruta, J., Jaw, E., Modera, P., Rajashekar, U., Spielman, L. A., Ghajar, J. 2017; 182: 120-123

  Abstract

  Human visual tracking performance is known to be reduced with an increase of the target's speed and oscillation frequency, but changes in brain states following a concussion may alter these frequency responses. The goal of this study was to characterize and compare frequency-dependent smooth pursuit velocity degradation in normal subjects and patients who had chronic postconcussion symptoms, and also examine cases of acutely concussed patients. Eye movements were recorded while subjects tracked a target that moved along a circular trajectory of 10° radius at 0.33, 0.40, or 0.67 Hz. Performance was characterized by the gain of smooth pursuit velocity, with reduced gain indicating reduced performance. The difference between normal and chronic patient groups in the pattern of decrease in the gain of horizontal smooth pursuit velocity as a function of the stimulus frequency reflected patients performing more poorly than normal subjects at 0.4 Hz while both groups performing similarly at 0.33 or 0.67 Hz. The performance of acute patients may represent yet another type of frequency response. The findings suggest that there may be ranges of stimulus frequencies that differentiate the effects of concussion from normal individuals.

  View details for DOI 10.7205/MILMED-D-16-00093

  View details for Web of Science ID 000398947100020

  View details for PubMedID 28291462

• Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery Carney, N., Totten, A. M., O'Reilly, C., Ullman, J. S., Hawryluk, G. W., Bell, M. J., Bratton, S. L., Chesnut, R., Harris, O. A., Kissoon, N., Rubiano, A. M., Shutter, L., Tasker, R. C., Vavilala, M. S., Wilberger, J., Wright, D. W., Ghajar, J. 2016: -?

  Abstract

  The scope and purpose of this work is 2-fold: to synthesize the available evidence and to translate it into recommendations. This document provides recommendations only when there is evidence to support them. As such, they do not constitute a complete protocol for clinical use. Our intention is that these recommendations be used by others to develop treatment protocols, which necessarily need to incorporate consensus and clinical judgment in areas where current evidence is lacking or insufficient. We think it is important to have evidence-based recommendations to clarify what aspects of practice currently can and cannot be supported by evidence, to encourage use of evidence-based treatments that exist, and to encourage creativity in treatment and research in areas where evidence does not exist. The communities of neurosurgery and neuro-intensive care have been early pioneers and supporters of evidence-based medicine and plan to continue in this endeavor. The complete guideline document, which summarizes and evaluates the literature for each topic, and supplemental appendices (A-I) are available online at https://www.braintrauma.org/coma/guidelines.TBI, traumatic brain injuryRESCUEicp, Randomised Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of ICP.

  View details for PubMedID 27654000

• Degradation of Binocular Coordination during Sleep Deprivation FRONTIERS IN NEUROLOGY Tong, J., Maruta, J., Heaton, K. J., Maule, A. L., Rajashekar, U., Spielman, L. A., Ghajar, J. 2016; 7

  Abstract

  To aid a clear and unified visual perception while tracking a moving target, both eyes must be coordinated, so the image of the target falls on approximately corresponding areas of the fovea of each eye. The movements of the two eyes are decoupled during sleep, suggesting a role of arousal in regulating binocular coordination. While the absence of visual input during sleep may also contribute to binocular decoupling, sleepiness is a state of reduced arousal that still allows for visual input, providing a context within which the role of arousal in binocular coordination can be studied. We examined the effects of sleep deprivation on binocular coordination using a test paradigm that we previously showed to be sensitive to sleep deprivation. We quantified binocular coordination with the SD of the distance between left and right gaze positions on the screen. We also quantified the stability of conjugate gaze on the target, i.e., gaze-target synchronization, with the SD of the distance between the binocular average gaze and the target. Sleep deprivation degraded the stability of both binocular coordination and gaze-target synchronization, but between these two forms of gaze control the horizontal and vertical components were affected differently, suggesting that disconjugate and conjugate eye movements are under different regulation of attentional arousal. The prominent association found between sleep deprivation and degradation of binocular coordination in the horizontal direction may be used for a fit-for-duty assessment.

  View details for DOI 10.3389/fneur.2016.00090

  View details for Web of Science ID 000377585200002

  View details for PubMedID 27379009

• Clinical evaluation of concussion: the evolving role of oculomotor assessments NEUROSURGICAL FOCUS Sussman, E. S., Ho, A. L., Pendharkar, A. V., Ghajar, J. 2016; 40 (4)

  Abstract

  Sports-related concussion is a change in brain function following a direct or an indirect force to the head, identified in awake individuals and accounting for a considerable proportion of mild traumatic brain injury. Although the neurological signs and symptoms of concussion can be subtle and transient, there can be persistent sequelae, such as impaired attention and balance, that make affected patients particularly vulnerable to further injury. Currently, there is no accepted definition or diagnostic criteria for concussion, and there is no single assessment that is accepted as capable of identifying all patients with concussion. In this paper, the authors review the available screening tools for concussion, with particular emphasis on the role of visual function testing. In particular, they discuss the oculomotor assessment tools that are being investigated in the setting of concussion screening.

  View details for DOI 10.3171/2016.1.FOCUS15610

  View details for Web of Science ID 000373476500006

  View details for PubMedID 27032924

• Executive summary of concussion guidelines step 1: systematic review of prevalent indicators. Neurosurgery Carney, N., Ghajar, J., Jagoda, A., Bedrick, S., Davis-O'Reilly, C., du Coudray, H., Hack, D., Helfand, N., Huddleston, A., Nettleton, T., Riggio, S. 2014; 75: S1-2

  View details for DOI 10.1227/NEU.0000000000000434

  View details for PubMedID 24867198

• Concussion guidelines step 1: systematic review of prevalent indicators. Neurosurgery Carney, N., Ghajar, J., Jagoda, A., Bedrick, S., Davis-O'Reilly, C., du Coudray, H., Hack, D., Helfand, N., Huddleston, A., Nettleton, T., Riggio, S. 2014; 75: S3-S15

  Abstract

  Currently, there is no evidence-based definition for concussion that is being uniformly applied in clinical and research settings.To conduct a systematic review of the highest-quality literature about concussion and to assemble evidence about the prevalence and associations of key indicators of concussion. The goal was to establish an evidence-based foundation from which to derive, in future work, a definition, diagnostic criteria, and prognostic indicators for concussion.Key questions were developed, and an electronic literature search from 1980 to 2012 was conducted to acquire evidence about the prevalence of and associations among signs, symptoms, and neurologic and cognitive deficits in samples of individuals exposed to potential concussive events. Included studies were assessed for potential for bias and confound and rated as high, medium, or low potential for bias and confound. Those rated as high were excluded from the analysis. Studies were further triaged on the basis of whether the definition of a case of concussion was exclusive or inclusive; only those with wide, inclusive case definitions were used in the analysis. Finally, only studies reporting data collected at fixed time points were used. For a study to be included in the conclusions, it was required that the presence of any particular sign, symptom, or deficit be reported in at least 2 independent samples.From 5437 abstracts, 1362 full-text publications were reviewed, of which 231 studies were included in the final library. Twenty-six met all criteria required to be used in the analysis, and of those, 11 independent samples from 8 publications directly contributed data to conclusions. Prevalent and consistent indicators of concussion are (1) observed and documented disorientation or confusion immediately after the event, (2) impaired balance within 1 day after injury, (3) slower reaction time within 2 days after injury, and/or (4) impaired verbal learning and memory within 2 days after injury.The results of this systematic review identify the consistent and prevalent indicators of concussion and their associations, derived from the strongest evidence in the published literature. The product is an evidence-based foundation from which to develop diagnostic criteria and prognostic indicators.GCS, Glasgow Coma ScaleLOC, loss of consciousnessPCE, potential concussive eventPTA, posttraumatic amnesiaSOT, Sensory Organization TestSSD, signs, symptoms, neurologic deficits, and cognitive deficits.

  View details for DOI 10.1227/NEU.0000000000000433

  View details for PubMedID 25006974

• Possible Medication-Resistant Deficits in Adult ADHD. Journal of attention disorders Maruta, J., Spielman, L. A., Tseretopoulos, I. D., Hezghia, A., Ghajar, J. 2014

  Abstract

  The nature of ADHD, especially in adulthood, is not well-understood. Therefore, we explored subcomponents of attention in adult ADHD.Twenty-three adults with ADHD were tested on neurocognitive and visual tracking performance both while on their regular prescription stimulant medication and while abstaining from the medication for 1 day. Pairwise comparisons to 46 two-for-one matched normal controls were made to detect medication-resistant effects of ADHD, and within-participant comparisons were made to detect medication-sensitive effects in patients.Even when on medication, patients performed more poorly than controls on a spatial working memory task, and on visual tracking and simple reaction time tasks immediately following other attention-demanding tasks. Patients' visual tracking performance degraded while off-medication in a manner consistent with reduced vigilance.There may be persistent cognitive impairments in adult ADHD despite medication. In addition, the benefit of stimulants seems reduced under cognitive fatigue.

  View details for PubMedID 24970719

• Predictive Visual Tracking: Specificity in Mild Traumatic Brain Injury and Sleep Deprivation MILITARY MEDICINE Maruta, J., Heaton, K. J., Mau, A. L., Ghajar, J. 2014; 179 (6): 619-625

  Abstract

  We tested whether reduced cognitive function associated with mild traumatic brain injury (mTBI) and sleep deprivation can be detected and distinguished using indices of predictive visual tracking. A circular visual tracking test was given to 13 patients with acute mTBI (recruited within 2 weeks of injury), 127 normal control subjects, and 43 healthy subjects who were fatigued by 26-hour sleep deprivation. Eye movement was monitored with video-oculography. In the mTBI-related portion of the study, visual tracking performance of acute mTBI patients was significantly worse than normal subjects (p < 0.001). In the sleep-deprivation-related portion of the study, no change was detected between the two baseline measures separated by 2 to 3 weeks, but the 26-hour sleep deprivation significantly degraded the visual tracking performance (p < 0.001). The mTBI subjects had substantially worse visual tracking than sleep-deprived subjects that could also be identified with different visual tracking indices, indicating possible different neurophysiological mechanisms. Results suggest that cognitive impairment associated with mTBI and fatigue may be triaged with the aid of visual tracking measures.

  View details for DOI 10.7205/MILMED-D-13-00420

  View details for Web of Science ID 000340806500006

  View details for PubMedID 24902128

• Detecting eye movement abnormalities from concussion. Progress in neurological surgery Maruta, J., Ghajar, J. 2014; 28: 226-233

  Abstract

  An attention-based biomarker may be useful for concussion screening. A key role of attention is to generate time-based expectancies of specific sensory information, and it is postulated that postconcussion cognitive impairments and symptoms may stem from a primary deficit in this predictive timing mechanism. There is a close relationship between gaze and attention, but in addressing predictive timing, there is a need for an appropriate testing paradigm and methods to quantify oculomotor anomalies. We have utilized a continuous predictive visual tracking paradigm because human visual tracking requires predicting the temporal course of a stimulus and dynamically synchronizing the required action with the stimulus. We have shown that concussion patients often show disrupted gaze-target synchronization characterized by large gaze position error variability and overall phase advancement. Various attention components interact with visual tracking, and thus there is a possibility that different neurological and physiological conditions produce identifiable visual tracking characteristics. Analyzing neuromotor functions, specifically oculomotor synchronization, can provide a fast, accurate, and reliable assessment of cognitive functions. © 2014 S. Karger AG, Basel.

  View details for DOI 10.1159/000358786

  View details for PubMedID 24923406

• Individual Differences in Distinct Components of Attention are Linked to Anatomical Variations in Distinct White Matter Tracts. Frontiers in neuroanatomy Niogi, S., Mukherjee, P., Ghajar, J., McCandliss, B. D. 2010; 4: 2-?

  Abstract

  Inter-subject variations in white matter tract properties are known to correlate with individual differences in performance in cognitive domains such as attention. The specificity of such linkages, however, is largely unexplored at the level of specific component operations of attention associated with distinct anatomical networks. This study examines individual performance variation within three functional components of attention - alerting, orienting, and conflict processing - identified by the Attention Network Task (ANT), and relates each to inter-subject variation in a distinct set of white matter tract regions. Diffusion tensor imaging data collected at 3T was used to calculate average fractional anisotropy within a set of individualized a priori defined regions of interest using the Reproducible Objective Quantification Scheme (ROQS) (Niogi and McCandliss, 2006; Niogi et al., 2007). Results demonstrate three functionally distinct components of attention that each correlate distinctly with three white matter tract regions. Structure-function correlations were found between alerting and the anterior limb of the internal capsule, orienting and the splenium of the corpus callosum, and conflict and the anterior corona radiata. A multiple regression/dissociation analysis demonstrated a triple dissociation between these three structure-function relationships that provided evidence of three anatomically and functionally separable networks. These results extend previous findings from functional imaging and lesion studies that suggest these three components of attention are subserved by dissociable networks, and suggest that variations in white matter tract microstructure may modulate the efficiency of these cognitive processes in highly specific ways.

  View details for DOI 10.3389/neuro.05.002.2010

  View details for PubMedID 20204143

• Increasing Adherence to Brain Trauma Foundation Guidelines for Hospital Care of Patients With Traumatic Brain Injury CRITICAL CARE NURSE Saherwala, A. A., Bader, M., Stutzman, S. E., Figueroa, S. A., Ghajar, J., Gorman, A. R., Minhajuddin, A., Olson, D. M. 2018; 38 (1): E11–E20

  Abstract

  The Brain Trauma Foundation has developed treatment guidelines for the care of patients with acute traumatic brain injury. The Adam Williams Initiative is a program established to provide education and resources to encourage hospitals across the United States to incorporate the guidelines into practice.To explore the relationship in hospitals between participation in the Adam Williams Initiative and adherence to the Brain Trauma Foundation guidelines for patients with acute traumatic brain injury.Hospitals that participated in the Adam Williams Initiative entered data into an online tracking system of patients with traumatic brain injury for at least 2 years after the initial site training. Data included baseline hospital records and daily records on hospital care of patients with traumatic brain injury, including blood pressure, intracranial pressure, cerebral perfusion pressure, oxygenation, and other data relevant to the 15 key metrics in the Brain Trauma Foundation guidelines.The 16 hospitals funded by the Adam Williams Initiative had good overall adherence to the 15 key metrics of the recommendations detailed in the Brain Trauma Foundation guidelines. Variability in results was primarily due to data collection methods and analysis.The Adam Williams Initiative helps promote adherence to the Brain Trauma Foundation guidelines for hospital care of patients with traumatic brain injury by providing a platform for developing and standardizing best practices. Participation in the initiative is associated with high adherence to clinical guidelines, a situation that may subsequently improve care and outcomes for patients with traumatic brain injury.

  View details for DOI 10.4037/ccn2018691

  View details for Web of Science ID 000426966400002

  View details for PubMedID 29437084

• Living Guideline Development in Traumatic Brain Injury: Opportunities to Link Quality of Care, Research, and Better Patient Outcomes to a Future Research Agenda Kolakowsky-Hayner, S. A., Totten, A. M., Assasnik, S., Balamane, M., Ghajar, J. LIPPINCOTT WILLIAMS & WILKINS. 2017: E85–E86

  View details for Web of Science ID 000418588100053

• Chronic Post-Concussion Neurocognitive Deficits. II. Relationship with Persistent Symptoms FRONTIERS IN HUMAN NEUROSCIENCE Maruta, J., Spielman, L. A., Yarusi, B. B., Wang, Y., Silver, J. M., Ghajar, J. 2016; 10

  Abstract

  Individuals who sustain a concussion may continue to experience problems long after their injury. However, it has been postulated in the literature that the relationship between a concussive injury and persistent complaints attributed to it is mediated largely by the development of symptoms associated with posttraumatic stress disorder (PTSD) and depression. We sought to characterize cognitive deficits of adult patients who had persistent symptoms after a concussion and determine whether the original injury retains associations with these deficits after accounting for the developed symptoms that overlap with PTSD and depression. We compared the results of neurocognitive testing from 33 patients of both genders aged 18-55 at 3 months to 5 years post-injury with those from 140 control subjects. Statistical comparisons revealed that patients generally produced accurate responses on reaction time-based tests, but with reduced efficiency. On visual tracking, patients increased gaze position error variability following an attention demanding task, an effect that may reflect greater fatigability. When neurocognitive performance was examined in the context of demographic- and symptom-related variables, the original injury retained associations with reduced performance at a statistically significant level. For some patients, reduced cognitive efficiency and fatigability may represent key elements of interference when interacting with the environment, leading to varied paths of recovery after a concussion. Poor recovery may be better understood when these deficits are taken into consideration.

  View details for DOI 10.3389/fnhum.2016.00045

  View details for Web of Science ID 000370120800001

  View details for PubMedID 26912999

• Chronic Post-Concussion Neurocognitive Deficits. I. Relationship with White Matter Integrity FRONTIERS IN HUMAN NEUROSCIENCE Maruta, J., Palacios, E. M., Zimmerman, R. D., Ghajar, J., Mukherjee, P. 2016; 10

  Abstract

  We previously identified visual tracking deficits and associated degradation of integrity in specific white matter tracts as characteristics of concussion. We re-explored these characteristics in adult patients with persistent post-concussive symptoms using independent new data acquired during 2009-2012. Thirty-two patients and 126 normal controls underwent cognitive assessments and MR-DTI. After data collection, a subset of control subjects was selected to be individually paired with patients based on gender and age. We identified patients' cognitive deficits through pairwise comparisons between patients and matched control subjects. Within the remaining 94 normal subjects, we identified white matter tracts whose integrity correlated with metrics that indicated performance degradation in patients. We then tested for reduced integrity in these white matter tracts in patients relative to matched controls. Most patients showed no abnormality in MR images unlike the previous study. Patients' visual tracking was generally normal. Patients' response times in an attention task were slowed, but could not be explained as reduced integrity of white matter tracts relating to normal response timing. In the present patient cohort, we did not observe behavioral or anatomical deficits that we previously identified as characteristic of concussion. The recent cohort likely represented those with milder injury compared to the earlier cohort. The discrepancy may be explained by a change in the patient recruitment pool circa 2007 associated with an increase in public awareness of concussion.

  View details for DOI 10.3389/fnhum.2016.00035

  View details for Web of Science ID 000369850900001

  View details for PubMedID 26903842

• Filling in the gaps: Anticipatory control of eye movements in chronic mild traumatic brain injury NEUROIMAGE-CLINICAL Diwakar, M., Harrington, D. L., Maruta, J., Ghajar, J., El-Gabalawy, F., Muzzatti, L., Corbetta, M., Huang, M., Lee, R. R. 2015; 8: 210-223

  Abstract

  A barrier in the diagnosis of mild traumatic brain injury (mTBI) stems from the lack of measures that are adequately sensitive in detecting mild head injuries. MRI and CT are typically negative in mTBI patients with persistent symptoms of post-concussive syndrome (PCS), and characteristic difficulties in sustaining attention often go undetected on neuropsychological testing, which can be insensitive to momentary lapses in concentration. Conversely, visual tracking strongly depends on sustained attention over time and is impaired in chronic mTBI patients, especially when tracking an occluded target. This finding suggests deficient internal anticipatory control in mTBI, the neural underpinnings of which are poorly understood. The present study investigated the neuronal bases for deficient anticipatory control during visual tracking in 25 chronic mTBI patients with persistent PCS symptoms and 25 healthy control subjects. The task was performed while undergoing magnetoencephalography (MEG), which allowed us to examine whether neural dysfunction associated with anticipatory control deficits was due to altered alpha, beta, and/or gamma activity. Neuropsychological examinations characterized cognition in both groups. During MEG recordings, subjects tracked a predictably moving target that was either continuously visible or randomly occluded (gap condition). MEG source-imaging analyses tested for group differences in alpha, beta, and gamma frequency bands. The results showed executive functioning, information processing speed, and verbal memory deficits in the mTBI group. Visual tracking was impaired in the mTBI group only in the gap condition. Patients showed greater error than controls before and during target occlusion, and were slower to resynchronize with the target when it reappeared. Impaired tracking concurred with abnormal beta activity, which was suppressed in the parietal cortex, especially the right hemisphere, and enhanced in left caudate and frontal-temporal areas. Regional beta-amplitude demonstrated high classification accuracy (92%) compared to eye-tracking (65%) and neuropsychological variables (80%). These findings show that deficient internal anticipatory control in mTBI is associated with altered beta activity, which is remarkably sensitive given the heterogeneity of injuries.

  View details for DOI 10.1016/j.nicl.2015.04.011

  View details for Web of Science ID 000373187100022

  View details for PubMedCentralID PMC4473731

• Impact of falls on early mortality from severe traumatic brain injury. Journal of trauma management & outcomes Gerber, L. M., Ni, Q., Härtl, R., Ghajar, J. 2009; 3: 9-?

  Abstract

  The causes of severe traumatic brain injury (TBI) vary by age and other demographic characteristics. Mortality after trauma is higher for elderly than younger patients. This study is based on 2779 patients with severe TBI treated at 24 trauma centers enrolled in a New York State quality improvement program. The prospectively collected database includes information on age, sex, mechanism of injury, initial Glasgow Coma Scale score, blood pressure, pupillary assessment, and CT scan findings. This multi-center study was conducted to explore the impact of falls on early mortality from severe TBI among the elderly.After exclusion criteria were applied, a total of 2162 patients were eligible for analysis. Falls contributed to 21% of all severe TBI, 12% occurring from > 3 meters and 9% from < 3 meters. Two-week mortality ranged from 18% due to injuries other than falls to 31% due to falls from < 3 meters (p =< 0.0001). Mortality after a severe TBI is much greater among older people, reaching 58% for people 65 years and older sustaining a fall from < 3 meters.Among those 65 and older, falls contributed to 61% of all injuries and resulted in especially high mortality among individuals experiencing low falls. Preventive efforts directed toward older people to avoid falls from < 3 meters could have a significant impact on mortality.

  View details for DOI 10.1186/1752-2897-3-9

  View details for PubMedID 19643003