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SURVIVAL OUTCOME FOLLOWING DECOMPRESSIVE CRANIECTOMY IN TRAUMATIC BRAIN INJURY.
Neuropsychology 2009, Vol. 23, No.
There have been a number of excellent reviews on neurocognitive outcomes after pediatric TBI. They have, however, focused on a subsample of this population (e.g., mild injuries [Satz et al., 1997]) or on a specic cognitive domain (e.g., executive function [Levin & Hanten, 2005]). Further, to the best of our knowledge, there has not been a systematic meta-analytic review of neurocognitive outcomes across domains, accounting for time post injury, injury severity, and age at injury. In this review, we attempted to provide a systematic, quantitative summary of the literature.
changes in raw scores. Further, we are aware that in cases where more than one measure of a function (e.g., attention) were reported, we did not observe the independent observations prerequisite for inclusion in the effect size calculations. We decided to include multiple measures of the same neurocognitive domain within the same study because we believe that each measure contributes uniquely to the study of a given neurocognitive domain (e.g., sustained vs. divided attention) and that eliminating measures may bias the results. We also had no basis of eliminating one subskill wihin a given domain in favor of another. The following neurocognitive domains were included in the analyses: General Intellectual Functioning (FSIQ or its equivalent; Verbal IQ; and Performance IQ); Attention/Executive Functions (working memory, processing speed/reaction time, attention, uency, inhibition, and problem solving); Memory (verbal/visual immediate/delayed); and Visual Perceptual/Motor skills. Although there were several pivotal studies of language functions, academic skills, and motor skills, we focused on more traditional neurocognitive domains to simplify our analyses. Global measures of functioning were also excluded (e.g., combined visual and verbal memory composites) because they provided redundant information and potentially erroneously combined skill areas that are uniquely affected after injury.
injury severity and time post injury. The effect sizes derived from the three sets of analyses provide complimentary ndings and a unique perspective on neurocognitive outcomes and recovery after pediatric TBI that none of the analyses can do independently. In subsequent paragraphs, the ndings for each severity group is reviewed with references made to the corresponding summary statistic tables. The tables include three sets of statistics. Crosssectional studies summarizing case-control and case-case (more severe compared to less severe) studies are presented in the a and b rows of Table 1, respectively. In these analyses, a negative case-control effect size indicates that the cases performed more poorly than the controls. Similarly, a negative case-case effect size indicates that the more severe groups performed more poorly than the less severe group. The magnitude of these differences is reected in the respective weighted mean effect sizes listed in corresponding sections in Table 1. Further, summaries from longitudinal studies addressing recovery over time are presented in the corresponding c rows of Table 1, and compare the more proximal evaluation to a later evaluation. For example, a negative effect size comparing the Time 1 and Time 2 data points from longitudinal analyses indicate that the Time 2 scores are comparatively higher. The magnitude of the effect sizes provides a standardized measure of the degree of the differences, which we have interpreted as recovery. Table 2 lists all of the neurocognitive measures contributing to the effect sizes tabulated by domain.
Case-control studies (Table 1, rows 1-14a) showed negligible or small differences between the Mild and Control groups at all time points for FSIQ, PIQ, working memory, problem solving, visual immediate memory, and visual perceptual functioning. Negligible differences were also noted for VIQ and attention through Time 2, but small effects were noted at Time 3. The apparent effect size increase in VIQ was present even if only the single study contributing to all three time points was considered. The small effect noted for attention at Time 3, on the other hand, was due largely to a study of a younger age at injury cohort (not in earlier analyses). Small group differences were apparent up to 2 years post injury in verbal immediate and delayed memory, which resolved by Time 3. Small to moderate effects were noted for processing speed at all time points. Finally, generally negligible differences in uency were noted at Time 1. This difference, however, appeared to get larger over time and was in the moderate range by Time 3. (The single study contributing to this statistic was also based on data from a younger age at injury cohort). Case-case studies (Table 1, rows 114b) showed no differences between the Mild and Moderate groups at any time point in verbal immediate memory and uency, and at Time 3 for visual delayed memory. Although no meaningful group differences in problem solving were apparent at Time 1, the groups are better differentiated over time, with a large effect size noted by Time 3. Across all three time points, small (and frequently negligible) effects were apparent for attention, working memory, and verbal delayed memory whereas small to moderate effects were noted for VIQ (resolved by Time 3), PIQ, processing speed, and visual perceptual functioning. For visual immediate memory, a moderate effect size (although inconsistent across studies) was apparent at Time 1, with groups less differentiated over time.
Longitudinal studies (Table 1, rows 114c) did not show changes in VIQ, FSIQ, attention, working memory, or visual perceptual functioning. There were no longitudinal studies addressing uency, memory, or inhibition that met study inclusion criteria. However, in both verbal immediate and delayed memory, combining cross-sectional data from studies that used the same measure at Time 1 and Time 3 suggested unremarkable change over time. Small changes for processing speed were noted, with considerable improvements in problem by Time 3. Figure 1 summarizes the effect sizes for three key ndings (case-control postacute and chronic studies, and longitudinal studies) from the analyses discussed above. Effect sizes from casecontrol studies show that postacutely (Time 1), the majority of the neurocognitive domains reviewed were either not affected or were minimally affected (see Figure 1A). By Time 3 (chronic phase), some of the impairments apparent at earlier time points had resolved. In several cases, however, increasing case-control differences were apparent by Time 3 (chronic phase) (see Figure 1B). With the exception of VIQ, however, many of the effects were not statistically signicant because of relatively large standard errors indicating inconsistency across study results. Of note, large effects in some domains (e.g., uency) were apparent in studies of a younger age at injury cohort (27 at injury) (Anderson, Morse, Catroppa, Haritou, & Rosenfeld, 2004). With few impairments noted postacutely, little, if any, recovery was observed in longitudinal studies by Time 3, with some noteworthy exceptions, including problem solving, PIQ, and processing speed (see Figure 1C). Of all the measures administered, problem solving may be one of the more likely domains to be affected by practice effects. Assuming so, the Mild group appears to gain substantially from these effects while the Moderate and Severe groups gain comparably less. Also of interest, the Mild group appears to make notable gains in PIQ and processing speed (factored into the PIQ on Wechsler Scales). Because all scores used in the meta-analysis were standard scores (accounting for age related development), signicant changes in performance from Time 1 to Time 3 suggest that the groups made improvements above and beyond that expected during normal development. This nding is somewhat surprising because PIQ and processing speed are typically not prone to practice effects. Also of note, the Mild and Moderate groups, particularly with regard to measures of intelligence, processing speed, attention, and working memory, appear to show the same pattern of recovery, despite the Mild groups smaller discrepancy from Controls. In summary, the Mild TBI group showed generally few, if any, impairments in aspects of general intelligence, attention/executive skills, and memory, as well as some recovery in these areas at around two years post injury.
Domain Intelligence Processing speed/reaction time Attention Working memory Fluency Inhibition Problem solving Memory Visual spatial Measures Editions of the the Wechsler Scales of Intelligence (Preschool, Child, Adult), Stanford-Binet Intelligence Scales, and the respective composite scores derived from these measures (e.g., FSIQ, VIQ, PIQ). Tests of reaction time (e.g., CANTAB) or the Processing Speed Index (PSI) of the Wechsler Scales (or subtest scores comprising the PSI when PSI not reported). Paper/pencil measures: Trails A and B, Letter Cancellation Test, subtests of the TEA-Ch, and contingency naming tests. Computerized measures: versions of the Continuous Performance Tests. Versions of verbal and visual span tests and n-back tests, Wechsler Scales Working Memory (WMI) or Freedom from Distractibility (FDI) Indices (or subtest scores comprising the latter when WMT or FDI not reported). Timed verbal uency tests (category or letter). Versions of the Go-No Go test and the Interference subtest of the Stroop. Measures of planning and problem solving, including WCST, the Category Test, Stockings of Cambridge (CANTAB), delayed alternation tasks, Tower of London Test, and the 20 Questions Test. Subtests and composites from various batteries of verbal/nonverbal, immediate/delayed memory, including CMS, CVLT, TOMAL, WRAML, Rivermead Behavioral Memory Test, Rey-O, RAVLT, and several nonpublished/experimental list learning tasks. Measures of visual motor and visual perceptual processing, including the Perceptual Organization Index from Wechsler Scales, Tactual Performance Location trial, copy trial of the Rey-Osterrieth Complex Figure, Bentons Line Orientation Test, and various versions of the Mazes test (Kiel Locomotor Maze, Austin Maze, Porteus Maze).
1B). There were also signicant impairments in executive skills, including processing speed, attention, uency, inhibition, and problem solving. In contrast, working memory, memory, and visual perceptual skills appeared largely commensurate with the Controls (see Figure 1B). Although few longitudinal studies were available for review, substantial improvement in intellectual functioning (specically PIQ) and processing speed were apparent, with no changes in VIQ, attention, working memory, problem solving, or visual perceptual functioning noted (see Figure 1C).
Figure 1. Summary of effects between TBI and control groups for each neurocognitive domain in the postacute (Time 1) and chronic (Time 3) phases, and recovery trends. (A) Time 1 (acute/post-acute) versus Control effect sizes by injury severity and domain in cross-sectional studies. (B) Time 3 (chronic) versus Control effect sizes by injury severity and domain in cross-sectional studies. (C) Time 3 versus Time 1 (Recovery) effect sizes by injury severity and domain in longitudinal studies.
resembles the Controls. In contrast, there are notable decits in the Moderate group and although this group shows recovery relative to their acute functioning, they do not catch up to the Control group. The Severe TBI group, however, despite some improvements relative to functioning in the acute stage, shows a slower rate of development so that the gap between the Severe and Control groups expands over time.
Figure 2. Summary diagram of trends in neurocognitive outcomes and recovery over time.
not necessarily reective of impairment or lack thereof in a given skill set (Strauss & Allred, 1987).
A signicant limitation of this meta-analysis was that many published studies could not be included because they did not have discrete intervals post injury and severity ratings for which effect sizes could be derived. Also excluded were studies that did not report scores in a form from which effect sizes could be calculated. The unfortunate consequence was that there were, at times, a small number or single studies used to derive the statistics in certain domains. In some instances, it was difcult to know precisely how to assign a value for a moderating variable (e.g., injury severity and/or time post injury) in a given study. This may have introduced error when examining the effects of those moderator variables. There are few studies that report on injury severity outcomes separately within well-dened time spans. There are even a smaller number that report on longitudinal outcomes. For a better understanding of the course of recovery, we need more longitudinal studies with well-dened severity indicators and discrete time points post injury. In addition, longitudinal studies with smaller and better dened age at injury time bands are necessary so that the effects of normal development and its interruption because of a head injury can be adequately evaluated. Finally, in an attempt to control for premorbid variables contributing to outcome, the control group for comparison should be carefully chosen. There were only a handful of studies that used an other injury control group instead of healthy control groups.
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Roch Longueépée, Founder & CEO, Restoring Dignity, Address to the Nation on Special Needs Children.

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