Case presentation: Traumatic Brain Injury

1
Case presentationTraumatic Brain Injury

• Joanne Wrench
• Department of Psychology
• University of Melbourne
• Australia
• Austin Health -Royal Talbot Rehabilitation
  Centre, Melbourne

2
Background information

• LS -20 year old male seen on a Spinal
  Rehabilitation Ward
• Hit by a car whilst riding his bicycle without a
  helmet
• Multiple injuries including C4 and C5 fractures
  resulting in incomplete quadriplegia and severe
  traumatic brain injury
• Referred for neuropsychological assessment for
  his frontal presentation

3
Background information

• Resuscitated at the scene, GCS of 3
• CT brain
• subarachnoid hemorrhage
• extensive bifrontal contusions (RgtL)
• contra-coup left lateral posterior temporal
  contusion
• Bifrontal craniotomy with cranial fossa repair,
  decompression of the optic canals and repair of
  subdural tear.
• Follow-up MR brain 10 days post injury
• occipital subarachoid hemorrhage, signal
  abnormality in corpus collosum

4
Background info cont.

• Seen by Psychiatric Registrar one month post
  injury - noted to have frontal presentation
• Disinhibition inappropriate comments
• Emotionally labile
• Decreased verbal fluency
• Tangential and impulsive
• MMSE 26/28
• Personality change noted by family
• Currently considered easy to manage on the ward

5
Complaint

• LS reported word finding difficulties and
  decreased concentration
• His mother felt he had ongoing memory
  difficulties, slowed thinking skills
• LS and his mother noted his increased verbosity
• Presentation
• Highly co-operative and attentive
• Verbose, somewhat tangential speech
• Some insight

6
Assessment results

• WAIS-III ASS
• Picture Completion 12
• Digit Span 8
• Information 5
• Similarities 6
• Matrix Reasoning 15
• Arithmetic 9
• WTAR Predicted VIQ86
• PIQ89
• FSIQ86
• Boston naming test 24
• Symbol digit slow

• WMS-III ASS
• Log mem I 10
• II 9
• Family pictures I 12
• II 11
• Verbal trails B 56s some errors
• Verbal Fluency F9 A6 S12
• Category fluency Animals 13
• WCST excellent
• Tower of london - passed all items in first
  trial
• Stroop - good

7
Summary of results

• General intellectual measures performance domain
  gt verbal domain
• Attentional function generally intact
• Verbal and visual memory fell well within normal
  limits
• Effective planning skills and no disinhibition on
  testing
• Difficulties
• Reduced speed of information processing
• Mentally shifting set
• Decreased verbal fluency
• Word finding difficulties

8
Summary

• Some cognitive deficits including features of
  executive dysfunction
• Executive dysfunction relatively mild when the
  extent of his frontal damage is considered
• Difficult to assess frontal functions
  comprehensively due to quadriplegia
• Recommendations included speech pathology
  referral