Traumatic brain injury (TBI) is a major cause of death and disability. TBI is frequently followed by cerebral ischemia which is a great contributor to secondary brain damage. The main causes of cerebral ischemia are pathophysiological changes in cerebral blood flow and metabolism. Treatment of TBI patients is currently based on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) targeted treatment protocols. However, ICP and CPP alone do not provide information of the oxygen availability in the brain. Monitoring of brain tissue oxygenation (BtipO2) may give additional and valuable information about the risk for development of ischemia in TBI patients. The aims of this thesis were to study BtipO2 monitoring devices in-vitro regarding accuracy and stability, to detect threshold level of cerebral ischemia in-vivo and finally to examine the cerebral oxygen levels and cerebral metabolism in TBI patients. The BtipO2 probes performed with high accuracy and stability at different clinically relevant oxygen concentrations. A pig TBI model was developed by step-wise intracranial volume/pressure increase. Volume increase resulted in a gradual increased ICP, decreased CPP, intracranial compliance and BtipO2, respectively. Brain death (BD) was confirmed by negative CPP and negligible amount of previously injected microspheres in the brain tissue. The model simulated the clinical development of BD in humans with a classical pressure-volume response and systemic cardiovascular reactions. The model should be suitable for studies of brain injury mechanisms. From the same in-vivo model it was also possible to detect the threshold level of cerebral ischemia in the pig, where BtipO2 below 10 mmHg and CPP below 30 mmHg was associated with an impaired cerebral metabolism (microdialysis lactate to pyruvate ratio >30). BtipO2 together with cerebral microdialysis were studied in 23 severe TBI patients. We observed different patterns of changes in BtipO2 and cerebral microdialysis biomarkers in focal and diffuse TBI.  Increased cerebral microdialysis levels of glutamate, glycerol or the lactate/pyruvate ratio were observed at BtipO2 < 5 mmHg, indicating increased vulnerability of the brain at this critical level of tissue oxygenation in TBI patients.

Objective: To examine sleep and wake disorders following traumatic brain injury (TBI) and their impact on recovery of cognition, communication and mood. Research Design: This three-manuscript thesis comprises an introduction to sleep in the context of human function and development. It is followed by a systematic review of the literature pertaining to sleep and wake disorders following TBI, and then explores the relationship between sleep and arousal disturbance and functional recovery of cognitive-communication through a single case study, pre–post intervention. Finally, a larger study longitudinally explores the impact of treatment to optimize sleep and wakefulness on recovery of cognition, communication and mood through objective and subjective measures, pre-post intervention. The thesis concludes with a chapter that addresses the implications of findings for rehabilitation from the perspective of the International Classification of Functioning, Disability and Health (ICF), and a presentation of future research directions for the field Methods: The first manuscript involved a systematic review and rating of the quality of evidence. The second manuscript involved the evaluation of sleep and wakefulness by objective measures, and longitudinally by self-report through the Daily Cognitive-Communication and Sleep Profile (DCCASP, © Wiseman-Hakes 2008, see Appendix S). Cognitive-communication abilities were also measured by the DCCASP. The third manuscript utilized a single case series and cohort design to evaluate sleep and wakefulness, and to examine cognition, communication and mood at baseline and following optimization of sleep and wakefulness. Results: For Manuscript One, 43 articles were reviewed for levels and quality of evidence across 5 domains: epidemiology, pathophysiology, neuropsychological implications, intervention and paediatrics. In Manuscript Two, we showed that there was a statistically and functionally significant relationship between perceived quality of sleep and language processing, attention and memory, seen across the phases of the intervention. In Manuscript Three, we showed that there were statistically and functionally significant improvements across several domains of cognition, communication and mood in response to treatment. Conclusions: Sleep and wake disorders after TBI are pervasive, and can negatively impact rehabilitation and recovery. There is a need for systematic evaluation and intervention for these disorders in all persons with TBI.

In two separate studies, we used diffusion tensor imaging (DTI)to examine white matter changes secondary to traumatic brain injury (TBI) and spinal cord injury (SCI). The first study examined the utility of DTI for a single case diagnosis of mild TBI (mTBI) and demonstrated that the anterior limb of the internal capsule and the genu of the corpus callosum were sensitive and specific to mTBI. The second study examined the sub-acute effects of SCI on white matter tissue in the brain and demonstrated that SCI patients have a significantly greater degree of FA asymmetry than control subjects in the superior and posterior corona radiata. The first study has provided preliminary proof of principal evidence that DTI can be used to diagnose mTBI in individual cases. The second study suggests that the degree of asymmetry may be a useful biomarker for detecting subtle white matter changes.

In two separate studies, we used diffusion tensor imaging (DTI)to examine white matter changes secondary to traumatic brain injury (TBI) and spinal cord injury (SCI). The first study examined the utility of DTI for a single case diagnosis of mild TBI (mTBI) and demonstrated that the anterior limb of the internal capsule and the genu of the corpus callosum were sensitive and specific to mTBI. The second study examined the sub-acute effects of SCI on white matter tissue in the brain and demonstrated that SCI patients have a significantly greater degree of FA asymmetry than control subjects in the superior and posterior corona radiata. The first study has provided preliminary proof of principal evidence that DTI can be used to diagnose mTBI in individual cases. The second study suggests that the degree of asymmetry may be a useful biomarker for detecting subtle white matter changes.

Brain injury is a serious clinical problem. The success of recovery from brain injury involves functional compensation in the affected brain area. We are interested in general mechanisms that underlie compensatory plasticity after brain damage, particularly when multiple brain areas or multiple modalities are included. In this thesis, I studied the function of auditory cortex after recovery from neonatal midbrain damage as a model system that resembles patients with brain damage or sensory dysfunction. I addressed maladaptive changes of auditory cortex after invasion by ectopic visual inputs. I found that auditory cortex contained auditory, visual, and multisensory neurons after it recovered from neonatal midbrain damage (Mao et al. 2011). The distribution of these different neuronal responses did not show any clustering or segregation. As might be predicted from the fact that auditory neurons and visual neurons were intermingled throughout the entire auditory cortex, I found that residual auditory tuning and tonotopy in the rewired auditory cortex were compromised. Auditory tuning curves were broader and tonotopic maps were disrupted in the experimental animals. Because lateral inhibition is proposed to contribute to refinement of sensory maps and tuning of receptive fields, I tested whether loss of inhibition is responsible for the compromised auditory function in my experimental animals. I found an increase rather than a decrease of inhibition in the rewired auditory cortex, suggesting that broader tuning curves in the experimental animals are not caused by loss of lateral inhibition. These results suggest that compensatory plasticity can be maladaptive and thus impair the recovery of the original sensory cortical function. The reorganization of brain areas after recovery from brain damage may require stronger inhibition in order to process multiple sensory modalities simultaneously. These findings provide insight into compensatory plasticity after sensory dysfunction and brain damage and new information about the role of inhibition in cross-modal plasticity. This study can guide further research on design of therapeutic strategies to encourage adaptive changes and discourage maladaptive changes after brain damage, sensory/motor dysfunction, and deafferentation.

Purpose: Traumatic brain injury (TBI) leads to important and deleterious neuroinflammation, as evidenced by edema, cytokine production, induction of nitric oxide synthase, and leukocyte infiltration. Strategies that block inflammatory and oxidative mediators have been shown to induce neuroprotective and anti-inflammatory effects after brain injury. After TBI, cerebral vascular endothelial cells play a crucial role in the pathogenesis of inflammation. In this study, we hypothesized that cerebral vascular endothelial cells play a crucial role in the pathogenesis of inflammation after TBI and, in conjunction with leukocytes, represent a key cellular target for statin therapy. We investigated the effect of acute and continuous treatment of simvastatin on behavior and inflammation in adult rats following experimental TBI. Materials and Methods: Cortical contusions were induced using a device adapted from the impact method. There were 3 groups: (1) sham group, craniotomy only; (2) control group, TBI without treatment; and (3) treatment group, TBI with simvastatin administration. The treatment group received 15 mg/kg of simvastatin daily for 3 days. Neurological function was assessed with the grip test (Grip strength meter, Singa). Results: Non-treatment control group had a significantly greater increase in ICAM-1 expression from pre-injury to the post-injury 72 h time point, compared to the simvastatin treatment group. The treatment group had a significantly smaller amount of reduction in successful trials in grip test than the control group did from baseline to 72 h. The analysis of western blot and pathological study also demonstrated similar results. Conclusion: Our findings indicate that continuous administration of simvastatin after injury attenuates the cerebral vascular endothelial inflammatory response and improves functional and histological outcomes in a rat model of TBI. This improvement is associated with a reduction in expression of ICAM-1 in the blood and brain after rat TBI when compared with the untreated control group. Hence, we recommend simvastatin administration in the first 72 h following TBI.

Traumatic brain injury (TBI) is a major health and socioeconomic concern in the United States and across the globe. Experimental models of TBI are used to study the mechanisms underlying cell dysfunction and death that result from injury, the functional deficits that result from injury, and the potential of various therapies to treat injury. This thesis explores the fundamental mechanical damage associated with brain trauma, investigating the effects of mechanical deformation on neurons at the molecular, cellular, tissue, and animal levels. First, a novel hydrogel system was developed to support 3-D neuronal cultures, and the cultures were studied in an in vitro model of neuronal injury. The dependence of cell viability on hydrogel stiffness and extracellular matrix ligand concentration revealed a role for molecular interactions in the cellular response to injury. Subsequently, in a rat model of TBI neuronal plasma membrane damage was observed coincidentally with cell death within the hippocampus; however not all permeable cells died, suggesting a complex role for plasma membrane damage in neuronal degeneration. The spatial profile of permeable cells in the hippocampus reveals further heterogeneity of neuronal plasma membrane damage, with populations of cells in certain hippocampal subregions exhibiting an increased vulnerability to plasma membrane damage. These observations support recent finite element model predictions of strains in the brain during injury. Finally a system for measuring locomotor disturbances is used for the first time following brain injury. Continued investigation of how neurons deform and fail mechanically will contribute to the understanding of the pathophysiology of brain injury and may help identify potential therapeutic targets.

Biomarker research is of great interest in the field of traumatic brain injury (TBI), since there are numerous potential markers that may indicate central nervous system damage, yet the brain is normally well isolated and discovery is at its infancy. Traditional methods for biomarker discovery include time consuming multi step chromatographic mass spectrometery (MS) techniques or pre-defined serial probing using traditional assays, making the identification of biomarker panels limiting and expensive. These shortfalls have motivated the development of a MS based probe that can be embedded into 3D neural cultures and obtain temporal and spatial information about the release of biomarkers. Using the high sensitivity MS ionization method of nano-electrospray ionization (nano-ESI) with an in-line microdialysis (MD) unit allows us to use MS to analyze low concentrations of TBI biomarkers from within cell cultures with no need for off-line sample manipulation. This thesis goes through the development of the probe by studying the theoretical principles, simulations and experimental results of the probe's capability to sample small local concentrations of a marker within cell culture matrix, the MD unit's sample manipulation capabilities, and the ability to detect markers using in-line MD-nano-ESI MS.

Fragestellung: Gegenstand dieser Untersuchung ist der diagnostische Nutzen der Neuro-Biomarker S100B-Protein und Neuronenspezifische Enolase (NSE) bei leichten Schädel-Hirn-Verletzungen im Kindesalter. Es wird untersucht, ob anhand der posttraumatischen S100B- und NSE-Serum-Konzentrationen Kinder mit einer Schädelprellung und einem leichten Schädel-Hirn-Trauma (SHT) differenziert werden können. Material und Methode: In einer prospektiven, klinischen Studie werden die posttraumatischen S100B- und NSE-Serum-Konzentrationen von Kindern im Alter zwischen 6 Monaten und 15 Jahren mit einer Schädelprellung oder einem leichten SHT untersucht. Kinder mit extrakraniellen Begleitverletzungen und Begleiterkrankungen sind ausgeschlossen. Die Blutentnahme erfolgt innerhalb von 6 Stunden nach dem Trauma. Es werden 2 diagnostische Gruppen definiert: Gruppe 1: asymptomatische Schädelprellungen (Glasgow-Coma-Scale [GCS] 15 Punkte), Gruppe 2: leichte SHT (GCS 13-15 Punkte) mit klinischen Zeichen einer Gehirnerschütterung (kurze Bewusstlosigkeit, Amnesie, Übelkeit, Erbrechen, Somnolenz, Kopfschmerzen, Schwindel, Sehstörungen, Kreislaufreaktion). Die S100B- und NSE- Konzentrationen werden zwischen beiden Diagnosegruppen verglichen. Die Korrelation zwischen S100B und NSE sowie zwischen den Markern und dem Alter der Kinder, dem Zeitraum zwischen Trauma und Blutentnahme, dem GCS-Wert und dem Vorhandensein von Kopfplatzwunden wird analysiert. Ergebnisse: 148 Kinder sind in die Studie eingeschlossen (53 Kinder mit einer Schädelprellung und 95 mit einem leichten SHT). Nach Adjustierung der gemessenen Marker-Konzentrationen auf Unterschiede im Alter und Zeitraum zwischen Trauma und Blutentnahme unterscheiden sich die S100B- und NSE-Konzentrationen nicht signifikant zwischen Kindern mit einer Schädelprellung und einem leichten SHT. Zwischen den S100B- und NSE-Konzentrationen besteht eine signifikant positive Korrelation. Beide Marker korrelieren signifikant negativ mit dem Alter und dem Entnahmezeitraum. Der GCS-Wert und das Vorhandensein von Kopfplatzwunden zeigen keinen Effekt auf die Marker-Konzentrationen. Schlussfolgerung: Die posttraumatischen S100B- und NSE-Serum-Konzentrationen zeigen keinen diagnostischen Nutzen bei der Differenzierung zwischen Kindern mit einer Schädelprellung und Kindern mit einem leichten SHT. S100B und NSE sind altersabhängige Marker.

This study examined the effects of a smoking cessation program using vouchers as reinforcers with individuals with traumatic brain injury and a history of substance abuse. The intervention was conducted at a residential facility that houses individuals with Traumatic Brain Injury (TBI). Vouchers were delivered contingent on reductions of carbon monoxide (CO) samples of 5 ppm or less across a shaping phase, and an abstinence induction phase. A standard pay phase was added at the end of the study to examine the effects of a standardized reinforcement scale with the abstinence criterion set at 8 ppm or less. Reductions in CO were not robust in the shaping and abstinence induction phase. The standard pay schedule showed some improvements in CO levels with less variability for two of the three participants.