Cerebral Perfusion Effects of Cognitive Training and Transcranial Direct Current Stimulation in Mild-Moderate TBI

Davin K Quinn, Joel Upston, Thomas Jones, Emma Brandt, Jacqueline Story-Remer, Violet Fratzke, J Kevin Wilson, Rebecca Rieger, Michael A Hunter, Darbi Gill, Jessica D Richardson, Richard Campbell, Vincent P Clark, Ronald A Yeo, Claude William Shuttleworth, Andrew R Mayer, Davin K Quinn, Joel Upston, Thomas Jones, Emma Brandt, Jacqueline Story-Remer, Violet Fratzke, J Kevin Wilson, Rebecca Rieger, Michael A Hunter, Darbi Gill, Jessica D Richardson, Richard Campbell, Vincent P Clark, Ronald A Yeo, Claude William Shuttleworth, Andrew R Mayer

Abstract

Background: Persistent post-traumatic symptoms (PPS) after traumatic brain injury (TBI) can lead to significant chronic functional impairment. Pseudocontinuous arterial spin labeling (pCASL) has been used in multiple studies to explore changes in cerebral blood flow (CBF) that may result in acute and chronic TBI, and is a promising neuroimaging modality for assessing response to therapies. Methods: Twenty-four subjects with chronic mild-moderate TBI (mmTBI) were enrolled in a pilot study of 10 days of computerized executive function training combined with active or sham anodal transcranial direct current stimulation (tDCS) for treatment of cognitive PPS. Behavioral surveys, neuropsychological testing, and magnetic resonance imaging (MRI) with pCASL sequences to assess global and regional CBF were obtained before and after the training protocol. Results: Robust improvements in depression, anxiety, complex attention, and executive function were seen in both active and sham groups between the baseline and post-treatment visits. Global CBF decreased over time, with differences in regional CBF noted in the right inferior frontal gyrus (IFG). Active stimulation was associated with static or increased CBF in the right IFG, whereas sham was associated with reduced CBF. Neuropsychological performance and behavioral symptoms were not associated with changes in CBF. Discussion: The current study suggests a complex picture between mmTBI, cerebral perfusion, and recovery. Changes in CBF may result from physiologic effect of the intervention, compensatory neural mechanisms, or confounding factors. Limitations include a small sample size and heterogenous injury sample, but these findings suggest promising directions for future studies of cognitive training paradigms in mmTBI.

Keywords: cerebral perfusion; cognitive training; pCASL; transcranial direct current stimulation; traumatic brain injury.

Copyright © 2020 Quinn, Upston, Jones, Brandt, Story-Remer, Fratzke, Wilson, Rieger, Hunter, Gill, Richardson, Campbell, Clark, Yeo, Shuttleworth and Mayer.

Figures

Figure 1
Figure 1
Behavioral and cognitive performance for all subjects from baseline to post-treatment to 1 month followup visit. (A) Depression symptoms (HAM-D). (B) Attention performance (WAIS-CD-S). (C,D) Executive function performance (EXAMINER Executive composite and working memory composite scores). Red, active; blue, sham; gray regions, standard error.
Figure 2
Figure 2
(A) Changes in global cerebral perfusion (CP) between baseline and post-treatment visits. (a) Mild TBI participants (circles). (b) Moderate TBI participants (triangles). Difference in CP between mild and moderate TBI participants was not significant. Red, active group; blue, sham group. (B) Scatter plot of Hopkins Verbal Learning Test (HVLT) retention score with cerebral perfusion (CP) for active (red) and sham (blue) groups. HVLT correlated mildly (r = −0.44) with reductions in CP.
Figure 3
Figure 3
Cerebral perfusion (CP) in inferior frontal gyrus/pars triangularis (IFG) from baseline to post-treatment visit. (A) In left IFG, active group (red) demonstrated no change in CP, while sham (blue) decreased. In right IFG, CP increased in active group but decreased in sham group. (B) 3-D visualization of change in CP over time in active and sham groups. Blue, decreased CP; red, increased.

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