Jamshid Ghajar MD, PhD, FACS, is a board certified neurosurgeon, Clinical Professor of Neurosurgery, Moghadam Family Director of the Stanford Brain Performance Center and President of the Brain Trauma Foundation.

He completed the MD/PhD program at Cornell University Medical College. During his residency training in neurosurgery at New York Presbyterian Hospital, he invented and patented several neurosurgical devices that are currently used worldwide. After residency, he joined the faculty at the New York Presbyterian Hospital-Cornell Medical Center and was a founder of the Brain Trauma Foundation (BTF) in 1986. The mission of the BTF is to improve the outcome of patients with traumatic brain injury (TBI). He joined the neurosurgery faculty at Stanford in February 2014.

Learn more about the Stanford Brain Performance Center:

Clinical Focus

  • Neurosurgery
  • Concussion, traumatic brain injury

Academic Appointments

Administrative Appointments

  • Clinical Professor of Neurological Surgery, Weill Cornell Medical College (2003 - 2014)
  • Chief of Neurosurgery, The Jamaica Hospital-Cornell Trauma Center. New York (1989 - 2014)
  • President, Brain Trauma Foundation (1995 - Present)
  • Clinical Professor of Neurosurgery, Stanford University Medical School (2014 - Present)
  • Moghadam Family Director, Stanford Brain Performance Center (2019 - Present)

Honors & Awards

  • Honorary Police Surgeon, New York Police Department (2007-2014)
  • Ellis Island Award, Ellis Island Award Committee (2013)
  • American Iranian Council Award, American Iranian Council (2001)

Boards, Advisory Committees, Professional Organizations

  • Committee on Trauma, American College of Surgeons (2012 - Present)

Professional Education

  • Residency: New York Presbyterian Cornell Campus Neurosurgery Residency (1987) NY
  • Residency: New York Presbyterian Cornell Campus Neurology Residency (1983) NY
  • Internship: New York Presbyterian Cornell Campus General Surgery Residency (1982) NY
  • Medical Education: Cornell University School of Medicine Registrar (1981) NY
  • Board Certification: American Board of Neurological Surgery, Neurosurgery (1993)

Community and International Work

  • Brain Trauma Foundation, New York and Palo Alto


    Traumatic Brain Injury

    Partnering Organization(s)

    Indian Head Injury Foundation

    Populations Served

    Traumatic Brain Injury patients



    Ongoing Project


    Opportunities for Student Involvement



  • Jamshid Ghajar. "United States Patent 7,849,525 Apparatus for Reducing Brain and Cervical Spine Injury due to Rotational Movement", G-Brace, Dec 14, 2010
  • Jamshid Ghajar. "United States Patent 7,819,818 Cognition and Motor Timing Diagnosis Using Smooth Eye Pursuit Analysis", SyncThink, Oct 26, 2010
  • Jamshid Ghajar. "United States Patent 7,708,700 Method for Improving Cognition and Motor Timing", SyncThink, May 4, 2010
  • Jamshid Ghajar. "United States Patent 7,384,399 Cognition and Motor Timing Diagnosis and Training System and Method", SyncThink, Jun 8, 2008

Current Research and Scholarly Interests

Principal Investigator,
“Concussion Definition Consortium – An Evidence Based Project”. Department of Defense. There are over 40 definitions of concussion but none are evidence based- i.e. come from well done studies. We will extract the most salient data from well run studies that are designed to give us a "snapshot" of what concussion is.

Principal Investigator,
“Multi-Dimensional Model for Brain Trauma”. The goal is to develop a dynamic model for concussion, validate it on a retrospective dataset, and design a second study to validate it on a prospective dataset. Department of Defense.

Principal Investigator,
“EYE-TRAC Advance”. Testing 10,000 subjects with normal and post concussive eye tracking. Military and civilian athletes are included. Department of Defense.

Principal Investigator,
B-TEC (Brain Trauma Evidence-based Consortium). Combines Stanford B-TEC clinical trials coordinating center with the Brain Trauma Foundation's B-TEC evidence-based center to promote and coordinate an evidence-based approach to the spectrum of brain trauma from concussion to coma.

2022-23 Courses

All Publications

  • In Reply: Evolution and Impact of the Brain Trauma Foundation Guidelines. Neurosurgery Hawryluk, G. W., Ghajar, J. 2022

    View details for DOI 10.1227/neu.0000000000002105

    View details for PubMedID 35951735

  • Rationale and Methods for Updated Guidelines for the Management of Penetrating Traumatic Brain Injury. Neurotrauma reports Hawryluk, G. W., Selph, S., Lumba-Brown, A., Totten, A. M., Ghajar, J., Aarabi, B., Ecklund, J., Shackelford, S., Adams, B., Adelson, D., Armonda, R. A., Benjamin, J., Boone, D., Brody, D., Dengler, B., Figaji, A., Grant, G., Harris, O., Hoffer, A., Kitigawa, R., Latham, K., Neal, C., Okonkwo, D. O., Pannell, D., Rosenfeld, J. V., Rosenthal, G., Rubiano, A., Stein, D. M., Stippler, M., Talbot, M., Valadka, A., Wright, D. W., Davis, S., Bell, R. 2022; 3 (1): 240-247


    Penetrating traumatic brain injury (pTBI) affects civilian and military populations resulting in significant morbidity, mortality, and healthcare costs. No up-to-date and evidence-based guidelines exist to assist modern medical and surgical management of these complex injuries. A preliminary literature search revealed a need for updated guidelines, supported by the Brain Trauma Foundation. Methodologists experienced in TBI guidelines were recruited to support project development alongside two cochairs and a diverse steering committee. An expert multi-disciplinary workgroup was established and vetted to inform key clinical questions, to perform an evidence review and the development of recommendations relevant to pTBI. The methodological approach for the project was finalized. The development of up-to-date evidence- and consensus-based clinical care guidelines and algorithms for pTBI will provide critical guidance to care providers in the pre-hospital and emergent, medical, and surgical settings.

    View details for DOI 10.1089/neur.2022.0008

    View details for PubMedID 35919507

    View details for PubMedCentralID PMC9279118

  • A Review of Implementation Concepts and Strategies Surrounding Traumatic Brain Injury Clinical Care Guidelines. Journal of neurotrauma Lumba-Brown, A., Prager, E. M., Harmon, N., McCrea, M., Bell, M. J., Ghajar, J., Pyne, S., Cifu, D. 2021


    Despite considerable efforts to advance the science surrounding traumatic brain injury (TBI), formal efforts supporting the current and future implementation of scientific findings within clinical practice and healthcare policy are limited. While many and varied guidelines inform the clinical management of TBI across the spectrum, clinicians and healthcare systems are not broadly adopting, implementing, and/or adhering to them. As part of the Brain Trauma Blueprint TBI State of the Science, an expert workgroup was assembled to guide this review article, which describes: 1) Possible etiologies of inadequate adoption and implementation; 2) Enablers to successful implementation strategies; and 3) Strategies to mitigate the barriers to adoption and implementation of future research.

    View details for DOI 10.1089/neu.2021.0067

    View details for PubMedID 34714147

  • Sex Differences in Common Measures of Concussion in College Athletes. The Journal of head trauma rehabilitation Teramoto, M., Grover, E. B., Cornwell, J., Zhang, R., Boo, M., Ghajar, J., Lumba-Brown, A. 2021


    OBJECTIVE: Female athletes may be more likely to sustain a concussion and may vary in symptom presentation and neurocognitive impairments as compared with males. Scientific literature is limited by subjective assessments and underproportioned representation of women-the scope and etiology of sex-based differences are unknown. This study investigates sex-based differences in sports concussion assessments among college varsity athletes.DESIGN AND SETTING: Retrospective study of an institution's athletic head injury database.PARTICIPANTS: Acute postinjury and baseline data from 111 college athletes sustaining concussions between 2016 and 2018, diagnosed by a concussion specialist physician.MAIN OUTCOME MEASURES: Concussion assessments examined included the Sports Concussion Assessment Tool (SCAT5) and Vestibular Oculomotor Screening (VOMS) performed within 3 days (24-72 hours) of injury.RESULTS: No significant difference by sex was observed in the SCAT5 total symptom evaluation scores or severity scores, Standardized Assessment of Concussion, or Balance Error Scoring System (P > .05) within 3 days of head injury. Females did report more "pressure in the head" severity scores from baseline to postconcussion (2.7 ± 1.5 increased symptomatology in females vs 1.8 ± 1.3 increase in males, P = .007). The VOMS test resulted in significant sex differences in smooth pursuit [0.6 ± 1.4 increase in females (P < .001) vs 0.2 ± 0.6 increase in males (P = .364)], horizontal saccades [0.6 ± 1.2 increase in females (P < .001) vs 0.2 ± 0.5 increase in males (P = .149)], and vertical saccades [0.9 ± 1.9 increase in females (P < .001) vs 0.3 ± 0.7 increase in males (P = .206)].CONCLUSION: Our study did not show sex-based differences in baseline or acute postconcussive symptom reporting in most concussion assessment parameters, challenging previous research suggesting that females report more symptoms than males. Females did have significant differences in symptom provocation using the VOMS.

    View details for DOI 10.1097/HTR.0000000000000732

    View details for PubMedID 34698682

  • Evolution and Impact of the Brain Trauma Foundation Guidelines. Neurosurgery Hawryluk, G. W., Ghajar, J. 2021


    The Brain Trauma Foundation (BTF) Guidelines for the Management of Severe Head Injury were the first clinical practice guidelines published by any surgical specialty. These guidelines have earned a reputation for rigor and have been widely adopted around the world. Implementation of these guidelines has been associated with a 50% reduction in mortality and reduced costs of patient care. Over their 25-yr history the traumatic brain injury (TBI) guidelines have been expanded, refined, and made increasingly more rigorous in conjunction with new clinical evidence and evolving methodologic standards. Here, we discuss the history and accomplishments of BTF guidelines for TBI as well as their limitations. We also discuss planned changes to future TBI guidelines intended to increase their utility and positive impact in an evolving medical landscape. Perhaps the greatest limitation of TBI guidelines now is the lack of high-quality clinical research as well as novel diagnostics and treatments with which to generate substantially new recommendations.

    View details for DOI 10.1093/neuros/nyab357

    View details for PubMedID 34634822

  • Visuomotor Synchronization: Military Normative Performance. Military medicine Maruta, J., Spielman, L. A., Ghajar, J. 2021


    INTRODUCTION: Cognitive processes such as perception and reasoning are preceded and dependent on attention. Because of the close overlap between neural circuits of attention and eye movement, attention may be objectively quantified with recording of eye movements during an attention-dependent task. Our previous work demonstrated that performance scores on a circular visual tracking task that requires dynamic synchronization of the gaze with the target motion can be impacted by concussion, sleep deprivation, and attention deficit/hyperactivity disorder. The current study examined the characteristics of performance on a standardized predictive visual tracking task in a large sample from a U.S. Military population to provide military normative data.MATERIALS AND METHODS: The sample consisted of 1,594 active duty military service members of either sex aged 18-29years old who were stationed at Fort Hood Army Base. The protocol was reviewed and approved by the U.S. Army Medical Research and Materiel Command Institutional Review Board. Demographic, medical, and military history data were collected using questionnaires, and performance-based data were collected using a circular visual tracking test and Trail Making Test. Differences in visual tracking performance by demographic characteristics were examined with a multivariate analysis of variance, as well as a Kolmogorov-Smirnov test and a rank-sum test. Associations with other measures were examined with a rank-sum test or Spearman correlations.RESULTS: Robust sex differences in visual tracking performance were found across the various statistical models, as well as age differences in several isolated comparisons. Accordingly, norms of performance scores, described in terms of percentile standings, were developed adjusting for age and sex. The effects of other measures on visual tracking performance were small or statistically non-significant. An examination of the score distributions of various metrics suggested that strategies preferred by men and women may optimize different aspects of visual tracking performance.CONCLUSION: This large-scale quantification of attention, using dynamic visuomotor synchronization performance, provides rigorously characterized age- and sex-based military population norms. This study establishes analytics for assessing normal and impaired attention and detecting changes within individuals over time. Practical applications for combat readiness and surveillance of attention impairment from sleep insufficiency, concussion, medication, or attention disorders will be enhanced with portable, easily accessible, fast, and reliable dynamic eye-tracking technologies.

    View details for DOI 10.1093/milmed/usab320

    View details for PubMedID 34318327

  • External Lumbar Drainage following Traumatic Intracranial Hypertension: A Systematic Review and Meta-Analysis. Neurosurgery Badhiwala, J., Lumba-Brown, A., Hawryluk, G. W., Ghajar, J. 2021


    BACKGROUND: Traumatic brain injury (TBI) often results in elevations in intracranial pressure (ICP) that are refractory to standard therapies. Several studies have investigated the utility of external lumbar drainage (ELD) in this setting.OBJECTIVE: To evaluate the safety and efficacy of ELD or lumbar puncture with regard to immediate effect on ICP, durability of the effect on ICP, complications, and neurological outcomes in adults with refractory traumatic intracranial hypertension.METHODS: A systematic review and meta-analysis were conducted beginning with a comprehensive search of PubMed/EMBASE. Two investigators reviewed studies for eligibility and extracted data. The strength of evidence was evaluated using GRADE methodology. Random-effects meta-analyses were performed to calculate pooled estimates.RESULTS: Nine articles detailing 6 studies (N=110) were included. There was moderate evidence that ELD has a significant immediate effect on ICP; the pooled effect size was -19.5mmHg (95% CI -21.0 to -17.9mmHg). There was low evidence to indicate a durable effect of ELD on ICP up to at least 24 h following ELD. There was low evidence to indicate that ELD was safe and associated with a low rate of clinical cerebral herniation or meningitis. There was very low evidence pertaining to neurological outcomes.CONCLUSION: Given preliminary data indicating potential safety and feasibility in highly selected cases, the use of ELD in adults with severe TBI and refractory intracranial hypertension in the presence of open basal cisterns and absence of large focal hematoma merits further high-quality investigation; the ideal conditions for potential application remain to be determined.

    View details for DOI 10.1093/neuros/nyab181

    View details for PubMedID 34171100

  • Phenotyping the Spectrum of Traumatic Brain Injury: A Review and Pathway to Standardization. Journal of neurotrauma Pugh, M. J., Kennedy, E., Prager, E. M., Humpherys, J., Dams-O'Connor, K., Hack, D., McCafferty, M. K., Wolfe, J., Yaffe, K. C., McCrea, M., Ferguson, A. R., Lancashire, L., Ghajar, J., Lumba-Brown, A. 2021


    It is widely appreciated that the spectrum of traumatic brain injury (TBI), mild through severe, contains distinct clinical presentations, variably referred to as subtypes, phenotypes, and/or clinical profiles. As part of the Brain Trauma Blueprint TBI State of the Science, we review the current literature on TBI phenotyping with an emphasis on unsupervised methodological approaches, and describe five phenotypes that appear similar across reports. However, we also find the literature contains divergent analysis strategies, inclusion criteria, findings, and use of terms. Further, while some studies delineate phenotypes within a specific severity of TBI, others derive phenotypes across the full spectrum of severity. Together, these facts confound direct synthesis of findings. To overcome this, we introduce PhenoBench, a freely available code repository for the standardization and evaluation of raw phenotyping data. With this review and toolset, we provide a pathway towards robust, data-driven phenotypes that can capture the heterogeneity of TBI, enabling reproducible insights and targeted care.

    View details for DOI 10.1089/neu.2021.0059

    View details for PubMedID 33858210

  • 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. 2020; 86 (2): 221–29
  • A management algorithm for adult patients with both brain oxygen and intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC). Intensive care medicine Chesnut, R., Aguilera, S., Buki, A., Bulger, E., Citerio, G., Cooper, D. J., Arrastia, R. D., Diringer, M., Figaji, A., Gao, G., Geocadin, R., Ghajar, J., Harris, O., Hoffer, A., Hutchinson, P., Joseph, M., Kitagawa, R., Manley, G., Mayer, S., Menon, D. K., Meyfroidt, G., Michael, D. B., Oddo, M., Okonkwo, D., Patel, M., Robertson, C., Rosenfeld, J. V., Rubiano, A. M., Sahuquillo, J., Servadei, F., Shutter, L., Stein, D., Stocchetti, N., Taccone, F. S., Timmons, S., Tsai, E., Ullman, J. S., Vespa, P., Videtta, W., Wright, D. W., Zammit, C., Hawryluk, G. W. 2020


    BACKGROUND: Current guidelines for the treatment of adult severe traumatic brain injury (sTBI) consist of high-quality evidence reports, but they are no longer accompanied by management protocols, as these require expert opinion to bridge the gap between published evidence and patient care. We aimed to establish a modern sTBI protocol for adult patients with both intracranial pressure (ICP) and brain oxygen monitors in place.METHODS: Our consensus working group consisted of 42 experienced and actively practicing sTBI opinion leaders from six continents. Having previously established a protocol for the treatment of patients with ICP monitoring alone, we addressed patients who have a brain oxygen monitor in addition to an ICP monitor. The management protocols were developed through a Delphi-method-based consensus approach and were finalized at an in-person meeting.RESULTS: We established three distinct treatment protocols, each with three tiers whereby higher tiers involve therapies with higher risk. One protocol addresses the management of ICP elevation when brain oxygenation is normal. A second addresses management of brain hypoxia with normal ICP. The third protocol addresses the situation when both intracranial hypertension and brain hypoxia are present. The panel considered issues pertaining to blood transfusion and ventilator management when designing the different algorithms.CONCLUSIONS: These protocols are intended to assist clinicians in the management of patients with both ICP and brain oxygen monitors but they do not reflect either a standard-of-care or a substitute for thoughtful individualized management. These protocols should be used in conjunction with recommendations for basic care, management of critical neuroworsening and weaning treatment recently published in conjunction with the Seattle International Brain Injury Consensus Conference.

    View details for DOI 10.1007/s00134-019-05900-x

    View details for PubMedID 31965267

  • Concussion Disrupts Normal Brain White Matter Microstructural Symmetry. Frontiers in neurology Maruta, J., Mallott, J. M., Sulioti, G., Ghajar, J., Palacios, E. M., Mukherjee, P. 2020; 11: 548220


    Injuries and illnesses can alter the normal bilateral symmetry of the brain, and determining the extent of this disruption may be useful in characterizing the pathology. One way of quantifying brain symmetry is in terms of bilateral correlation of diffusion tensor metrics between homologous white matter tracts. With this approach, we hypothesized that the brains of patients with a concussion are more asymmetrical than those of healthy individuals without a history of a concussion. We scanned the brains of 35 normal individuals and 15 emergency department patients with a recent concussion. Fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD) were determined for regions of interest (ROI) defined by a standard white-matter atlas that included 21 bilateral ROIs. For each ROI pair, bilateral correlation coefficients were calculated and compared between the two subject groups. A symmetry index, defined as the ratio between the difference and the sum of bilateral measures, was also calculated for each ROI pair and compared between the groups. We found that in normal subjects, the extent of symmetry varied among regions and individuals, and at least subtle forms of structural lateralization were common across regions. In patients, higher asymmetry was found overall as well as in the corticospinal tract specifically. Results indicate that a concussion can manifest in brain asymmetry that deviates from a normal state. The clinical utility of characterizing post-concussion pathology as abnormal brain asymmetry merits further exploration.

    View details for DOI 10.3389/fneur.2020.548220

    View details for PubMedID 33262738

  • Guidelines for the Management of Severe Traumatic Brain Injury: 2020 Update of the Decompressive Craniectomy Recommendations. Neurosurgery Hawryluk, G. W., Rubiano, A. M., Totten, A. M., O'Reilly, C. n., Ullman, J. S., Bratton, S. L., Chesnut, R. n., Harris, O. A., Kissoon, N. n., Shutter, L. n., Tasker, R. C., Vavilala, M. S., Wilberger, J. n., Wright, D. W., Lumba-Brown, A. n., Ghajar, J. n. 2020


    When the fourth edition of the Brain Trauma Foundation's Guidelines for the Management of Severe Traumatic Brain Injury were finalized in late 2016, it was known that the results of the RESCUEicp (Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension) randomized controlled trial of decompressive craniectomy would be public after the guidelines were released. The guideline authors decided to proceed with publication but to update the decompressive craniectomy recommendations later in the spirit of "living guidelines," whereby topics are updated more frequently, and between new editions, when important new evidence is published. The update to the decompressive craniectomy chapter presented here integrates the findings of the RESCUEicp study as well as the recently published 12-mo outcome data from the DECRA (Decompressive Craniectomy in Patients With Severe Traumatic Brain Injury) trial. Incorporation of these publications into the body of evidence led to the generation of 3 new level-IIA recommendations; a fourth previously presented level-IIA recommendation remains valid and has been restated. To increase the utility of the recommendations, we added a new section entitled Incorporating the Evidence into Practice. This summary of expert opinion provides important context and addresses key issues for practitioners, which are intended to help the clinician utilize the available evidence and these recommendations. The full guideline can be found at:

    View details for DOI 10.1093/neuros/nyaa278

    View details for PubMedID 32761068

  • Sex-Related Differences in Neurosensory Alterations Following Blunt Head Injury. Frontiers in neurology Lumba-Brown, A. n., Niknam, K. n., Cornwell, J. n., Meyer, C. n., Ghajar, J. n. 2020; 11: 1051


    Background: There is heterogeneity in neurosensory alterations following mild traumatic brain injury. Commonly assessed neurosensory symptoms following head injury include symptom reports and measures of oculomotor impairment, auditory changes, and vestibular impairment. Hypothesis/Purpose: Neurosensory alterations are prevalent acutely following mild traumatic brain injury secondary to blunt head trauma during collegiate varsity sports and may vary by sex and sport. Study Design: Retrospective study of a large collegiate athletic database. Methods: Analyses were performed using an established single University dataset of 177 male and female collegiate varsity athletes who were diagnosed with concussion/mild traumatic brain injury between September 2013 and October 2019. Descriptive and comparative analyses were performed on individual and grouped acute concussion assessments pertaining to neurosensory alterations obtained within 72 h of injury using components of the Sports Concussion Assessment Tool Version 5 and Vestibular/Ocular-Motor Screening. Results: Females had significantly more abnormal smooth pursuit (p-value: 0.045), convergence (p-value: 0.031), and visual motion sensitivity tests results (p-value: 0.023) than males. There were no differences in neurosensory alterations when grouped by overall auditory, vestibular, or oculomotor impairments. The majority of sports-related concussions occurred during football (50, 28.25%), wrestling (21, 11.86%), water polo (15, 8.47%), and basketball (14, 7.91%). Abnormal vestibular assessments were high in these top four sports categories, but statistically significant differences in overall auditory, vestibular, or oculomotor impairments were not reached by individual sport. However, water polo players had higher abnormal individual assessments related to balance reports on the sideline (60.00%, p-value: 0.045) and in the clinic setting (57.14%, p-value: 0.038) as compared to all other sports. Conclusion: While neurosensory alterations are prevalent in both male and female athletes acutely post-concussion, females have a higher incidence of abnormalities in smooth pursuit, convergence, and visual motion sensitivity and may benefit from early rehabilitation.

    View details for DOI 10.3389/fneur.2020.01051

    View details for PubMedID 33041988

    View details for PubMedCentralID PMC7522405

  • A management algorithm for patients with intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC). Intensive care medicine Hawryluk, G. W., Aguilera, S., Buki, A., Bulger, E., Citerio, G., Cooper, D. J., Arrastia, R. D., Diringer, M., Figaji, A., Gao, G., Geocadin, R., Ghajar, J., Harris, O., Hoffer, A., Hutchinson, P., Joseph, M., Kitagawa, R., Manley, G., Mayer, S., Menon, D. K., Meyfroidt, G., Michael, D. B., Oddo, M., Okonkwo, D., Patel, M., Robertson, C., Rosenfeld, J. V., Rubiano, A. M., Sahuquillo, J., Servadei, F., Shutter, L., Stein, D., Stocchetti, N., Taccone, F. S., Timmons, S., Tsai, E., Ullman, J. S., Vespa, P., Videtta, W., Wright, D. W., Zammit, C., Chesnut, R. M. 2019


    BACKGROUND: Management algorithms for adult severe traumatic brain injury (sTBI) were omitted in later editions of the Brain Trauma Foundation's sTBI Management Guidelines, as they were not evidence-based.METHODS: We used a Delphi-method-based consensus approach to address management of sTBI patients undergoing intracranial pressure (ICP) monitoring. Forty-two experienced, clinically active sTBI specialists from six continents comprised the panel. Eight surveys iterated queries and comments. An in-person meeting included whole- and small-group discussions and blinded voting. Consensus required 80% agreement. We developed heatmaps based on a traffic-light model where panelists' decision tendencies were the focus of recommendations.RESULTS: We provide comprehensive algorithms for ICP-monitor-based adult sTBI management. Consensus established 18 interventions as fundamental and ten treatments not to be used. We provide a three-tier algorithm for treating elevated ICP. Treatments within a tier are considered empirically equivalent. Higher tiers involve higher risk therapies. Tiers 1, 2, and 3 include 10, 4, and 3 interventions, respectively. We include inter-tier considerations, and recommendations for critical neuroworsening to assist the recognition and treatment of declining patients. Novel elements include guidance for autoregulation-based ICP treatment based on MAP Challenge results, and two heatmaps to guide (1) ICP-monitor removal and (2) consideration of sedation holidays for neurological examination.CONCLUSIONS: Our modern and comprehensive sTBI-management protocol is designed to assist clinicians managing sTBI patients monitored with ICP-monitors alone. Consensus-based (class III evidence), it provides management recommendations based on combined expert opinion. It reflects neither a standard-of-care nor a substitute for thoughtful individualized management.

    View details for DOI 10.1007/s00134-019-05805-9

    View details for PubMedID 31659383

  • Concussion Guidelines Step 2: Evidence for Subtype Classification. Neurosurgery Lumba-Brown, A., Teramoto, M., Bloom, O. J., Brody, D., Chesnutt, J., Clugston, J. R., Collins, M., Gioia, G., Kontos, A., Lal, A., Sills, A., Ghajar, J. 2019


    BACKGROUND: Concussion is a heterogeneous mild traumatic brain injury (mTBI) characterized by a variety of symptoms, clinical presentations, and recovery trajectories. By thematically classifying the most common concussive clinical presentations into concussion subtypes (cognitive, ocular-motor, headache/migraine, vestibular, and anxiety/mood) and associated conditions (cervical strain and sleep disturbance), we derive useful definitions amenable to future targeted treatments.OBJECTIVE: To use evidence-based methodology to characterize the 5 concussion subtypes and 2 associated conditions and report their prevalence in acute concussion patients as compared to baseline or controls within 3 d of injury.METHODS: A multidisciplinary expert workgroup was established to define the most common concussion subtypes and their associated conditions and select clinical questions related to prevalence and recovery. A literature search was conducted from January 1, 1990 to November 1, 2017. Two experts abstracted study characteristics and results independently for each article selected for inclusion. A third expert adjudicated disagreements. Separate meta-analyses were conducted to do the following: 1) examine the prevalence of each subtype/associated condition in concussion patients using a proportion, 2) assess subtype/associated conditions in concussion compared to baseline/uninjured controls using a prevalence ratio, and 3) compare the differences in symptom scores between concussion subtypes and uninjured/baseline controls using a standardized mean difference (SMD).RESULTS: The most prevalent concussion subtypes for pediatric and adult populations were headache/migraine (0.52; 95% CI=0.37, 0.67) and cognitive (0.40; 95% CI=0.25, 0.55), respectively. In pediatric patients, the prevalence of the vestibular subtype was also high (0.50; 95% CI=0.40, 0.60). Adult patients were 4.4, 2.9, and 1.7 times more likely to demonstrate cognitive, vestibular, and anxiety/mood subtypes, respectively, as compared with their controls (P<.05). Children and adults with concussion showed significantly more cognitive symptoms than their respective controls (SMD=0.66 and 0.24; P<.001). Furthermore, ocular-motor in adult patients (SMD=0.72; P<.001) and vestibular symptoms in both pediatric and adult patients (SMD=0.18 and 0.36; P<.05) were significantly worse in concussion patients than in controls.CONCLUSION: Five concussion subtypes with varying prevalence within 3 d following injury are commonly seen clinically and identifiable upon systematic literature review. Sleep disturbance, a concussion-associated condition, is also common. There was insufficient information available for analysis of cervical strain. A comprehensive acute concussion assessment defines and characterizes the injury and, therefore, should incorporate evaluations of all 5 subtypes and associated conditions.

    View details for DOI 10.1093/neuros/nyz332

    View details for PubMedID 31432081

  • Disrupted White Matter Microstructure of the Cerebellar Peduncles in Scholastic Athletes After Concussion FRONTIERS IN NEUROLOGY Mallott, J. M., Palacios, E. M., Maruta, J., Ghajar, J., Mukherjee, P. 2019; 10
  • 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


    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 PubMedID 30877299

  • Concussion Subtype Identification With the Rivermead Post-concussion Symptoms Questionnaire. Frontiers in neurology Maruta, J., Lumba-Brown, A., Ghajar, J. 2018; 9: 1034


    Classifying concussion in key subtypes according to presenting symptomatology at an early post-injury stage is an emerging approach that may allow prediction of clinical trajectories and delivery of targeted treatments. The Rivermead Post-concussion Symptoms Questionnaire (RPQ) is a simple, freely available, and widely used tool for assessment of the presence and severity of various post-concussion symptoms. We aimed to probe the prevalence among athletes of symptom classes associated with identified concussion phenotypes using the RPQ at baseline and acutely after a concussion. Participants of organized sports aged 12-30 years were baseline-assessed with the expectation that some would experience a concussion during the study period. Concussed athletes were re-assessed within 2 weeks of their injuries. The RPQ was supplemented with three specific questions and reworded for baseline assessment. A binomial test was used to contrast the prevalence of an attribute in the concussed cohort against the probability established by the baseline observation. Three thousand and eighty-eight athletes were baseline-assessed and eighty-nine were re-assessed post-concussion. All concussed athletes endorsed having some elevated symptoms in the RPQ, and such endorsements were more prevalent than those among normal athletes. Moderate-to-severe post-concussion symptoms of specific classes tended to be endorsed with few additional symptoms of other classes of similar intensities. Elevated symptoms detected with the RPQ within as short as 2 weeks after a concussion may help delineate patients' clinical subtypes and guide their treatment. Further refinement of symptom questionnaires and use of objective measures will be needed to properly populate the concussion subtype classification.

    View details for DOI 10.3389/fneur.2018.01034

    View details for PubMedID 30559709

    View details for PubMedCentralID PMC6287109

  • Concussion Subtype Identification With the Rivermead Post-concussion Symptoms Questionnaire FRONTIERS IN NEUROLOGY Maruta, J., Lumba-Brown, A., Ghajar, J. 2018; 9
  • Association of Visual Tracking Metrics With Post-concussion Symptomatology FRONTIERS IN NEUROLOGY Maruta, J., Spielman, L. A., Rajashekar, U., Ghajar, J. 2018; 9
  • Association of Visual Tracking Metrics With Post-concussion Symptomatology. Frontiers in neurology Maruta, J., Spielman, L. A., Rajashekar, U., Ghajar, J. 2018; 9: 611


    Attention impairment may provide a cohesive neurobiological explanation for clusters of clinical symptoms that occur after a concussion; therefore, objective quantification of attention is needed. Visually tracking a moving target is an attention-dependent sensorimotor function, and eye movement can be recorded easily and objectively to quantify performance. Our previous work suggested the utility of gaze-target synchronization metrics of a predictive visual tracking task in concussion screening and recovery monitoring. Another objectively quantifiable performance measure frequently suggested for concussion screening is simple visuo-manual reaction time (simple reaction time, SRT). Here, we used visual tracking and SRT tasks to assess changes between pre- and within-2-week post-concussion performances and explore their relationships to post-concussion symptomatology. Athletes participating in organized competitive sports were recruited. Visual tracking and SRT records were collected from the recruited athlete pool as baseline measures over a 4-year period. When athletes experienced a concussion, they were re-assessed within 2 weeks of their injury. We present the data from a total of 29 concussed athletes. Post-concussion symptom burden was assessed with the Rivermead Post-Concussion Symptoms Questionnaire and subscales of the Brain Injury Screening Questionnaire. Post-concussion changes in visual tracking and SRT performance were examined using a paired t-test. Correlations of changes in visual tracking and SRT performance to symptom burden were examined using Pearson's coefficients. Post-concussion changes in visual tracking performance were not consistent among the athletes. However, changes in several visual tracking metrics had moderate to strong correlations to symptom scales (r up to 0.68). On the other hand, while post-concussion SRT performance was reduced (p < 0.01), the changes in the performance metrics were not meaningfully correlated to symptomatology (r ≤ 0.33). Results suggest that visual tracking performance metrics reflect clinical symptoms when assessed within 2 weeks of concussion. Evaluation of concussion requires assessments in multiple domains because the clinical profiles are heterogeneous. While most individuals show recovery within a week of injury, others experience prolonged recovery periods. Visual tracking performance metrics may serve as a biomarker of debilitating symptoms of concussion implicating attention as a root cause of such pathologies.

    View details for DOI 10.3389/fneur.2018.00611

    View details for PubMedID 30093880

    View details for PubMedCentralID PMC6070608

  • 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


    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 PubMedID 30482349

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


    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 PubMedID 29250026

  • 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-?


    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


    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: -?


    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, 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


    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

    View details for PubMedCentralID PMC4904152

  • 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)


    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


    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


    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


    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


    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

  • Age-specific cerebral perfusion pressure thresholds and survival in children and adolescents with severe traumatic brain injury*. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies Allen, B. B., Chiu, Y. L., Gerber, L. M., Ghajar, J., Greenfield, J. P. 2014; 15 (1): 62-70


    Evidence-based traumatic brain injury guidelines support cerebral perfusion pressure thresholds for adults at a class 2 level, but evidence is lacking in younger patients. The purpose of this study is to identify the impact of age-specific cerebral perfusion pressure thresholds on short-term survival among patients with severe traumatic brain injury.Institutional review board-approved, prospective, observational cohort study.Level I or II trauma centers in New York State.Data on all patients with a postresuscitation Glasgow Coma Score less than 9 were added in the Brain Trauma Foundation prospective New York State TBI-trac database.We calculated the survival rates and relative risks of mortality for patients with severe traumatic brain injury based on predefined age-specific cerebral perfusion pressure thresholds. A higher threshold and a lower threshold were defined for each age group: 60 and 50 mm Hg for 12 years old or older, 50 and 35 mm Hg for 6-11 years, and 40 and 30 mm Hg for 0-5 years. Patients were stratified into age groups of 0-11, 12-17, and 18 years old or older. Three exclusive groups of CPP-L (events below low cerebral perfusion pressure threshold), CPP-B (events between high and low cerebral perfusion pressure thresholds), and CPP-H (events above high cerebral perfusion pressure threshold) were defined. As an internal control, we evaluated the associations between cerebral perfusion pressure events and events of hypotension and elevated intracranial pressure. Survival was significantly higher in 0-11 and 18 years old or older age groups for patients with CPP-H events compared with those with CPP-L events. There was a significant decrease in survival with prolonged exposure to CPP-B events for the 0-11 and 18 years old and older age groups when compared with the patients with CPP-H events (p = 0.0001 and p = 0.042, respectively). There was also a significant decrease in survival with prolonged exposure to CPP-L events in all age groups compared with the patients with CPP-H events (p< 0.0001 for 0- to 11-yr olds, p = 0.0240 for 12- to 17-yr olds, and p < 0.0001 for 18-yr old and older age groups). The 12- to 17-year olds had a significantly higher likelihood of survival compared with adults with prolonged exposure to CPP-L events (< 50 mm Hg). CPP-L events were significantly related to systemic hypotension for the 12- to 17-year-old group (p = 0.004) and the 18-year-old and older group (p < 0.0001). CPP-B events were significantly related to systemic hypotension in the 0- to 11-year-old group (p = 0.014). CPP-B and CPP-L events were significantly related to elevated intracranial pressure in all age groups.Our data provide new evidence that cerebral perfusion pressure targets should be age specific. Furthermore, cerebral perfusion pressure goals above 50 or 60 mm Hg in adults, above 50 mm Hg in 6- to 17-year olds, and above 40 mm Hg in 0- to 5-year olds seem to be appropriate targets for treatment-based studies. Systemic hypotension had an inconsistent relationship to events of low cerebral perfusion pressure, whereas elevated intracranial pressure was significantly related to all low cerebral perfusion pressure events across all age groups. This may impart a clinically important difference in care, highlighting the necessity of controlling intracranial pressure at all times, while targeting systolic blood pressure in specific instances.

    View details for DOI 10.1097/PCC.0b013e3182a556ea

    View details for PubMedID 24196011

    View details for PubMedCentralID PMC4077612

  • 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-?


    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

    View details for PubMedCentralID PMC2831631

  • The predictive brain state: asynchrony in disorders of attention? The Neuroscientist : a review journal bringing neurobiology, neurology and psychiatry Ghajar, J., Ivry, R. B. 2009; 15 (3): 232-42


    It is postulated that a key function of attention in goal-oriented behavior is to reduce performance variability by generating anticipatory neural activity that can be synchronized with expected sensory information. A network encompassing the prefrontal cortex, parietal lobe, and cerebellum may be critical in the maintenance and timing of such predictive neural activity. Dysfunction of this temporal process may constitute a fundamental defect in attention, causing working memory problems, distractibility, and decreased awareness.

    View details for DOI 10.1177/1073858408326429

    View details for PubMedID 19074688

    View details for PubMedCentralID PMC4342364

  • Structural dissociation of attentional control and memory in adults with and without mild traumatic brain injury BRAIN Niogi, S. N., Mukherjee, P., Ghajar, J., Johnson, C. E., Kolster, R., Lee, H., Suh, M., Zimmerman, R. D., Manley, G. T., McCandliss, B. D. 2008; 131: 3209-3221


    Memory and attentional control impairments are the two most common forms of dysfunction following mild traumatic brain injury (TBI) and lead to significant morbidity in patients, yet these functions are thought to be supported by different brain networks. This 3 T magnetic resonance diffusion tensor imaging (DTI) study investigates whether microstructural integrity of white matter, as measured by fractional anisotropy (FA) within a small set of individually localized regions of interest (ROIs), is associated with these cognitive domains in normal adults and adults with mild TBI. Results in a sample of 23 normal controls reveal a significant correlation between attentional control and FA within a ROI in the left hemisphere anterior corona radiata. Furthermore, the controls demonstrate a correlation between memory performance and FA in a ROI placed in the uncinate fasciculus. Next, to examine whether these relationships are found in the pathological ranges of attention, memory and microstructural white matter integrity associated with mild TBI, these analyses were applied to a group of 43 mild TBI patients. Results, which generally demonstrated a wider range of attention, memory and FA scores, replicated the correlation between attentional control and FA in left hemisphere anterior corona radiata, as well as the correlation between memory performance and FA in the uncinate fasciculus. These two sets of brain-behaviour relationships were highly specific, as shown by a lack of correlation between attention and uncinate fasciculus FA and the lack of correlation between memory performance and anterior corona radiata FA. Furthermore, a 'correlational double dissociation' was demonstrated to exist between two distinct frontal structures independently associated with attention and memory, respectively, via a series of multiple regression analyses in both normal controls and adults with mild TBI. The results of the multiple regression analyses provide direct evidence that tract-specific variation in microstructural white matter integrity among normal controls and among mild TBI patients can account for much of the variation in performance in specific cognitive domains. More generally, such findings suggest that diffusion anisotropy measurement can be used as a quantitative biomarker for neurocognitive function and dysfunction.

    View details for DOI 10.1093/brain/awn247

    View details for Web of Science ID 000261996700012

    View details for PubMedID 18952679

  • Increased oculomotor deficits during target blanking as an indicator of mild traumatic brain injury. Neuroscience letters Suh, M., Basu, S., Kolster, R., Sarkar, R., McCandliss, B., Ghajar, J. 2006; 410 (3): 203-7


    Given the susceptibility of cerebellar-cortical tracts to shearing injury from traumatic brain injury (TBI), we investigated impairment in the generation of predictive eye movements and its relationship to cognitive deficits in mild TBI patients using a smooth pursuit target-blanking paradigm. Compared to a target-tracking paradigm without blanking, this paradigm more greatly necessitates the generation of predictive eye movements, which are subserved by brain regions involved in cognitive processing. Mild TBI patients showed impaired prediction of target trajectories during target blanking, demonstrated by generation of saccades at earlier and more variable time points, as well as greater and more variable oculomotor error compared to controls. In addition, California Verbal Learning Test (CVLT-II) scores related to working memory, learning, and executive function were more highly correlated with oculomotor variability during target blanking than during target tracking. Our results suggest that a disruption of cerebellar-cortical connections in TBI may account for both oculomotor and cognitive impairment, and that measures of predictive eye movements during target blanking may be a sensitive metric of cognitive deficits after mild TBI.

    View details for DOI 10.1016/j.neulet.2006.10.001

    View details for PubMedID 17055156

  • Deficits in predictive smooth pursuit after mild traumatic brain injury. Neuroscience letters Suh, M., Kolster, R., Sarkar, R., McCandliss, B., Ghajar, J. 2006; 401 (1-2): 108-13


    Given that even mild traumatic brain injury (TBI) may produce extensive diffuse axonal injury (DAI), we hypothesized that mild TBI patients would show deficits in predictive smooth pursuit eye movements (SPEM), associated with impaired cognitive functions, as these processes are dependent on common white matter connectivity between multiple cerebral and cerebellar regions. The ability to predict target trajectories during SPEM was investigated in 21 mild TBI patients using a periodic sinusoidal paradigm. Compared to 26 control subjects, TBI patients demonstrated decreased target prediction. TBI patients also showed increased eye position error and variability of eye position, which correlated with decreased target prediction. In all subjects, average target prediction, eye position error and eye position variability correlated with scores related to attention and executive function on the California Verbal Learning Test (CVLT-II). However, there were no differences between TBI and control groups in average eye gain or intra-individual eye gain variability, or in performance on the Wechsler Abbreviated Scale of Intelligence (WASI), suggesting that the observed deficits did not result from general oculomotor impairment or reduced IQ. The correlation between SPEM performance and CVLT-II scores suggests that predictive SPEM may be a sensitive assay of cognitive functioning, including attention and executive function. This is the first report to our knowledge that TBI patients show impaired predictive SPEM and eye position variability, and that these impairments correlate with cognitive deficits.

    View details for DOI 10.1016/j.neulet.2006.02.074

    View details for PubMedID 16554121

  • 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


    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 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
  • 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


    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


    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

    View details for PubMedCentralID PMC4748060

  • 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


    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-?


    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

    View details for PubMedCentralID PMC2739840