Head Injury, Brain injury, Head trauma, Contusion

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Traumatic Brain Injury

Head injury; Head trauma; mild TBI; Contusion; Concussion

Defining Traumatic Brain Injury

Injury to the brain caused by and external force resulting in total or partial impairment of brain function.
Head injury is any trauma that leads to injury of the scalp, skull, or brain. The injuries can range from a minor bump on the skull to serious brain injury.

The "Silent Epidemic" - Traumatic Brain Injury (TBI) occurs more frequently than breast cancer and AIDS combined, yet it is not considered a massive public-health problem. TBI is the leading cause of death in people under 45 years old, and many times is misdiagnosed or not diagnosed at all.

Trauma can be induced by:
1. Spinning - rotational forces cause the brain to hit the skull upon sudden stop
2. Impact - sudden blow to the head
3. Penetration - skull is broken through

There are several types of brain injuries. Two common types of head injuries are:

- Concussion, the most common type of traumatic brain injury
- Contusion, which is a bruise on the brain

Considerations

Every year, millions of people sustain a head injury. Most of these injuries are minor because the skull provides the brain with considerable protection. The symptoms of minor head injuries usually go away on their own. More than half a million head injuries a year, however, are severe enough to require hospitalization.

Learning to recognize a serious head injury, and implementing basic first aid, can make the difference in saving someone's life.

In patients who have suffered a severe head injury, there is often one or more other organ systems injured. For example, a head injury is sometimes accompanied by a spinal injury.

Epidemiology:

The most common causes of traumatic brain injury are:
- violence
- slip and fall
- motor vehicle accidents
- firearms
- construction
- sports
- bicycles & other transports

Annual incidence of traumatic brain injury in the United States alone are estimated to be 1.5 million. This number is more than breast cancer, AIDS, Multiple Sclerosis and spinal cord injury combined.

Center for Disease Control; Jan 2006 Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths, 2002-2006

Some head injuries result in prolonged or non-reversible brain damage. This can occur as a result of bleeding inside the brain or forces that damage the brain directly. These more serious head injuries may cause:

. Changes in personality, emotions, or mental abilities
. Speech and language problems
. Loss of sensation, hearing, vision, taste, or smell
. Seizures
. Paralysis
. Coma

Classification Systems:

Traumatic brain injury can be classified as either closed or open/penetrating.

- A closed head injury means you received a hard blow to the head from striking an object.
- An open, or penetrating, head injury means you were hit with an object that broke the skull and entered the brain. This usually happens when you move at high speed, such as going through the windshield during a car accident. It can also happen from a gunshot to the head.

Additionally, brain injury can be classified as either focal or diffuse.

- Focal injury occurs in a targeted area of the brain from a direct mechanical force. Common focal injuries include contusion (bruise), laceration (tearing) and hemorrhage (bleeding).
- Diffuse injury occurs over a large area of the brain. Diffuse axonal injury results from damage to the white matter of the brain where the axon is sheared and individual nerve fibers become unusable. Intracranial pressure from swelling of the brain is also a type of diffuse injury

More sophisticated classification systems have been developed to aid physicians in their diagnosis of head injury.

Concussion Grading Scale

Glasgow Coma Scale

The Glasgow Coma Scale is the most widely used grading scale to assess patients neurological status. However, there are over sixteen different grading systems that currently exist, the most recent being over ten years old. The American Academy of Neurology (AAN) is developing a new grading system that is scheduled to be introduced in 2012.

Symptoms

The signs of a head injury can occur immediately or develop slowly over several hours. Even if the skull is not fractured, the brain can bang against the inside of the skull and be bruised. (This is called a concussion.) The head may look fine, but complications could result from bleeding inside the skull. Here are some of the most common symptoms for brain injury:

When encountering a person who just had a head injury, try to find out what happened. If he or she cannot tell you, look for clues and ask witnesses. In any serious head trauma, always assume the spinal cord is also injured.

The following symptoms suggest a more serious head injury -- other than a concussion or contusion -- and require emergency medical treatment:

. Loss of consciousness, confusion, or drowsiness
. Low breathing rate or drop in blood pressure
. Convulsions
. Fracture in the skull or face, facial bruising, swelling at the site of the injury, or scalp wound
. Fluid drainage from nose, mouth, or ears (may be clear or bloody)
. Severe headache
. Initial improvement followed by worsening symptoms
. Irritability (especially in children), personality changes, or unusual behavior
. Restlessness, clumsiness, lack of coordination
. Slurred speech or blurred vision
. Inability to move one or more limbs
. Stiff neck or vomiting
. Pupil changes
. Inability to hear, see, taste, or smell

Diagnosis:

Several types of advanced diagnostic tools are available to neurologists for the study of brain injury.

1. Neuropsychological Evaluation - a testing method through which a neuropsychologist can acquire information patient's cognitive, motor, behavioral, language, and executive functioning. This information can help guide a neurologist toward diagnosis of cognitive deficiencies and other neurological issues.

2. Magnetic Resonance Imaging (MRI) provides good contrast between the different soft tissues of the body, which makes it especially useful in imaging the brain.

3. Electroencephalogram (EEG) - useful in the diagnosis of seizure disorders, confusion, head injuries, brain tumors, degenerative diseases, infections, and metabolic disturbances that affect the brain.

4. Video Electronystagmography (VENG) - maps out the "circuitry" of the brain using infrared cameras which track the exact position and movement of the pupils in each eye. VENG is commonly used to diagnose balance issues such as dizziness and vertigo.

5. Computerized tomography scan (CT) - combines special x-ray equipment with sophisticated computers to produce multiple images or pictures of the brain providing greater clarity and more details than regular x-ray exams.

New Advances is Technology:

Technological advances are enabling the development of sophisticated instrumentation for neurological evaluation. While these techniques may represent the future of neurological analysis, their cost remain high thus preventing their more routine use in diagnosing brain injury.

1. MRI + Diffusion Tensor Imaging (DTI) - measures the rate of diffusion of water through the neural axons of white matter of the brain. Neurologists can study the neural pathways in the brain and compare the differences between normal patients and patients with brain injury.

Images courtesy of Cedars-Sinai hospital; http://www.cedars-sinai.edu/Medical-Professionals/Imaging-Center/Neuroradiology/MRI-with-DTI.aspx

2. Magnetoencephalography (MEG) - a technique for mapping brain activity by recording magnetic fields produced by electrical currents occurring naturally in the brain. Although similar to EEG which records electric fields, MEG measures magnetic fields which are distorted less than electric fields by the skull and scalp resulting in better spatial resolution.

3. Positron Emission Tomography (PET) - produces a three-dimensional image or picture of functional processes in the body by detecting pairs of gamma rays emitted indirectly by tracer. Three-dimensional images of tracer concentration within the body are then constructed by computer analysis. When used in combination with MRI and CT scans neurologist are able to evaluate both anatomic and metabolic information (i.e., what the structure is, and what it is doing biochemically).

Treatment:

1. Recognition - initial neurological evaluation aims to define the severity of the injury and accompanying symptoms

2. Education - counseling the patient to help them understand they are not alone. Many others in the world suffer just like them. People around them may not understand what they are going through, or others may make them feel guilty for the treatment they receive because they look healthy on the outside.

3. Pharmacological Treatment – many drugs exist to help with depression, pain, anxiety and lack of energy.

4. Head Injury Rehabilitation - restoration of functions that can be restored, and learning how to do things differently when functions cannot be restored.

5. Cranial Nerve Treatment - type of therapy to restore loss of smell, taste, sight, ability to swallow and balance

6. Symptomatic Treatment – wide variety of symptoms require help of other specialists in areas such as orthopedics, ophthalmology, psychiatry, chiropractic and more

Orange County Neurology Medical Center

Neurologist - Brain Injury - Nerve Damage - Neurological Disorders

Traumatic Brain Injury