2019 Conference

What is tbi?

Long Range Complications of Brain Injury

Any or all of the complications caused by the TBI may occur in varying degrees. Good pre-hospital care, appropriate trauma treatment, and intensive rehabilitation are needed to alleviate symptoms and prevent complications or secondary disabilities.


  • memory loss (short and long term)
  • problems in arousal, attention, and concentration
  • problems in initiating action, planning action, and follow up
  • problems in judgment
  • difficulty in recognizing own cognitive deficits/limits
  • difficulty with abstract thinking (needs simple, concrete direction)
  • difficulty in generalizing from a specific time, place, or idea
  • spatial disorientation (problems with perception, direction, etc.)
  • slowness of thought process
  • slowness and/or difficulty with speech


  • fatigability; maintaining attention and activity produces fatigue
  • visual impairment
  • hearing impairment
  • loss of taste
  • spasticity
  • hemiparesis
  • seizures


  • anxiety and depression
  • emotional-lability (swings in mood)
  • "denial"
  • inappropriate behaviors (impulsivity, disinhibition, lack of social judgment, and appreciation of subtleties)
  • egocentricity (focus on one's self; loss of social perspective)
  • agitation/outbursts
  • sexual dysfunction
  • loss of social network/isolation

Facts About Brain Injury

  • Incidence: 200/100,000
  • Brain injuries are the most frequent reason for visits to physicians and emergency rooms.
  • A brain injury occurs every 16 seconds; a death from brain injury occurs every 12 minutes.
  • One out of 80 children born this year are expected to die of a vehicular-induced brain injury, probably before their 25th birthday.
  • The typical brain injury victim is a young male between the ages of 16 and 24 who is injured in a vehicular accident.
  • Brain injuries require 3.5 million days of hospitalization and loss of more than 35,000 years of productive work annually.
  • Typically, a severely injured survivor requires between 5-10 years of intensive rehabilitation with long-term follow-up.
  • Each year, there are 2,000 new cases of "persistent vegetative state" in the US as a result of brain injury.
  • A survivor of severe brain injury requires between $4.1 million and $9 million in lifetime care.
  • Brain injury kills more Americans under the age of 34 than all other causes combined and has claimed more lives since the turn of the century than all US wars combined.
  • The only cure for traumatic brain injury is prevention!

Some Factors Which May Affect Outcome After Brain Injury

  • Age at time of injury
  • Severity and location of injury to brain
  • Length of time in coma
  • Pre-existing personality characteristics
  • Motivation for recovery
  • Quality and quickness of prehospital and hospital care
  • Rapidity of entry into brain injury rehabilitation program
  • Nature of support network and involvement of family

Indicators and Symptoms of Brain Injury

  • change or loss of consciousness
  • dizziness
  • headache
  • loss of memory of events immediately before injury
  • visual disturbances
  • vomiting
  • staggering, loss of balance, muscle weakness
  • numbness of either arm or leg
  • seizures
  • blood or fluid from ears, nose, or throat
  • slurred speech or nonsense speech

What is Brain Injury?
A serious brain injury usually results in a loss of consciousness (coma), which may be brief—lasting only a few minutes—or may extend to days, weeks, or months. If the period of coma is short, return to full or nearly full function is likely; but as time in a coma lengthens, intellectual and speech impairment, behavioral disorders, and related physical disabilities can occur.

It is important to note that a person does not have to lose consciousness to have sustained a brain injury. Minor brain trauma, where there is little or no loss of consciousness and no resulting hospitalization, can also cause temporary or permanent damage to the brain.

Why is brain injury called the silent epidemic?
Because of the magnitude of the problem, brain trauma has remained largely unknown by the American public. There are currently 5.3 million individuals—a little more than 2 percent of the U.S. population—living with a disability resulting from a traumatic brain injury. When considering an individual’s family and circle(s) of support, brain injury touches the lives of approximately one in every 10 persons in the United States. The annual statistics of brain injury are staggering:

  • 1 million people are treated and released from hospital emergency departments
  • 230,000 people are hospitalized and survive
  • 80,000 Americans experience the new onset of long-term disability following hospitalization for traumatic brain injury (TBI)
  • 50,000 people die

Common Causes of Brain Injury

  • Falls

o        Bicycle Crashes:

      • More kids ages five to 14 go to the hospital emergency departments with injuries related to biking than with any other sport.
      • Each year, about 567,000 people go to hospital emergency departments with bicycle-related injuries; about 350,000 of those injured are children under 15. Of those children, about 130,000 sustain brain injuries.

·         Motor Vehicle Crashes

o       motor vehicle crashes are the leading cause of TBI and injury-related deaths for 15-to 49-year-olds.

o       Brain and chest injuries are the most frequent cause of death in collisions without seatbelts.

o       Seat belts are 57 percent effective in preventing traumatic and fatal brain injuries.

  • Sporting Activities

o        Sports Concussions:

      • A concussion is a condition of temporarily altered mental status as a result of a head trauma.
      • Every year, an estimated 300,000 concussions occur in the United States.
  • Violence
    • 60 percent of gun-related TBI's are a result of a suicide attempt and 37 percent are a result of an intentional assault.
    • Violent behavior is especially dangerous to the brain, because hits are often directed to the head.
    • Firearm and non-firearm assaults together make up for 17 percent of all TBI's.
    • Firearms are the leading cause of death from brain injury.

o        Shaken Baby Syndrome:

      • Shaken Baby Syndrome is caused by vigorous shaking of an infant or young child from the arms, legs, chest or shoulders.
      • One shaken baby in three dies as a result of this abuse.
      • Shaken Baby Syndrome (SBS) is a leading cause of morbidity and mortality in infants.
      • One third of the victims of SBS survive with minor consequences, one-third suffer permanent injury and one-third die.

o        Domestic Violence:

      • It is estimated that a woman is beaten every nine seconds in the United States, which results in the leading cause of emergency room visits for women.
      • The head is a primary target in domestic attacks and the effects of this abuse can result in cumulative brain injuries.

·         Acquired Brain Injury

o        Acquired brain injury (ABI) refers to any type of brain damage that occurs after birth. It can include damage sustained by infection, disease, lack of oxygen or a blow to the head. Around 160,000 Australians are coping with some form of acquired brain injury, with more men (2.2 per cent) affected than women (1.6 per cent). Most people with ABI can expect to improve with treatment and support.

How brain injury occurs
Brain injury can occur in the following ways:

·         Sudden onset - caused by trauma, infection, lack of oxygen (for example, during near drowning or suicide attempts), strokes or drug use episodes.

·         Insidious onset - from prolonged alcohol or substance abuse, tumors or degenerative neurological diseases.

What are the different types of ABI?

Brain injury may occur in one of two ways:

  • closed brain injury
    Closed brain injuries occur when there is a non-penetrating injury to the brain with no break in the skull. A closed brain injury is caused by a rapid forward or backward movement and shaking of the brain inside the bony skull that results in bruising and tearing of brain tissue and blood vessels. Closed brain injuries are usually caused by car accidents and falls. Shaking a baby can also result in this type of injury (called shaken baby syndrome).
  • penetrating brain injury
    Penetrating, or open head injuries occur when there is a break in the skull, such as when a bullet pierces the brain.

What is diffuse axonal injury (DAI)?

Diffuse axonal injury is the shearing (tearing) of the brain's long connecting nerve fibers (axons) that occurs when the brain is injured as it shifts and rotates inside the bony skull. DAI usually causes coma and injury to many different parts of the brain. The changes in the brain are often microscopic and may not visualize on computed tomography (CT scan) or magnetic resonance imaging (MRI) scans.

What is primary and secondary brain injury?

Primary brain injury refers to the sudden and profound injury to the brain that is considered to be more or less complete at the time of impact. This occurs at the time of the car accident, gunshot wound, or fall.

Secondary brain injury refers to the changes that evolve over a period of time (from hours to days) after the primary brain injury. It includes an entire cascade of cellular, chemical, tissue, or blood vessel changes in the brain that contribute to further destruction of brain tissue.


A range of causes
Acquired brain injury is any damage to the brain that happens after birth. There are many causes of head injury in children and adults. The most common injuries are from motor vehicle accidents (where the person is either riding in the car or is struck as a pedestrian), from violence, from falls, or as a result of shaking a child (as seen in cases of child abuse).The specific symptoms or losses of functioning depend on which brain areas are affected. Some of the causes include:

·         Alcohol or drugs - which can poison the brain.

·         Aneurysms- An aneurysm is a cardiovascular disease that occurs when an artery is widened because of a weak artery wall. An aneurysm typically ruptures near the brain, causing significant brain damage.

·         Disease - such as AIDS, Alzheimer's disease, cancer, multiple sclerosis or Parkinson's disease.

·         Lack of oxygen - called anoxic brain injury (for example, injury caused by a near drowning).

·         Physical injury - such as an impact to the head, which may occur in car or sporting accidents, fights or falls.

·         Stroke - when a blood vessel inside the brain breaks or is blocked, destroying the local brain tissue.


How brain injury affects a person
The long term effects of brain injury are difficult to predict. They will be different for each person and can range from mild to profound. It is common for many people with ABI to experience increased fatigue (mental and physical) and some slowing down in the speed with which they process information, plan and solve problems. They may experience changes to their behavior and personality, physical and sensory abilities, or thinking and learning.

What causes bruising and internal damage to the brain?
When there is a direct blow to the head, the bruising of the brain and the damage to the internal tissue and blood vessels is due to a mechanism called coup-countercoup. A bruise directly related to trauma at the site of impact is called a coup lesion (pronounced COO). As the brain jolts backwards, it can hit the skull on the opposite side and cause a bruise called a countercoup lesion. The jarring of the brain against the sides of the skull can cause shearing (tearing) of the internal lining, tissues, and blood vessels leading to internal bleeding, bruising, or swelling of the brain.

The brain
The brain is the powerhouse of the body, even though it only makes up two per cent of the body's weight. This soft, jelly-like organ has countless billions of neural cross-connections. It functions using a combination of electrical and chemical means. The brain oversees the workings of the body, while its higher functions give us consciousness and personality. The brain is divided into two halves, the left hemisphere and the right hemisphere. Each hemisphere is further subdivided into lobes. Different functions are governed by different parts of the brain, which is suspended in a chemical 'soup' called cerebrospinal fluid. This fluid nourishes the brain and serves as a shock absorber. The brain is connected to the rest of the body via the spinal cord. Together, the brain and spinal cord make up the central nervous system.

Traumatic brain injury
Traumatic brain injury (TBI) is not the same as head injury, since a person can sustain damage to the face, scalp and skull without necessarily injuring their brain. TBI is considered a form of acquired brain injury, and refers to brain damage caused by an impact to the head. When the head is heavily struck, the brain slams violently against the inside of the skull, causing physical injuries such as bruising, swelling, bleeding, twisting or tearing of tissue. There are degrees of injury, ranging from a momentary loss of consciousness (which can happen from, say, a punch to the face) to a long term bout of unconsciousness or coma.

Treatment and care
A range of tests, including x-rays and CT brain scans, can help pinpoint the exact areas of damage. In some cases, surgery may be needed. Recovery depends on the extent and location of the brain damage, the age and general health of the individual, the speed of first aid received and the quality of treatment.

The consequences of a person having an ABI are far reaching. Coming to terms with any loss of functioning and going through the rigors of rehabilitation can be difficult. The person with an ABI will have great distress. Family, friends and partners will also experience difficulties as they deal with the emotional and practical burdens, the interruptions to family life and role changes.

An ABI can affect intimate relationships, friendships, social networks, recreational and vocational activities. It may force the person themselves and their immediate family to adapt to a completely new way of life and new kinds of relationships.

Caring for someone who has had a brain injury may bond a family closer together. It may also impose enormous burdens on the family, which may tear it apart. It will help if family members:

·         Have enough information about the effects of ABI

·         Appreciate the difficulties that might be encountered

·         Understand that recovery is a slow process.

Survival for caregivers requires staying with the present, rather than brooding about how catastrophic the future may be; highlighting the strengths and daily achievements, rather than the weaknesses; making time to care for themselves; and being wise enough to ask for help when it is needed.

What are the possible results of brain injury?

Some brain injuries are mild, with symptoms disappearing over time with proper attention. Others are more severe and may result in permanent disability. The long-term or permanent results of brain injury may require post-injury and possibly life-long rehabilitation. Effects of brain injury may include:

cognitive deficits

  • coma
  • confusion
  • shortened attention span
  • memory problems and amnesia
  • problem solving deficits
  • problems with judgment
  • inability to understand abstract concepts
  • loss of sense of time and space
  • decreased awareness of self and others
  • inability to accept more than one- or two-step commands simultaneously

motor deficits

  • paralysis or weakness
  • spasticity (tightening and shortening of the muscles)
  • poor balance
  • decreased endurance
  • inability to plan motor movements
  • delays in initiation
  • tremors
  • swallowing problems
  • poor coordination

perceptual or sensory deficits

  • changes in hearing, vision, taste, smell, and touch
  • loss of sensation or heightened sensation of body parts
  • left- or right-sided neglect
  • difficulty understanding where limbs are in relation to the body
  • vision problems, including double vision, lack of visual acuity, or limited range of vision

communication and language deficits

  • difficulty speaking and understanding speech (aphasia)
  • difficulty choosing the right words to say (apraxia)
  • slow, hesitant speech and decreased vocabulary
  • difficulty forming sentences that make sense
  • problems identifying objects and their function
  • problems with reading, writing, and ability to work with numbers

functional deficits

  • impaired ability with activities of daily living (ADLs) such as dressing, bathing, and eating
  • problems with organization, shopping, or paying bills
  • problems with vocational issues
  • inability to drive a car or operate machinery

social difficulties

  • impaired social capacity resulting in self-centered behavior
  • difficulties in making and keeping friends
  • difficulties understanding and responding to the nuances of social interaction

regulatory disturbances

  • fatigue
  • changes in sleep patterns and eating habits
  • dizziness
  • headache
  • loss of bowel and bladder control

personality or psychiatric changes

  • apathy
  • decreased motivation
  • emotional lability
  • irritability
  • anxiety and depression
  • disinhibition, including temper flare-ups, aggression, cursing, lowered frustration tolerance, and inappropriate sexual behavior

Certain psychiatric disorders are more likely to develop if damage changes the chemical composition of the brain.

traumatic epilepsy

Epilepsy occurs in 2 to 5 percent of all people who sustain brain injury, but it is much more common with severe or penetrating injuries. While most seizures occur immediately after the injury, or within the first year, it is also possible for epilepsy to surface years later. Epilepsy includes both major or generalized seizures and minor or partial seizures.

Can the brain heal after being injured?

Most studies suggest that once brain cells are destroyed or damaged, for the most part, they do not regenerate. However, recovery after brain injury can take place, as, in some cases, other areas of the brain compensate for the injured tissue, or the brain learns to reroute information and function around the damaged areas. The exact amount of recovery is not predictable at the time of injury and may be unknown for months or even years. Each brain injury and rate of recovery is unique. Recovery from a severe brain injury often involves a prolonged or life-long process of treatment and rehabilitation.

What is coma?

Coma is an altered state of consciousness that may be very deep (unconsciousness) so that no amount of stimulation will cause the patient to respond, or it can be a state of reduced consciousness, so that the patient may move about or respond to pain. Not all patients with brain injury are comatose. The depth of coma, and the time a patient spends in a coma varies greatly depending on the location and severity of the brain injury. Some patients emerge from a coma and have a good recovery; others have significant disabilities.

How is coma measured?
Depth of the coma is usually measured in the emergency and intensive care settings using a Glascow coma scale. The scale (from 3 to 15) assesses eye opening, verbal response, and motor response. A high score indicates a greater amount of consciousness and awareness.

In rehabilitation settings, another measurement scale is often used to indicate a patient's level of response and ability to function. It is called a Rancho scale and is named for the rehabilitation hospital where it was created, Rancho Los Amigos, in California.

Rancho scales are based on how the patient reacts to external stimuli and the environment. The scales consist of eight different levels and each patient will progress through the levels with starts and stops, progress and plateaus. A brief summary of the components of the Rancho scale include the following:

Level I

No Response

The patient is in a deep coma and appears soundly asleep; absence of any response to stimuli.

Level II

General Response

The patient responds to pain or repeated stimuli with non-purposeful movements or increased activity.

Level III

Local Response

The patient's response is more specific, such as turning the head toward a sound or following a simple command. Responses are delayed and inconsistent.

Level IV

Confused - Agitated

The patient is in a heightened state of response, confused, agitated, attempts to pull out tubes, bites, hits, or kicks caregivers. Behavior is inappropriate and speech is often incoherent.

Level V

Confused - Inappropriate -
Not agitated

The patient appears alert and can follow simple commands. Responses are confused and non-purposeful. Memory is impaired and speech is often inappropriate.

Level VI

Confused - Appropriate

The patient shows purposeful behaviors but requires direction and supervision for activities such as dressing and eating; becoming more aware of the environment; memory improving.

Level VII

Automatic - Appropriate

The patient goes about activities appropriately with minimal confusion, but often appears "robot-like." Judgment, thinking, and problem solving remain impaired.

Level VIII

Purposeful - Appropriate

The patient is oriented with improving memory and skills. May still require supervision due to impaired cognitive ability.

The brain injury rehabilitation program:

Rehabilitation of the patient with a brain injury begins during the acute treatment phase. As the patient's condition improves, a more extensive rehabilitation program is often begun. The success of rehabilitation depends on many variables, including the following:

  • nature and severity of the brain injury
  • type and degree of any resulting impairments and disabilities
  • overall health of the patient
  • family support

It is important to focus on maximizing the patient's capabilities at home and in the community. Positive reinforcement helps recovery by improving self-esteem and promoting independence.

The goal of brain injury rehabilitation is to help the patient return to the highest level of function and independence possible, while improving the overall quality of life - physically, emotionally, and socially.

Areas covered in brain injury rehabilitation programs may include:

Patient need:


Self-care skills, including activities of daily living (ADLs)

Feeding, grooming, bathing, dressing, toileting, and sexual functioning

Physical care

Nutritional needs, medications, and skin care

Mobility skills

Walking, transfers, and self-propelling a wheelchair

Communication skills

Speech, writing, and alternative methods of communication

Cognitive skills

Memory, concentration, judgment, problem solving, and organizational skills

Socialization skills

Interacting with others at home and within the community

Vocational training

Work-related skills

Pain management

Medications and alternative methods of managing pain

Psychological testing and counseling

Identifying problems and solutions with thinking, behavioral, and emotional issues

Family support

Assistance with adapting to lifestyle changes, financial concerns, and discharge planning


Patient and family education and training about brain injury, safety issues, home care needs, and adaptive techniques

The brain injury rehabilitation team:

The brain injury rehabilitation team revolves around the patient and family and helps set short- and long-term treatment goals for recovery. Many skilled professionals are part of the pulmonary rehabilitation team, including any/all of the following:

  • neurologist/neurosurgeon
  • physiatrist
  • internists and specialists
  • rehabilitation nurse
  • social worker
  • physical therapist
  • occupational therapist
  • speech/language pathologist
  • psychologist/neuropsychologist/psychiatrist
  • recreation therapist
  • audiologist
  • dietitian
  • vocational counselor
  • orthotist
  • case manager
  • respiratory therapist
  • chaplain

Types of brain injury rehabilitation programs:

There are a variety of brain injury treatment programs, including the following:

  • acute rehabilitation programs
  • subacute rehabilitation programs
  • long-term rehabilitation programs
  • transitional living programs
  • behavior management programs
  • day-treatment programs
  • independent living programs

Where to get help

·         Your doctor

·         Neurologist (your doctor will refer you)

·         Acquired Brain Injury associations.

Things to remember

·         Acquired brain injury refers to any type of brain damage that happens after birth.

·         Causes of ABI include disease, blows to the head, alcohol and drug use, or oxygen deprivation.

·         Coping with the consequences of acquired brain injury can be difficult for everyone, including family members.



Consequences of a Traumatic Brain Injury


How are Complications from a TBI Treated?


Postconcussion Syndrome

Within days to weeks of a head injury approximately 40 percent of TBI survivors develop troubling symptoms called postconcussion syndrome (PCS). A person need not have suffered a concussion or loss of consciousness to develop the syndrome and many people with mild TBI suffer from PCS. Symptoms include headache, dizziness, vertigo (a sensation of spinning around or of objects spinning around the person), memory problems, trouble concentrating, sleeping problems, restlessness, irritability, apathy, depression, and anxiety. These symptoms may last for a few weeks after the head injury. The syndrome is more common in individuals who had psychological symptoms, such as depression or anxiety, before the injury. Treatment for PCS may include medicines for pain and psychological conditions, and counseling to develop coping skills.



About 25 percent of patients with brain contusions or hematomas and about 50 percent of patients with penetrating head injuries will develop seizures within the first 24 hours of the injury. These seizures generally stop within a week. Doctors typically only treat these seizures if they continue beyond a week. Seizures occurring more than one week after injury are referred to as post-traumatic epilepsy and are treated with medications. The medications may need to be taken by the survivor for months or years following the injury.



Our brains continually produce and drain a fluid called cerebrospinal fluid (CSF). When the brain is injured the drainage of CSF may be affected and CSF may build up. This condition is called hydrocephalus. The build-up of fluid can lead to increased pressure in the brain. Hydrocephalus may begin during the early stages of TBI but not be apparent until much later. However, it usually is diagnosed within the first year after the injury. Symptoms can include a decreased level of consciousness, changes in behavior, lack of coordination or balance, and loss of the ability to hold urine. Treatment may include draining CSF through a small plastic tube called a shunt. The shunt typically runs under the skin from the head to the abdomen, where the fluid drains and is reabsorbed by the body.


Leakage of CSF

Skull fractures can tear the membranes that cover the brain, leading to leakage of CSF. While the leaking fluid may be trapped between the membranes that surround the brain, it may also leak out of the nose or ears. Surgery may be necessary to repair the fracture and stop the leakage.



Tears that let CSF out of the brain cavity can also allow air and bacteria into the cavity. An infection of the membrane around the brain is called meningitis and is a dangerous complication of TBI. Most infections develop within a few weeks of the initial trauma and result from skull fractures or penetrating injuries. Standard treatment includes antibiotics and sometimes surgery to remove the infected tissue.


Damaged Blood Vessels in the Brain

Any injury to the head or brain usually results in some damage to blood vessels in the brain. While the body usually quickly repairs damage to small blood vessels, an injury to larger vessels can result in serious complications. Damage to a major artery supplying blood to the brain can cause a stroke in one of two ways: 1) bleeding from an artery (called a hemorrhagic stroke), or 2) a blood clot that forms in an injured artery. When a clot forms in a major artery it can block blood flow, depriving the area that the artery supplies with blood of needed oxygen and nutrients (known as an ischemic stroke). Symptoms of a blood clot in the head include headache, vomiting, seizures, paralysis on one side of the body, and semi-consciousness.


Surgery is necessary to repair an injured blood vessel responsible for a hemorrhagic stroke. Ischemic strokes can be treated with a drug that dissolves clots (a “thrombolytic” drug) if the stroke is diagnosed within a few hours of the beginning of symptoms and there is no evidence of bleeding in the brain. The drug can be given intravenously or through a tube (catheter) that is inserted into an artery in the groin and then advanced to the brain and then into the clogged artery, where the medication is administered through the catheter. Administering the drug through a catheter at the site of the clot has a higher chance of success than intravenous medication but is usually only performed at stroke centers by a team of specialists that can be rapidly assembled twenty-four hours a day.


Cranial Nerve Injuries

Cranial nerves are nerves running from the brain through openings in the skull and to areas in the head such as the eyes, ears, and face. Skull fractures, especially at the base of the skull, can injure cranial nerves. The seventh cranial nerve, called the facial nerve, is the most commonly injured cranial nerve in TBI. An injured facial nerve can result in paralysis of facial muscles. When facial muscles are paralyzed, facial expressions such as smiling will not be symmetrical. Nerve injuries may heal spontaneously. If they do not, surgery may, in certain circumstances, be able to restore nerve function.



Pain is a common symptom of TBI and can be a significant complication for conscious patients in the period immediately following a TBI. Headache is the most common type of pain, but other kinds of pain can also occur.


Complications for Unconscious Patients

Serious complications for patients who are unconscious, in a coma, or in a vegetative state include bed or pressure sores of the skin, repeated bladder infections, pneumonia or other life-threatening infections, and the failure of multiple organs, such as the kidneys, lungs, and heart.


General Trauma

When a TBI occurs there is usually trauma to not only the brain but other parts of the body as well. These injuries require immediate and specialized care and can complicate treatment of and recovery from the TBI.


What Disabilities Can Result From a TBI?

Disabilities resulting from a TBI depend upon the severity of the injury, the location of the injury, and the age and general health of the individual.


Cognitive Disabilities

“Cognition” describes the processes of thinking, reasoning, problem solving, information processing, and memory. Most patients with severe TBI, if they recover consciousness, suffer some cognitive disability. People with moderate to severe TBI have more problems with cognitive deficits than survivors with mild TBI, but a history of several mild TBIs (for example, a football player) may have a cumulative effect. Recovery from cognitive deficits is greatest within the first six months after the injury and is usually more gradual after that. Most improvements can be expected within two years of the injury.



The most common cognitive impairment among severely head-injured survivors is memory loss, characterized by some loss of older memories and the partial inability to retain new memories. Some of these patients may experience post-traumatic amnesia, which can involve the complete loss of memories either before or after the injury.


Concentration and attention

Many survivors with even mild to moderate head injuries who experience cognitive deficits become easily confused or distracted and have problems with concentration and attention.


Executive functioning

Many individuals with a mild to moderate TBI also have problems with higher level, so-called “executive” functions, such as planning, organizing, abstract reasoning, problem solving, and making judgments. This disability may make it difficult to return to the same job or school setting the individual was in before the injury.


Language and communication

Language and communication are frequent problems for TBI survivors. Some individuals have trouble recalling words and speaking or writing in complete sentences (called non-fluent aphasia). They may speak in broken phrases and pause frequently. They are usually aware of what is happening and may become extremely frustrated.


Other survivors may speak in complete sentences and use correct grammar but for the listener the speech is pure gibberish, full of invented or meaningless words (called fluent aphasia). TBI survivors with this problem are often unaware that they make little sense and become angry with others for not understanding them.


Other survivors can think of the appropriate language but cannot easily speak the words because they are unable to use the muscles needed to form the words and produce the sounds (called dysarthria). Speech is slow, slurred, and garbled.


Impairment of the Senses

Many TBI survivors have problems with one of the five senses, especially vision. They may not register what they are seeing or may be slow to recognize objects. Some individuals develop tinnitus, a ringing or roaring in the ears. Others may develop a persistent bitter taste in the mouth or complain of a constant foul smell. Some TBI survivors feel persistent skin tingling, itching, or pain. Although rare, these conditions are hard to treat.


Impairment of Hand-Eye Coordination

TBI survivors often have difficulty with hand-eye coordination. Because of this, they may be prone to bumping into or dropping objects or may seem generally unsteady. They may have difficulty driving a car, working complex machinery, or playing sports.


Emotional and Behavioral Problems

Most TBI survivors have some emotional or behavioral problems. Family members often find that personality changes and behavioral problems are the most difficult disabilities to deal with. Emotional problems can include depression, apathy, anxiety, irritability, anger, paranoia, confusion, frustration, agitation, difficulty sleeping, and mood swings. Problem behaviors may include aggression and violence, impulsiveness, loss of inhibitions, acting out, being uncooperative, emotional outbursts, childish behavior, impaired self-control, impaired self awareness, inability to take responsibility or accept criticism, being concerned only with oneself, inappropriate sexual activity, and alcohol or drug abuse. Sometimes TBI survivors stop maturing emotionally, socially, or psychologically after the trauma, which is a particularly serious problem for children and young adults. Many TBI survivors who show psychiatric or behavioral problems can be helped with medication and psychotherapy.


What Other Long-Term Problems Can be Associated With a TBI?


Alzheimer's Disease (AD)

AD is a degenerative disease in which the individual suffers progressive loss of memory and other cognitive abilities. Recent research suggests an association between head injury in early adulthood and the development of AD later in life; the more severe the head injury, the greater the risk of developing AD. Some evidence indicates that a head injury may interact with other factors to trigger the disease and may hasten the onset of the disease in individuals already at risk.


Parkinson's Disease and Other Motor Problems

Parkinson's disease may develop years after TBI if the part of the brain called the basal ganglia was injured. Symptoms of Parkinson's disease include tremors, rigidity or stiffness, slow movement or inability to move, a shuffling walk, and stooped posture. Despite many scientific advances in recent years, no cure has yet been discovered and the disease progresses in severity.

Other movement disorders that may develop after TBI include tremor, uncoordinated muscle movements, and sudden contractions of muscles.


What Kinds of Rehabilitation Does a TBI Survivor Need?

Rehabilitation is a vital part of the recovery process for a TBI survivor. Moderately to severely injured patients usually first receive treatment and care in an intensive care unit of a hospital. Once stable, the survivor can be transferred. At this point survivors follow many different paths toward recovery depending on their needs.


It is important for TBI survivors and their families to select the best setting for rehabilitation. There are several options, including home-based rehabilitation, hospital outpatient rehabilitation, inpatient rehabilitation centers, comprehensive day programs at rehabilitation centers, supportive living programs, independent living centers, club-house programs, school-based programs for children, and others. The TBI survivor, family, and rehabilitation team members should work together to find the best place for the survivor to recover.


Some patients may need medication for physical and emotional problems resulting from the TBI. Great care must be taken in prescribing medications because TBI patients are more prone to side effects and may react to some drugs. It is important for the family to provide social support for the survivor by being involved in the rehabilitation program. Family members may also benefit from counseling in order to cope with the demands and stress of helping to care for a TBI survivor.


Individualized Treatment Programs

It is important that TBI survivors receive an individualized rehabilitation program based upon the person’s strengths and capacities. Rehabilitation services also need to be modified over time to adapt to the survivor’s changing needs. Moderately to severely injured patients require rehabilitation treatment that draws on the skills of many specialists. This involves individually tailored treatment programs in the areas of physical therapy, occupational therapy (learning skills for the activities of daily living), speech/language therapy, physiatry (specialists in rehabilitation medicine), psychology/psychiatry, and social support.

The overall goal of rehabilitation after a TBI is to improve the survivor’s ability to function at home and in society. Therapists help the individual adapt to disabilities or make modifications to the home to make everyday activities easier.


Traumatic Brain Injuries Recent Research


1) Seven of eight patients in a vegetative state regained consciousness after being treated with Sinemet.

Sinemet (levodopa-carbidopa) is a drug used to treat Parkinson’s disease, a disease of the brain that leads to tremors and loss of coordination. Eight patients who had been in a vegetative state for a mean of 104 days following traumatic brain injuries were given Sinemet as part of a research study. All of the patients showed some signs of improvement within 13 days. Seven of the patients subsequently regained consciousness within a mean time of 31 days.
Brain Research. 2004 Nov 5; 1026(1): 11-22.

2) New treatments to limit brain cell death following traumatic brain injury show promise.

Injury to any part of the body triggers an extremely complex reaction by the body, which is only partially understood. It is known that some components of the reaction may actually worsen the original injury. Swedish researchers have recently confirmed that a particular protein (ERK) in nerve and brain cells worsens the initial injury. They also found that two drugs (U0126 and S-PBN) known to have a protective effect on the brain following injury reduced the activity of the ERK protein. The amount of brain atrophy in experimental animals with TBI treated with either of the drugs was 60% less than the atrophy in untreated animals. Use of the drugs in experimental trials with people is being proposed.
Journal of Neurotrauma. 2004 September; 21(9): 1168-82

 3) Cyclosporin A has a protective effect following experimental diffuse traumatic brain injury.

One of the harmful effects of traumatic brain injury is on a part of brain cells that produces energy for the cells (the mitochondria). Cyclosporin A, a drug already being used to prevent the body’s immune system from rejecting organ transplants and to treat patients with auto-immune conditions, was studied at the Medical College of Virginia as a possible treatment for traumatic brain injury. The drug was administered either intravenously or into the brain itself in laboratory animals following traumatic brain injury. The researchers found a significant increase in the energy production of brain cells in injured animals treated with cyclosporin A. Clinical trials in people will be the next step in the study of Cyclosporin A as a treatment for TBI.
Journal of Neurotrauma. 2004 September; 21(9): 1154-67.

4) In the future transplantation of neural progenitor cells may aid in the recovery from traumatic brain injury.

In recent years scientists have discovered the existence of neural progenitor cells (NPCs). These brain cells, which are found in people and animals of all ages, are capable of dividing and changing into several different kinds of brain cells, including neurons, oligodendrocytes, and astrocytes. Experiments have been conducted in which NPCs were transplanted into the brains of mice with traumatic brain injury. Mice with transplanted NPCs showed significant improvement in motor abilities one week after transplantation and the results were still present one year later. The mice also showed significant improvement in spatial learning abilities. Trnasplantation of NPCs into people may one day help people with TBIs recover from their injuries.
Brain Research. 2004 November 5; 1026(1): 11-22.

 5) Magnesium has value in the treatment of traumatic brain injury.

Magnesium is a trace mineral needed by our bodies. Following traumatic brain injury magnesium levels are reduced. Previous experiments have shown that laboratory animals treated with magnesium following traumatic brain injury had less severe short term motor and cognitive deficits than untreated animals. Researchers at the University of Pennsylvania investigated whether administering magnesium shortly after a TBI had long term (eight months post injury) benefits for laboratory animals. They concluded that magnesium did not show any benefit in improving learning deficits or loss of cortical brain tissue. They did find, however, that there was a reduction in the loss of brain tissue in the area of the brain called the hippocampus.
Journal of the American College of Nutrition. 2004 October; 23(5): 529S-533S.

 6) Two hormones show promise in controlling the amount of brain swelling following traumatic brain injury.

Brain swelling following traumatic brain injury can lead to additional brain cell death and brain damage. Swelling is caused by inflammation that occurs in response to the injury. The inflammatory response is extremely complex and involves both cells that are part of the body’s immune system and chemicals, some of which are produced by the immune cells. Research is being conducted into ways of lessening the inflammatory response following TBI with the goal of reducing brain swelling. Two drugs that show promise in reducing inflammation include the hormones progesterone and allopregnanolone. The drugs appear to work by reducing the levels of chemicals associated with the inflammatory response.
Experimental Neurology. 2004 Oct; 189(2): 404-12.

 7) Transplantation of bone marrow cells improves healing from traumatic brain injury in laboratory experiments.

Cells in bone marrow develop into red and white blood cells. To study whether bone marrow cells could increase new brain cells following traumatic brain injury, groups of laboratory rats given bone marrow cells either intravenously or directly into the brain were compared with untreated rats. Fifteen days following the injections, the treated rat brains had significantly more new brain cell development in the areas around the brain injury and in a part of the brain called the subventricular zone, where cells that can develop into new brain cells ordinarily are found. The treated rats also had greater motor function than the untreated rats.
Neurosurgery. 2004 November; 55(5): 1185-1193.

8) Pituitary gland dysfunction is common in survivors of traumatic brain injury.

Irish investigators have confirmed in a study that it is common for people with TBIs to have abnormally low functioning of their pituitary glands. Because the pituitary affects many hormones, many different symptoms of pituitary dysfunction can occur. It is important for low functioning of the pituitary to be diagnosed because this condition can be successfully treated.
Journal of Clinical Endocrinology and Metabolism. 2004 October; 89(10): 4929-36.

 9) Drugs to stimulate the production of a chemical naturally produced in the brain may help in the treatment of people with traumatic brain injury.

Brain cells and nerve cells communicate with electrical and chemical signals. British researchers have discovered that parts of the brain (the base of the forebrain and the hippocampus) associated with a specific brain chemical (acetylcholine) were less dense in people with ongoing symptoms of traumatic brain injury than in people who had never had a traumatic brain injury. This has led to an investigation as to whether drugs that stimulate the brain to produce more of the naturally produced chemical will be helpful in treating TBI.
Brain. 2004 November 17.

 10) Hyperbaric oxygen therapy is being studied as a treatment of traumatic brain injury.

“Hyperbaric” oxygen simply means oxygen that is given at pressures greater than atmospheric pressure, which is the pressure of the air we normally breathe. To achieve high pressures, a compression chamber is used. These chambers look like a miniature submarine and are built to withstand the high air pressure created inside them, which is where the patient is treated. Compression chambers were first used to treat divers with “the bends,” a condition that occurs when a diver ascends too rapidly and nitrogen compressed in the blood as a result of high underwater pressure expands too rapidly for the body to adapt.

Hyperbaric oxygen is now used to treat conditions other than those related to diving. Australian researchers studied whether hyperbaric oxygen was an effective treatment of TBI while patients were still in an intensive care unit following injury. They found that the treatment did reduce the risk of dying from the injury but did not find conclusive evidence that it improved outcomes in patients who survived. They concluded that at present the evidence was insufficient to support use of hyperbaric oxygen in the treatment of TBI but was sufficient to support more studies.
Cochrane Database Systems Review. 2004 October; 18; (4): CD004609.

Speakers Bureau
This is a program that talks to school children and general audiences educating them on how  to avoid risk taking behavior and encourages them to adopt healthy habits to avoid brain injury. In the grade schools, the program emphasizes the use of helmets while playing sports, and using safety belts in cars. In high school, the consequences and costs—financial and human—of violence and drunk/drugged driving is included in the program.

If you would like a speaker to visit your school, please contact us.

For more information, please contact us.


Updated: 04 May 2005


MOLECULAR DAMAGE FROM TBI ONGOING FOR YEARS In a recent paper further evidence of secondary or delayed cell death following TBI was shown. The diffuse and wide spread damage is progressive and prolonged for months or years after the initial insult. Areas continued to be vulnerable to such ongoing destruction are the cortex, hippocampus, thalamus, striatum and sub cortical nuclei.

DEPRESSION AND TBI Several recent studies continue to solidify the relationship between depression and traumatic brain injury. A multicenter study (Seel RT 2003) showed that patients with TBI are at "great" risk for developing depressive symptoms. Unemployment and poverty may be substantial risk factors in the development of depressive symptoms. A study tracking the psychiatric illnesses following TBI (Fann JR 2004) found that 34% of those with mild TBI had a high initial and ongoing risk of persistent psychiatric illnesses.

PEDIATRIC TBI EQUALS WORSE OUTCOME An experiment, with one-week old rats who sustained TBI, has clearly shown that the trauma triggered cell death (apoptosis) in the brains of the very young rats was far greater than those in older rats. These results help explain the unfavorable outcomes of very young pediatric head trauma patients and outlines again the importance of trying to prevent secondary cell death following head trauma.

SPECT SCAN VALIDATED IN TBI SPECT scanning of the brain, which has received increasing recognition in the past five years, has again shown to be sensitive to TBI. In a variation known as Proton Magnetic Residence Spectroscopy (1 H-MRS) the relationship of brain chemicals in the brain following trauma, which are now seen to be markers for diffuse axonal injury. The levels of chemicals have a significant correlation with the functional status of the patient. Thus, localized 1H-MRS has the potential to be used for detecting diffuse axonal injury (DAI) in TBI patients and can be useful as a guide to future rehabilitation.

EARLY SYMPTOMS OF TBI LINKED TO OUTCOME Mild traumatic brain injury patient's symptoms were used to predict severity of post traumatic complaints six-months after injury. It was found that the patients complaining of headache, dizziness, or nausea at the emergency room after mild traumatic brain injury strongly associate with the severity of symptoms six-months after. Patients at the emergency room without headache, dizziness, nausea did much better at six-months following injury than those who had these complaints (R deKra 2002)


WATCH YOUR PITUITARY Pituitary gland function and levels of growth hormone can be adversely affected by TBI. A recent study (Aimaretti, G. 2004) suggest that careful screening of the pituitary function should occur following TBI. Keeping these systems in chemical balance will speed TBI recovery.

MAGNETIC FIELDS MAY REDUCE DEPRESSION FOLLOWING TBI Many patients have depression following brain injury which does not respond to antidepressant drugs. The authors of the study contend that there may be subclinical, partial complex seizure activity which continues for months or years after "recovery." Four patients who had such an injury showed significant improvement of depression after having burst-firing magnetic fields across their temporal lobe once a week for five weeks. (Baker-Price L.A. 1996).

NEW WAY OF DETECTING HEARING LOSS: Because many persons with traumatic brain injury are in a coma or otherwise unable to communicate their problems, it is often a bit difficult to determine if hearing loss is part of the injury. A recent study (Lew H. L. 2004) showed encouraging results by having the individual undergo brain stem auditory evoked potential. They follow this test up with CT scan of the bilateral temporal bones. Use of these two test may prove valuable in ruling out hearing loss in those with severe TBI.

EXERCISE HELPS: It has been found that treadmill activity, forced limb movement, and other physical activities help promote brain plasticity (ability to repair). A pattern of exercise before an injury promotes a defense against cell death. It is thought that in the chronic stages after brain injury, an exercise program might reactivate mechanism of healing and thus it is recommended to keep victims as physically active as possible. In a related study, recreational therapy was found to improve rehabilitation.

NEW VACCINE: Trauma induced brain injury can possibly be reduced, post-accident, by giving the patient a vaccination of Cop-1, a synthetic co-polymer used to treat MS. Such a vaccine may be available soon, and would be ideal for use at trauma centers and emergency room facilities. Do not expect this vaccination until, at least, 2005.

NEW WONDER DRUG?: Mifepristone, also known as the abortion pill, may have a wonderful side effect in that it protects brain cells. Experiments in mice have shown that the drug extends the life of neurons and protects against the cellular destruction which occurs in traumatic brain injury and for other reasons in a process called apoptosis.

BETTER NEUROLOGICAL OUTCOME: Trial studies of the drug, dexanabinol, briefly conducted in cases of severe head injury. Patients treated with the drug had increased positive blood flow after injury without dangerously low blood pressure. Overall the patients treated with the drug had faster and better neurologic outcome.

MAGNETIZATION TRANSFER RATIO (MTR): Research into new MRIs have shown promise into showing, more sensitively, brain damage due to trauma. The type of MRI known as Magnetization Transfer Ratio (MTR) has shown to be effective in detecting abnormalities in the white matter of the brain following trauma. These abnormalities were looked at in the splenium of the corpus callosum in the brain stem. (Sinson, G. 2002).

PROMISING NEW DRUG: Researchers at the University of Florida are working toward a treatment to curtail the secondary cell death which follows severe brain trauma. Early signs show that administration of the common chemotherapy drug Cyclosporin A, within 12 hours of injury interrupts the chain of events that can lead to the worsening of brain injury in the first day or two following trauma. Tests on animals show great promise in reducing swelling and regulation of calcium induced damage.

SAY NO TO HERBAL REMEDIES: The use of herbal supplements is common in the U.S. However, following a brain injury, remedies such as St. Johns Wort and Ginko Giloba, SHOULD BE AVOIDED. Studies show that they may induce mania in TBI patients. If you feel that you must take supplements, make sure you clear them with your doctor, especially if taken in conjunction with prescription medication. (Spinella M., 2002)

MRI USED FOR DIAGNOSIS OF MENTAL ILLNESS: Several hospital centers across the U.S. are beginning to use MRI (MRS) to diagnose mental illness such as depression and panic disorder. Changes in metabolic activity can clearly correlate with certain disorders. For example, evidence of bipolar disorder in the frontal lobes can be seen and changes associated with ADD in children, can be gleaned through changes in brain volume.

DRUG FOR SEVERE BRAIN INJURY: A recent study confirmed the safety and usefulness of intravenous dexanabinol (HU-211), in cases of severe head injury. Patients experienced excellent control of intra-cranial pressure, a common deadly side effect of brain injury. Patients on HU-211, also experienced faster and better neurologic outcome. (Knoller N., 2002)

Long Term Depression with TBI: A long term follow-up study on head injured veterans reported in the archives of general psychiatry showed that concussions and other head injuries in early adulthood may significantly raise the risk of depression decades later. This is consistent with earlier studies that show that head injured patients may be prone to depression shortly after the head injury. The study suggest that the risk of depression persists even fifty years after the injury. (Keep in mind that the study by McCallister and Flashman in 1999 concluded that 20% to 30% of mild TBI patients show major depression in the first year post injury) (T. Holsinger 2002).

QUANTITATIVE MAGNETIC RESONANCE: Dr. Erin Bigler of Brigham Young University and others are examining ways in which MRI studies can show demonstrable reductions in the volume or surface area of the brain after traumatic injury. The "atrophy" for shrinking of the brain after traumatic injury has been shown to be consistent with the aftermath of diffuse axonal injury (DAI) and focal brain injury. Following the early stages, this method of imaging the brain holds great promise in proving injury. (Bigler E. 2001)

BRAIN FOOD: The Annals of Neurology has found that creatine, a common food supplement administered to rats after traumatic brain injury, increased the repair of cortical tissue by 30% to 50%. (Sullivan P.G. 2000)

TREATMENT FOUND NOT EFFECTIVE: The New England Journal of Medicine in February 2001, reported that a hopeful therapy for brain injury, hypothermia, was not shown to be effective in reducing residual brain injury symptoms, as previously thought.

REHABILITATION HOPE: The Journal of Brain Injury recently reported that patients in the slow-to-recover subset of severe TBI, may benefit from longer trials of rehabilitation, with functional recovery continuing to improve months or years after injury. (Grey D.S. 2000)

CHILDREN AT GREATER RISK: The French study further confirmed that the "Kennard Principal" (that recovery from injury is greater in children that adults) appears to be false, especially in diffuse injuries. They recommended that final assessment of childhood outcome for TBI should be done only after several years. (Laurent-Bannier A. 2000)

DRIVING PROBLEMS: A study in Norway found that post injury TBI patients, had a highly increased percentage of involvement in driving accidents and recommended special assessment for driving post injury. (Mosberg A. 2000)

REHABILITATION: In a study of paid attendant care to victims of TBI, the main benefit was found to be that of friendship to the victim, and the study recommended further training to stress this important component of care. (McCluskey A. 2000)

PTSD: A study from this year in the Journal of Nervous and Mental Disorders found the rate of Post Traumatic Stress Syndrome in cases of severe traumatic brain injury to be 27% and recommended rehabilitation efforts to take this into account.

LOSS OF CONSCIOUSNESS: The study of brain injured athletes showed no relevant distinction in the outcome between athletes who loss consciousness and those who did not at the time of injury. (Lovell M.R. 1999)

CHILDREN MORE AT RISK: A study in rats showed that neuro-degeneration after trauma was worse in immature verses mature individuals, and cited as the cause Apoptotic Degeneration.

CELLULAR DAMAGE: In the studies that support the findings supporting the use of MRS, protein markers consistent with traumatic brain injury were found in injured patients and was consistent with the follow-up outcome of neuropsychological testing. (Ingebrigtsen T. 1999)

CELLULAR DAMAGE: Secondary damage after traumatic brain injury via lipid peroxidation (LPO) was found in patients within twenty-fours hours post injury. Treatment with natural or synthetic antioxidants was recommended. (Sutkovoi 1999)

HOPE FOR EPILEPSY: Wide spread use of nerve stimulators in patients with severe epilepsy have shown in 66% of patients a good to moderate reduction in reducing seizures. Patients undergo a one to two hour surgery to implant a stop-watch size device in the chest. The procedure, covered by most insurance, costs approximately $20,000.00.

LEAD POISONING FINDINGS: The recent study showed that blood lead concentrations much lower than previously thought, were associated with declines in cognitive and academic skills. Decreases in performance occurred in children having a blood level less than 5 micrograms per deciliter (ug/dL). These finding would indicate that the current blood level concentration cut off of 10 ug/dL is incorrect and would have to be lowered. (Lanphear 2000)

TINNITUS IMAGING: Ringing in the ears (Tinnitus) is a common and often terrible symptom of brain injury. Previously, there was no test to objectively determine the existence or non existence of this complaint. However, a recent study indicates that changes in the inner ear leading to Tinnitus may be detectable on MRI imaging of the ear. (Meriot 2001)

IMAGING IMPROVED: MRI imaging technology continues to be refined and improved. Adding magnetization transfer imaging (MTI) and contour plot analysis to MRI studies greatly adds to the sensitivity of the imaging in detecting signs of traumatic brain injury (McCowan J.C. 2000)

SURPRISING STATISTIC: There are apparently far more visits to the emergency room in the United States for traumatic brain injury than previously thought. A re-analysis of data from the calender year 1995 to 1996, showed one million visits, much higher than previously thought. (Guerrero 2000)

CHILDHOOD INJURY: A long term follow-up of victims of childhood brain injury showed continuing vocational problems at age 21. Again showing that children are not more immune to brain injury than adults. (Nybo 1999)

SLEEP DISORDERS: This study, among others, has confirmed that there is a direct relationship between traumatic brain injury and the emergents of sleep disorders. The severity and impact of chronic sleep disorder is just now beginning to be understood, and is far more of a problem than previously thought. (Beetar 1999)

INVISIBLE INJURIES: In this older study, reconfirmed by more recent studies, 686 victims of mild traumatic brain injury were examined and found to have completely normal neurological exams. The patients then underwent imaging studies and 18% of the patients were found to have lesions in the brain. (Stein 1993)

HYPERTENSION: Contrary to what was previously thought, cognitive decline in patients suffering from diabetes and hypertension starts at middle age rather than old age. (Knopman 2001)

MAGNETIC RESONANCE SPECTROCOPY (MRS): Yet another study confirms the exciting possibilities of this new diagnostic tool, which measures the relationship of brain chemicals utilizing MRI. The finding of certain relationships is consistent with the diagnosis of brain injury. (Brooks W.M. 2001)

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