What is tbi?
Long Range Complications of Brain Injury
Facts About Brain Injury
Some Factors Which May Affect Outcome After Brain Injury
Indicators and Symptoms of Brain Injury
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?
Common Causes of Brain Injury
o Bicycle Crashes:
· 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.
o Sports Concussions:
o Shaken Baby Syndrome:
o Domestic Violence:
· Acquired Brain Injury
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.
· 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:
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
· 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
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:
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?
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:
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:
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:
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:
Types of brain injury rehabilitation programs:
There are a variety of brain injury treatment programs, including the following:
· 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?
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.
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.
“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.
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
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LATEST MEDICAL RESEARCH
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
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