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Mar 05 2019

TRAUMATIC BRAIN INJURY

By Mabel Ruscitti and Arnavaz Eduljee, Cato Research

AWARENESS: Traumatic Brain Injury (TBI) occurs from a blow, jolt, bump or a penetrating object to the head.[1, 2] Traumatic brain injury can lead to brain cell death, inflammation, edema, hemorrhage, and severe disruption to normal brain cell function.  Concussion injury frequently results in persistent functional impairment including problems with cognitive function, memory, mood, and other personality disorders.  Traumatic brain injury is a leading cause of death and disability in industrialized societies, particularly among young people. It is most prevalent in males under 40 and in the elderly. 5.3 million Americans currently live with disabilities related to TBI. The causes of TBI include: falls, blunt trauma, motor vehicle crashes, sports injuries, violence, and explosive blasts from combat.[1] TBI ranges from mild to severe and there are two broad categories: closed and open. Closed TBI include: concussions (most common mild TBI, where patients completely recover), diffuse axonal injury (tearing of brain tissue occurring from sudden acceleration/deceleration such as in shaken baby syndrome and in some bicycle, car or motorcycle accidents), and contusions (bleeding from blows to the head); Open TBI consist of penetration injury from bullets or other objects.[1] Brain injury is a leading cause of combat casualties. In the military, there was a steady increase in the incidence of mild TBI among active U.S. service members between 1997 and 2007; however, the incidence rate has risen significantly over the past few years. This was most marked among those serving in Iraq and Afghanistan, where there was a 38.4% and 15.3% average annual increase in new cases, respectively.[3] Severe TBI is also one of the leading causes of death, with approximately 70% mortality, 50% of affected individuals dying before reaching medical care, and 20% dying after reaching a field hospital.[4]

SYMPTOMS: The symptoms of TBI can appear immediately or increase/decrease over time depending on the individual and type of trauma. Changes to the individual can be so dramatic, that they make it difficult for others to understand these changes.[5] Depending on the severity and part of the brain damaged, TBI can cause alteration of consciousness, impair thinking, decision making and reasoning, problem solving, concentration, memory, balance, movement, and/or sensation, and cause emotional problems (personality changes, impulsivity, anxiety, and depression) and seizures.[6] Brain damage involving frontal or temporal lobes results in poor reasoning and judgment skills, shortened attention span, needing more time to understand information, difficulty learning new things, difficulty beginning tasks, making plans or decisions, organizing, disinhibition, lack of impulse control, inappropriate behavior, angry outbursts, rigid thinking, getting stuck on a subject or activity, inability to empathize with others, slurred speech, difficulty with muscle coordination or balance, fatigue, weakness, insomnia, headaches, and full or partial paralysis.[1, 7, 8] Because of these sequelae, persons with brain injuries face serious employment and social challenges and isolation. Many end up estranged from family and friends due to their behavior,[9] which has become inappropriate, intolerable, and even frightening and dangerous at times.[8] In fact, 60‑80% of inmates have suffered at least one serious brain injury.[10] Because of the lasting impact in their quality of life, TBI survivors are at a high risk of depression,[1, 8] and may develop other mental illnesses such as obsessive compulsive disorder,[8] post-traumatic disorder, and substance abuse.[8] Additionally, they present an elevated suicide rate.[2, 11]

PROCEDURES: The majority of TBI cases seen in emergency rooms are treatable if diagnosed soon enough.[12] CT scans, MRI, neurological and neuropsychological testing (such as Columbia Suicide Severity Rating Scale, Post-Concussion Symptom Scale, Post-Traumatic Stress Disorder Checklist, Sheehan Disability Scale, pupillometry and others) are used in the diagnosis. The Glasgow Coma Scale is used to determine the initial severity of a brain injury, but no test can predict recovery. Survival of severe brain injury victims is dependent on avoiding or minimizing the secondary systemic and intracranial effects as a result of the initial trauma.[13] These secondary effects include hemorrhage, cerebral edema or inflammation, and multiple neurometabolic cascades of biochemical changes that ultimately exacerbate neuronal cell death.[13, 14] Procedures to reduce brain swelling after head injury include the use of mannitol or hypertonic saline.[15, 16] Barbiturates, ventriculostomy, and decompressive craniectomy may serve the same purpose.[16] There is no high-quality evidence that hypothermia is beneficial for severe TBI.[15] After initial acute treatment in the ICU, recovery from TBI may take months to years and involves inpatient rehabilitation by a multidisciplinary team including physicians, nurses, neurologists, neuropsychologists, occupational, physical, speech, and language therapists.[7, 17] After discharge, caregivers should be informed of possible sequelae and proven techniques to help calm down the TBI family member. Ongoing psychotherapy should be implemented, including cognitive behavioral therapy to improve problem-solving skills, self-esteem, and psychosocial functioning following TBI,[18] There are no FDA-approved medications yet for treating neuropsychiatric sequelae of TBI, thus, treatment should be symptom-based and employ the “start low, go slow” approach.[19] Drugs such as Namenda and Aricept might help with memory problems after brain injury.[20, 21] Over time, the patient should build a new identity and life based on his current abilities, interests, and passions.[22] The implementation of an adaptive living environment, home care aid, and a structured routine should be beneficial to the TBI survivor. Currently there are several clinical trials being conducted in TBI patients, some being funded by the Department of Defense in the US.

PREVENTION: Precautions to prevent TBI, include wearing protective helmets in sports and at the workplace (such as construction sites).[2] Drinking and driving should be avoided, and drivers and passengers should always wear lap belts and shoulder harnesses; child safety seats should be properly installed. To help prevent falls at home, there should be adequate lighting and no obstacles in walking pathways, and hand rails should be used on stairways and for the elderly, in the bathroom. Adequate shoe ware should be worn, and ice grippers should be used under icy weather.

 

REFERENCES

  1. Family Caregiver Alliance webpage. Traumatic Brain Injury. 2019; Available at: https://www.caregiver.org/traumatic-brain-injury; Accessed February 28, 2019.
  2. HealthDay website. When Head Injuries Make Life Too Hard, Suicide Risk May Rise. 2019; Available at: https://consumer.healthday.com/cognitive-health-information-26/traumatic-brain-injury-1002/when-head-injuries-make-life-too-hard-suicide-risk-may-rise-736720.html; Accessed February 28, 2019.
  3. Cameron KL, Marshall SW, Sturdivant RX, Lincoln AE. Trends in the incidence of physician-diagnosed mild traumatic brain injury among active duty U.S. military personnel between 1997 and 2007. J Neurotrauma 2012;29(7):1313-1321.
  4. Sapsford W. Penetrating brain injury in military conflict: does it merit more research? J R Army Med Corps 2003;149(1):5-14.
  5. Brain Injury Association of America website. Adults: What to Expect at Home. @biaamerica, 2019; Available at: https://www.biausa.org/brain-injury/about-brain-injury/adults-what-to-expect/adults-what-to-expect-at-home.
  6. National Institute of Neurological Disorders and Stroke website. Traumatic Brain Injury: Hope Through Research. 2019; Available at: https://www.ncbi.nlm.nih.gov/pubmed/; Accessed February 28, 2019.
  7. Family Caregiver Alliance webpage. Coping with Behavior Problems after Head Injury. 2019; Available at: https://www.caregiver.org/coping-behavior-problems-after-head-injury; Accessed February 28, 2019.
  8. PsychToday. After Brain Injury: The Dark Side of Personality Change Part I. @PsychToday, 2019; Available at: http://www.psychologytoday.com/blog/professor-cromer-learns-read/201203/after-brain-injury-the-dark-side-personality-change-part-i; Accessed February 28, 2019.
  9. Brainline website. Loss of Relationships After a TBI Is Often the Most Devastating Outcome. 2012; Available at: https://www.brainline.org/video/loss-relationships-after-tbi-often-most-devastating-outcome; Accessed February 28, 2019, 2012-07-30.
  10. Northern Brain Injury Association website. Welcome to the Northern Brain Injury Association. 2019; Available at: http://nbia.ca/; Accessed February 28, 2019.
  11. Hudak A, Warner M, de la Plata CM, Moore C, Harper C, Diaz-Arrastia R. Brain morphometry changes and depressive symptoms after traumatic brain injury. Psychiatry Res 2011;191(3):160-165.
  12. Brain Injury Canada website. Prevention and Treatment. 2019; Available at: https://www.braininjurycanada.ca/acquired-brain-injury/prevention-and-treatment/; Accessed February 28, 2019.
  13. Case Western Reserve University School of Medicine web site. Primary vs. Secondary Insults in Traumatic Brain Injury. 2019; Available at: http://casemed.case.edu/clerkships/neurology/NeurLrngObjectives/TBI%20primary%20vs%20secondary.htm; Accessed February 28, 2019.
  14. Morganti-Kossmann C, Semple B, Ziebell J, Yan E, Bye N, Kossmann T. 10 – Modulation of Immune Response by Head Injury. In: New Insights to Neuroimmune Biology. Elsevier ed.   2010:193-220.
  15. Cochrane website. Mannitol for acute traumatic brain injury. 2019; Available at: https://www.cochrane.org/CD001049/INJ_mannitol-for-acute-traumatic-brain-injury; Accessed February 28, 2019.
  16. McBride DW, Szu JI, Hale C, Hsu MS, Rodgers VG, Binder DK. Reduction of Cerebral Edema after Traumatic Brain Injury Using an Osmotic Transport Device. In: J Neurotrauma. Vol 31,   2014:1948-54.
  17. Model Systems Knowledge Translation Center (MSKTC) website. Traumatic Brain Injury and Acute Inpatient Rehabilitation | Model Systems Knowledge Translation Center (MSKTC). 2019; Available at: https://msktc.org/tbi/factsheets/traumatic-brain-injury-and-acute-inpatient-rehabilitation; Accessed February 28, 2019.
  18. Jorge RE, Arciniegas DB. Mood Disorders after TBI. Psychiatr Clin North Am 2014;37(1):13-29.
  19. Scher LM. Traumatic brain injury: Pharmacotherapy options for cognitive deficits. Current Psychiatry 2011;10(2):21-37.
  20. Brainline website. Can the Drugs Namenda and Aricept Help After Brain Injury? 2014; Available at: https://www.brainline.org/qa/can-drugs-namenda-and-aricept-help-after-brain-injury; Accessed February 28, 2019, 2014-09-10.
  21. Cochrane website. Pharmacotherapy for chronic cognitive impairment in traumatic brain injury – Dougall, D – 2015 | Cochrane Library. 2015; Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009221.pub2/full; Accessed February 28, 2019.
  22. PsychToday. After Brain Injury: The Dark Side of Personality Change Part 2. @PsychToday, 2019; Available at: http://www.psychologytoday.com/blog/professor-cromer-learns-read/201203/after-brain-injury-the-dark-side-personality-change-part-2; Accessed February 28, 2019.