TRAUMATIC BRAIN INJURY (T.B.I)

Summary

  • Traumatic brain injury is a non-congenial and non-degenerative injury that causes damage to the brain.
  • T.B.I is caused when the head hits an object violently or a sharp object enters the skull.
  • T.B.I patients exhibit mild to severe symptoms depending on the extent of brain damage.
  • T.B.I is diagnosed by neurological exam and medical tests like CT scan and fMRI.
  • In the early stages, acute treatments are provided while surgical treatments may be provided if necessary.
  • T.B.I can be prevented by taking precautionary measures like helmets, seat belts etc.

WHAT IS TRAUMATIC BRAIN INJURY (T.B.I)?

Traumatic brain injury refers to an acquired and non-degenerative head injury that leads to brain damage. T.B.I may affect a part of the brain or the entire brain. Sometimes the skull may also be fractured. Serious T.B.I cases require an immediate visit to the hospital.

Many survivors of T.B.I have to live with certain disabilities and cause a socioeconomic burden. For instance, in the US in 2010, T.B.I caused the direct and indirect cost of $76.5 billion (Rajajee, 2018).

TYPES OF T.B.I

 There are various types of T.B.I according to the extent and location of damage:

Concussion

If the head injury is mild that leads to brief unconsciousness but does not injure the brain permanently, it is called concussion.

Contusion

Injury to a particular area of the brain is called contusion. It damages only the affected side or side opposite to the area of traumatic impact.

Traumatic subarachnoid haemorrhage

It refers to bleeding in areas around the brain that are usually filled with cerebrospinal fluid.

Diffuse axonal injury

It occurs when the brain moves back and forth in the skull that shears the nerve cells. Axons connect the nerve cells throughout the brain and diffuse axonal injury affects a patient’s wakefulness.

Hematoma

When blood vessels are ruptured due to T.B.I, a blood clot may form known as a hematoma. Clots may be small or large in size and may form at various locations in the brain. Often the body reabsorbs clots, however, surgery may be required to remove the clot in other cases (McKee and Daneshvar, 2015).

PREVALENCE OF T.B.I

T.B.I is highly prevalent and affects people worldwide. The death rate across the globe caused by T.B.I is higher than any other traumatic injury. It has been reported that 69 million individuals are affected by T.B.I every year.

Greatest incidence of T.B.I has been observed in the Western Pacific and Southeast Asian countries (Dewan et al. 2018). In the US, 5.3 million people live with some disability caused by T.B.I. Children below the age of 15 are widely affected by brain injuries where they cause 2,685 deaths and 37,000 hospitalizations in the US (AANS, n.d.).

CAUSES & RISK FACTORS

T.B.I is caused when the head hits violently to an object or when some sharp thing enters the skull. The most common cause of T.B.I is falls from ladders, stairs etc. and vehicle-related accidents. Often T.B.I cases reported in hospitals are also caused by child abuse, violence, gunshots, assaults, military combats, blasts etc.

Many T.B.Is are also caused by sports like boxing, football, hockey, skateboarding etc. Children especially newborns are at high risk of T.B.I due to falls. Young adults are also at high risk of T.B.I primarily due to sports activities and accidents. Additionally, males of any age group are at high risk of T.B.Is.   

SYMPTOMS

Symptoms of TBI vary depending on the extent of damage caused to the brain.

Mild T.B.I symptoms

Often there are no symptoms of T.B.I until days or weeks after the injury. The mildest type of symptom includes concussion that is characterized by nausea, dizziness, headache, tiredness or neck pain.

Often the patients report buzzing in ears, bad taste in mouth and sensitivity to light as well. Patients may suffer from loss of consciousness for 30 min and 30 min to 24 h in mild and moderate T.B.I, respectively. 

Symptoms of severe T.B.I

A severe type of T.B.I may cause further symptoms like continuous headache, seizures, unclear speech, dilated eye pupils, numbness or weakness of limbs, bleeding from nose or ears, continuous nausea and vomiting and inability to awake from sleep.

Loss of consciousness is more than 24 h in severe T.B.I. The patient may undergo coma in which they cannot respond to any stimulus and remain unaware of their surroundings. Patients may also undergo vegetative state in which they may open eyes or make sounds but remain unaware of surroundings.

Patients may also develop photophobia or painful light sensitivity that is a significant indicator of brain damage. The fractures in the skull and deep wounds may also lead to various infections.

Prolonged symptoms of severe TBI causes emotional problems like anxiety, depression, aggression and personality changes, in the patients. Patients may also develop cognitive problems like lack of reasoning, judgements and memory (Silver, McAllister and Arciniegas, 2018).

DIAGNOSIS

T.B.I is diagnosed through a neurological exam by a doctor. When a patient is brought to the hospital, consciousness tests like Glassgow Coma Score are performed. The purpose of this test is to analyze a patient’s ability to open eyes, respond to orientation questions and ability to suitably respond to commands like holding or moving fingers.

Each question is assigned a score and this score helps to find the severity of T.B.I (Teasdale et al. 2014). Other diagnosis techniques include and imaging tests like computed tomography (CT) scan and functional magnetic resonance imaging (fMRI).    

CT scanning

Special X-ray equipment called computed tomography machine helps to examine brain injuries. This diagnostic imaging test helps to take pictures inside the brain thereby exposing any internal bleeding or brain damage quickly and efficiently.

For CT scanning, the patient has to wear a loose-fitting gown and any metal objects like jewellery has to be removed. The patient lies down flat on the CT exam table in a correct position and the table moves in a doughnut-shaped CT scanner.

The scanner takes multiple images and then the CT table moves out of the scanning machine. CT scan of the brain usually takes 10 min. CT scan is a simple, cost-effective, painless, accurate and non-invasive diagnostic test for T.B.I (Levin and Diaz-Arrastia, 2015).    

fMRI test

Functional Magnetic resonance imaging (fMRI) uses radio waves to analyze brain activity by measuring minor changes in blood flow. It is a non-invasive test that helps to find which parts of the brain are not functioning properly.

MRI machine is a cylindrical tube that is surrounded by a circular magnet. Like the CT scan, the patient is laid on a table that moves in the machine and required images are generated by the machine.  

MRI is not suitable for acute T.B.I because transferring an acutely injured patient to MRI scanner may be problematic. However, when the patient is stabilized, MRI may be performed to analyze lesions that cannot be detected through CT scan. 

TREATMENT

Depending on the extent and stage of injury, treatments for T.B.I are provided at various levels.

Initial treatment

Initially, in case of head trauma, the patient should lie down quietly while keeping the head in a slightly elevated position.

If the patient is wearing a helmet, it should not be removed. If the patient shows no breathing, movement or circulation, CPR should be started.

Acute treatment

When a patient reaches the hospital, health care professionals are examined with proper equipment for blood pressure, intracranial pressure and breathing. Regular oxygen flow is ensured and a tetanus shot may also be administered.

Acute treatment of T.B.I is done to reduce secondary injury and provide life support. Sedative medications may be provided to an individual to reduce anxiety and to prevent secondary injury.

Pressure in the brain may be monitored and controlled by surgically placing devices in the brain. Mechanical ventilation may be used to aid breathing and decrease pressure in the head. For providing adequate nutrition, fluid may be administered.

Surgical treatment

Depending on the results of diagnostic tests, surgical treatment may also be required. In case of internal bleeding, blood is drained from the skull. The overall objective of surgical treatments is to prevent swelling, maintain healthy blood flow and pressure in the brain.

Often repair of damaged blood vessels (hematomas) and tissues (contusions), is done through surgery. In case of excessive brain damage and swelling, the damaged portion is removed through surgery (Mendelow et al. 2015).       

RECOVERY

Rehabilitative care centers help the T.B.I patients recover from various long term issues caused by T.B.I. Rehabilitation often requires tailored approaches for various patients like occupational therapies, psychiatric approaches, physical therapies, speech therapies, social support etc.

Severely injured patients require constant care for preventing infections, mobility issues and respiratory issues. All the recovery strategies are designed to help the patient reach his maximum level of function after T.B.I. Patients may suffer from cognitive disabilities, disturbance in sensory processing and mental or behavior issues.

Rehabilitation centers also communicate with the families of affected people to educate them about the realistic expectations about patient’s recovery and how they can play their role in helped the affected person.   

PREVENTION

Although head injuries are very common, they can prevented by taking simple precautionary measures.

  • No alcohol or drugs

For instance, one should never drive after taking alcohol or drugs because they increase the chances of accidents.

  • Seat Belts and child seats

Seat belt should always be fastened while driving. Children should always be seated on back seats secured with child safety.

  • Helmets

Bikers and motorcyclists should wear helmets as they prevent brain injuries during accidents.

  • Preventive measures during sports

While playing games like football, boxing or ice-hockey and driving scooter, bike, skateboard, snowboard or horse, helmet must be worn. Play areas, windows and stairs should be made safe especially for children (Mass et al. 2017).  

Conclusion

In conclusion, T.B.I is a major health issue that affects the anatomy and functions of brain. Safety precautions in daily activities may help to avoid T.B.I. Additionally accurate primary healthcare services can have a significant role in preventing serious complications.   

References

AANS, n.d. Traumatic brain injury. Available from https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Traumatic-Brain-Injury. Accessed at 30th Sep 2019.

Dewan, M.C., Rattani, A., Gupta, S., Baticulon, R.E., Hung, Y.C., Punchak, M., Agrawal, A., Adeleye, A.O., Shrime, M.G., Rubiano, A.M. and Rosenfeld, J.V., 2018. Estimating the global incidence of traumatic brain injury. Journal of neurosurgery1(aop), pp.1-18.

Levin, H.S. and Diaz-Arrastia, R.R., 2015. Diagnosis, prognosis, and clinical management of mild traumatic brain injury. The Lancet Neurology14(5), pp.506-517.

Maas, A.I., Menon, D.K., Adelson, P.D., Andelic, N., Bell, M.J., Belli, A., Bragge, P., Brazinova, A., Büki, A., Chesnut, R.M. and Citerio, G., 2017. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. The Lancet Neurology16(12), pp.987-1048.

McKee, A.C. and Daneshvar, D.H., 2015. The neuropathology of traumatic brain injury. In Handbook of clinical neurology (Vol. 127, pp. 45-66). Elsevier.

Mendelow, A.D., Gregson, B.A., Rowan, E.N., Francis, R., McColl, E., McNamee, P., Chambers, I.R., Unterberg, A., Boyers, D., Mitchell, P.M. and STITCH (Trauma) Investigators, 2015. Early surgery versus initial conservative treatment in patients with traumatic intracerebral hemorrhage (STITCH [Trauma]): the first randomized trial. Journal of neurotrauma32(17), pp.1312-1323.

Rajajee, V., 2018. Traumatic brain injury: Epidemiology, classification, and pathophysiology. Available from https://www.uptodate.com/contents/traumatic-brain-injury-epidemiology-classification-and-pathophysiology#H712825373. Accessed at 30th Sep 2019.

Silver, J.M., McAllister, T.W. and Arciniegas, D.B. eds., 2018. Textbook of traumatic brain injury. American Psychiatric Pub. Teasdale, G., Maas, A., Lecky, F., Manley, G., Stocchetti, N. and Murray, G., 2014. The Glasgow Coma Scale at 40 years: standing the test of time. The Lancet Neurology13(8), pp.844-854.