Traumatic Brain Injury (Part 2)

By: Carine Human

In Part 1, Traumatic Brain Injury (TBI) was explored, along with the types of TBI and their symptoms. Part 2 will focus on the effects of TBI and how TBI is diagnosed and the symptoms of moderate and severe brain injury.

1.    Who is affected by TBI?
TBI is one of the leading causes of disability in South Africa and are relatively common, having a devastating impact on many people's lives. It is estimated that 89 000 new cases of TBI are reporting annually in our country. It is also the leading cause of mortality for people under the age of 45 years and affects men almost twice as much of woman, which is most probably due to men engaging more in reckless behavior and partake in more dangerous activities. Most people are oblivious to the scope of TBI and of its distressing nature. It is a common injury and sometimes missed initially when a medical team is focused on saving a patient's life. Death in TBI was very high before medical knowledge and technology advanced to control breathing with respirators and decrease intercranial pressure (the pressure in the fluid surrounding the brain). Despite these advances, the effects of TBI are significant.The effect of TBI are variable and depends on how much damage was caused to the brain. It varies from negligible damage to damage so severe that it impacts all areas of an individual's life. Neurological injury may produce physical, emotional, psychological, cognitive and behavioral changes. It often results in prolonged or non-reversible brain damage, which has grave implications for patients and families. These injuries may result in personality changes, physical disability, a state of coma or even death. Furthermore, they may have limited function of arms or legs, abnormal speech or language, loss of thinking ability and emotional challenges. As many victims are rendered incapable of looking after themselves, they must be cared for by their families or other service providers. Many people are fighting personal battles to overcome disabilities they have suffered as a result of TBI. They need support and assistance for themselves and their families in order tointegrate back into their communities in a much as possible. Change in brain function may result in a dramatic impact on family, work, social and community interaction.

2.    How is TBI diagnosed?
Brain injuries are categorised as an open (penetrating) or closed trauma and according to severity of the brain injury. It could range between a concussion to a more sever contusion. The various types of bleeding or hemorrhage within and around the brain could also cause focal brain damage. Bleeding in the brain may require emergency surgery to prevent intracranial pressure building, which may lead to death.Recovery of patients with TBI depends on how seriously the brain was injured and which areas were affected. Doctors will ascertain as much as possible as soon as possible about a patient's symptoms, how the injury occurred upon his admission to the emergency room.

One scale used to grade a patient's level of consciousness is the Glasgow Coma Score (GCS), which is a 15-point test. The patient's capability to:
1.    open his or her eye
2.    ability to respond appropriately to orientation questions, ("What is your name? What is the date today?")
3.    ability to follow commands ("Hold up two fingers, or give a "thumbs up"). If unconscious or unable to follow commands, the response to painful stimulation is checked.
From each category, a number is taken and added together to get the total GCS score. The score ranges from 3 to 15 and classifies an injury as mild, moderate, or severe. A high score indicates a good prognosis and a low score indicates a poor prognosis.

Another scale is the Ranchos Los Amigos Scale, which measures levels of awareness, cognition, behavior and interaction with the environment:
Level I: No Response
Level ll: Generalised Response
Level lll: LocalisedReponse
Level IV: Confused-agitated
Level V: Confused-inappropriate
Level VI: Confused-appropriate
Level Vll: Automatic-appropriate
Level Vlll: Purposeful-appropriate

Various scans can also be used to assist in diagnosis:

1.    Computed Tomography (CT) scanning is the gold standard for the radiologic assessment of a head injury. It is easy to perform and is a great test for detecting the presence of blood and fractures, which are the most important lesions to identify in an emergency. It is a noninvasive X-ray that provides detailed images of anatomical structures within the brain. A CT scan of the head is taken at the time of injury to quickly identify fractures, bleeding in the brain, blood clots (hematomas) and the extent of injury. CT scans are used throughout recovery to evaluate the evolution of the injury and to help guide decision-making about the patient's care.
2.    Magnetic Resonance Imaging (MRI) is a noninvasive test using a magnetic field and radiofrequency waves to give a detailed view of the soft tissues of the brain. A dye (contrast agent) may also be injected into the patient's bloodstream. MRI can detect subtle changes in the brain that cannot be seen on a CT scan.
3.    Magnetic Resonance Spectroscopy (MRS) provides information about the metabolism of the brain. The numbers produced from this scan provide a general prognosis about the patient's ability to recover from the injury.
4.    X-rays of the skull are recommended by some to evaluate patients with mild neurological dysfunction. Most large centers in SA however, have readily available CT scanning, which is a more accurate test and resulted in a declined of use of X-rays as routine in TBI patients.

3.    The symptoms and impact of TBI on the patient and others
Brain injury ranges from mild to severe. TBI results in permanent neurobiological damage, which may produce lifelong deficits in varying degrees. Moderate to severe brain injuries refer to injuries typically having the following characteristics:
    ModerateTBI is defined as a brain injury resulting in loss of consciousness from 20 minutes to 6 hours and a Glasgow Coma Scale of 9-12.

    Severe TBI is defined as a brain injury resulting in a loss of consciousness of longer than 6 hours and a Glasgow Coma Scale of 3-8.
The impact of moderate to severe TBI relates to the severity of initial injury, rate/stage of physiological recovery, functions affected, connotation of dysfunction to the individual, resources available during recovery as well as the areas of function unaffected by TBI. In summary, it may comprise of:

Cognitive deficits and difficulties with -Attention, concentration, distractibility, memory, processing speed, confusion, perseveration, impulsivity, language processing and/or executive functions
Speech and Language -Inability to understand the spoken word (receptive aphasia), difficulty speaking and being understood (expressive aphasia), slurred speech, speaking very fast or very slow and/or challenges with reading and/or with writing
Sensory -difficulties to interpret touch, temperature, movement, limb position and fine discrimination
Perceptual -the integration of sensory impressions into psychologically meaningful information
Vision -partial or total loss of vision, weakness of eye muscles and double vision (diplopia), blurred vision, problems judging distance, involuntary eye movements (nystagmus) and/or intolerance of light (photophobia)
Hearing -decrease in or loss of hearing, ringing in the ears (tinnitus) and/or increased sensitivity to sounds
Smell -loss or diminished sense of smell (anosmia)
Taste -loss or diminished sense of taste
Seizures -the convulsions associated with epilepsy that can be several types and can involve disruption in consciousness, sensory perception and/or or motor movements
Physical Changes -physical paralysis/spasticity, chronic pain, control of bowel and bladder, sleep disorders, loss of stamina, appetite changes, regulation of body temperature and/or menstrual difficulties
Social-Emotional -dependent behaviors, emotional ability, lack of motivation, irritability, aggression, depression, disinhibition and/or denial/lack of awareness
Implications of TBI may evidently be extremely immense. Part 3 will explore the various treatment options and support needed for patients and families or care givers, as well as prevention thereof.