Mental Health

Traumatic Brain Injuries

Today, we are seeing more people with traumatic brain injury (TBI) than ever before.  Sports injuries, high speed auto crashes, and combat explosions all have contributed to the proliferation of TBI. 

Sixty years ago, we had far fewer cars on the road.  There were only a few freeways, and most roads capped speeds at 35 mph.  Fewer cars and slower speeds meant there weren’t nearly as many accidents.  In the past, whether it was a sports injury, accident or combat, people with severe head injuries usually died.  Better technology, advanced surgical techniques, and improved trauma training have led to greatly increased survival numbers.  Studies show that one quarter of wounded soldiers evacuated from Iraq and Afghanistan have head and neck injuries, including those with severe brain trauma.  In the United States, there are an average of 1.4 million TBIs every year. Fifty thousand of that number die, but the rest survive, many with some level of permanent injury.  Prisons report that 87% of incarcerated persons have a history of head injury.  The problem is huge, and the science of effective treatment is in its infancy. 

How Does TBI Differ from Concussion?  Aren’t They the Same Thing?

All concussions are traumatic brain injuries, but not all TBIs are concussions. A concussion is one type of mild traumatic brain injury that usually occurs from a blow to the head.  Mild concussions may never be diagnosed.  Physicians once relied on the presence of two symptoms to diagnose concussion -- a brief loss of consciousness followed by amnesia for the event.  We now know a loss of consciousness is not required for a brain to be concussed. 

The term “trauma” means an injury caused by force.  A cut finger, a broken arm, and a ruptured spleen are all examples of traumatic injuries caused by an outside force.  TBIs occur when an outside force acts on the brain to penetrate it, shock it, vibrate it, or tear the tissues.  There are three basic types of TBI, open, closed, and crush injuries.  An open brain injury results when the skull is broken or torn open.  This allows the force to act directly on the soft tissues of the brain.  A bullet wound or fractured skull are examples of the open type, especially if skull fragments protrude into the tissue.  A closed head injury occurs when the brain is shaken, slammed, vibrated or rotated, but the skull remains intact.  When the head is compressed between two objects, a crush injury results, causing increased intracranial pressure, brain bleeds and skull fractures. Crush injuries may also leave an open skull.

Mechanisms of Injury

The brain can be injured in a number of ways.  These mechanisms of injury do not happen in isolation.  Some or all of them can occur together to cause damage to the brain tissues.

  • Shock waves. Brain tissue is very different than muscle or organ tissue.  It is soft and squishy like Jello.  A sharp blow to the head can send shock waves through the gelatinous brain tissue and surrounding membranes. The waves strike the opposite side of the skull and bounce back.  This back and forth wave action damages the delicate tissues.
  • Deceleration. Think of a crash test dummy hitting the windshield in a video.  Sudden decelerations rocket the brain tissue into the skull wall, ripping brain tissue away from membranes and supporting structures.  This is especially ominous in the brain stem.  The brain stem is attached to the spinal cord.  It has fibers connecting it to the brain but is not an attached portion of the brain.  If those fibers tear with a deceleration force, serious injury or even death will result.
  • Rotation. Unless someone whacks you over the head with a blunt object, a substantial direct hit is unusual.  Most of the time, a glancing blow strikes the head which causes a twisting or spinning motion as your neck rotates with the force.  This sudden, forceful rotation causes brain tissues to rotate as well, twisting or stretching tissues and connections.
  • Vibration. You’ve all heard the term “getting your bell rung.”  That is actually an apt and descriptive term.  When you hit the skull, it resonates just like a bell.  That vibration is communicated to the brain tissues within, causing damage.

Rotational, acceleration and deceleration mechanisms cause damage to the long axons that interconnect brain regions.  Deceleration and mechanical force often cause intercranial hemorrhage and hematoma that can displace and injure brain tissue, interfering with blood flow.

Every serious head injury is different and unique.  The force of the blow, the direction of the force, the location of impact, the age and health of the victim, history of previous head injuries, and the timing and quality of treatment all play a role in defining the injury.

Short-Term Effects of TBI

Many symptoms of injury can be seen almost immediately.   Patients often experience memory loss, headache, dizziness, inability to concentrate, difficulty with word finding, ringing ears, and unsteady gait.  They may also experience irritability, anxiety, and impulsive behavior.  Some of these symptoms can persist for months, even with a relatively mild TBI. 

Long-Term Effects of TBI

Short-term memory deficits and PTSD are common long-term consequences of TBI, even with mild TBI.  PTSD (post-traumatic stress disorder) is strongly associated with mild TBI.  The New England Journal of Medicine published an article in 2008, analyzing data on U.S. military personnel returning from Iraq after sustaining a mild TBI.  Forty three percent were diagnosed with PTSD on their return.  They experienced exaggerated startle response and panic attacks with racing heart and rapid breathing.  Many also experienced memory problems, chronic headaches, irritability and difficulty concentrating.  While symptoms and the duration of those symptoms vary from patient to patient, the following list sets out many of the well-known, long term effects of TBI:

  • Memory loss
  • Mood swings
  • Depression
  • Impaired vision
  • Sleep disorders
  • Chronic tinnitus (ringing in ears)
  • Impaired language skills
  • Coma or loss of consciousness
  • Loss of sensation in fingers, toes, and extremities
  • Increased risk of stroke and seizure
  • Impaired cognitive function
  • Loss of balance
  • Partial paralysis
  • Alzheimer’s, Parkinson’s, and other degenerative neurologic conditions.

In some patients, these effects may last for several years.  In others, they may last the patient’s lifetime.  TBI has been called “the invisible disease.”  The individual looks completely normal, and people expect him or her to be fully recovered from the injury.  Other people do not see the persistent effects that make returning to a preinjury life difficult or impossible for the victim.

Alzheimer’s and Parkinson’s   

There is now ample data showing that TBI creates increased levels of soluble amyloid-β peptides and causes amyloid plaque deposits in the brain.  These plaque deposits have been shown to be instrumental in causing Alzheimer’s.  Studies show that 20-30% of patients with Parkinson’s or Alzheimer’s have a history of head injury, while, 8-10 % of those diagnosed with Parkinson’s or Alzheimer’s have no TBI history.

We’ve been aware of the correlation between repetitive concussion and degenerative neurologic disease for decades.  Dementia pugilistica was a term coined to describe “punch drunk” boxers who had sustained repeated blows to the head.  People once viewed the “punch drunk” boxer as “funny.”  Comedians used the idea to create their comedy routines.  Today, we realize it was never funny.  That same condition often affects professional football players and wrestlers.  Our bodies cannot handle repeated head blows without serious consequences.  Thus, the controversy over kids playing tackle football.  Those high school and college kids with multiple concussions face an uncertain future.  Every parent needs to consider if the sport is worth the risk.

Developing Treatments

Researchers complain that evidence-based treatments for TBI are lacking. Physicians have an array of tools that improve outcomes in the early treatment of severe TBI.  They can monitor intercranial pressure, and if the brain swells, they can do surgery to relieve the pressure. They can force oxygen into swollen brain tissue to lessen the effects of hypoxia. They can sedate patients, give intravenous fluids, and administer drugs for seizures.  Research has shown that cooling the body to create a moderate hypothermia can reduce the incidence of death and severe brain injury.

Those tools increase patient survival and help prevent brain tissue death from lack of oxygen and increased intracranial pressure, but what about preventing those abnormal amyloid deposits?  What about repairing the tears in brain connections?  Has any progress been made?  The truth is that researchers still do not fully understand the mechanisms that cause degenerative brain disease.  Those issues are being heavily researched in the race to find treatments for Alzheimer’s and Parkinson’s. Researchers are hoping to develop a gene therapy or a vaccine to target abnormal deposits and remove them.  However, those therapies are a long way in the future.

Today, treatment focuses on helping patients recover as much function as possible using the knowledge we have.  Physical therapy, Occupational therapy, vocational therapy, counseling, and appropriate medications are currently the best tools available.  Public education is needed to help everyone understand the long-term consequences of TBI.  Families need more education and support.

We can and must use the current research to improve the helmets used by the military as well as football helmets.  More than padding is required.  Helmets must be designed to absorb impact and minimize shock and vibration, so the brain sloshes less within the skull.  We need to do a better job of diagnosing and treating mild concussion instead of blowing it off.  Our culture of tough it out and get back in the game does a real disservice to young athletes and military personnel.



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