Traumatic Brain Injury

A traumatic brain injury (TBI) is defined as a blow or jolt to the head or a penetrating head injury that disrupts the function of the brain. Not all blows or jolts to the head result in a TBI, however, and the severity of injuries can range from “mild,” which involves a brief change in mental status or consciousness, to “severe,” which involves an extended period of unconsciousness or amnesia after the injury.

Injury Causes

Half of all TBI’s are due to transportation accidents involving automobiles, motorcycles, bicycles and pedestrians. These accidents are the major cause of TBI in people under the age of 75. For those 75 and older, calls cause the majority of TBI’s. Approximately 20% of TBI’s are due to violence, such as firearm assaults and child abuse, and about 3% are due to sports injuries. What’s more, half of all TBI incidents involve alcohol use.

Common Symptoms

If you or someone you know has experiences any of the following symptoms following a bump on the head due to a vehicle accident, a sports injury, a fall or another injury, you should seek immediate medical attention:

  • Loss of consciousness, sometimes occurring a few hours after the injury
  • Dazed or confused feeling
  • Memory loss
  • Nausea or vomiting
  • Partial paralysis
  • Partial sensory loss
  • New neck pain
  • Numbness or weakness of the extremities
  • Unusual or prolonged headache
  • Bruising or discoloration around the eyes or behind the ears
  • Blood or clear, watery fluids coming from the ears or nose

Resulting Problems and Conditions

A TBI can result in short or long-term problems with independent function. In fact, 5.3 million Americans are currently living with a disability as a result of 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 patient. Some common disabilities include problems with the following brain functions:

  • Cognition: thinking, memory, and reasoning
  • Sensory Processing: sight, hearing, touch, taste and smell
  • Communication: expression and understanding
  • Behavior or Mental Health: Depression, anxiety, personality changes, aggression, acting out and social inappropriateness

More serious injuries may result in:

  • Stupor: An unresponsive state, but one in which an individual can be aroused briefly by a strong stimulus, such as sharp pain
  • Coma: A state in which an individual is totally unconscious, unresponsive, unaware and unarousable
  • Vegetative state: An individual is unconscious and unaware of his or her surroundings, but continues to have a sleep-wake cycle and periods of alertness
  • Persistent vegetative state (PVS): Occurs when an individual stays in a vegetative state for more than a month

Complications

Sometimes, health complications occur in the period immediately following a TBI. These complications are not types of TBI, but are distinct medical problems that result from the injury. Although complications are rare, the risk increases with the severity of the trauma. Complications of TBI include:

  • Immediate seizures
  • Hydrocephalus- A condition, often congenital, that is marked by abnormal and excessive accumulation of cerebrospinal fluid in the cerebral ventricles
  • Cerebrospinal Fluid (CSF)- A water-like fluid produced in the brain that circulates around and protects the brain and spinal cord
  • Infections
  • Vascular (vein) injuries
  • Cranial nerve injuries
  • Pain
  • Bed Sores
  • Multiple organ system failure in unconscious patients
  • Polytrauma- trauma to other parts of the body in addition to the brain

 

Note: These injuries require immediate and specialized care and can complicate treatment of TBI and slow recovery. They may include pulmonary (lung) dysfunction, cardiovascular (heart) dysfunction from blunt chest trauma; gastrointestinal dysfunction, fluid and hormonal imbalances, and other isolated complications.

 

Spinal Cord Injuries

Approximately 11,000 new cases of spinal cord injuries (SCI) occur every year in the United States. Of these, the most frequent injury is classified as a C5, followed by C4, C6, T12, and L1. In other words, about half of these injuries occur in the cervical area of the spine while the others affect the thoracic, lumbar or sacral areas. The CNI NeuroTrauma Service utilizes today’s most advanced diagnostic tests to determine precise classification of a patient’s injury in order to provide the most effective and immediate treatment and care.

Injury Causes

Motor vehicle crashes are the #1 cause of spinal cord injuries, accounting for nearly 40% overall. Other leading causes include acts of violence, falls and sports injuries.* It should be noted that the percentage of SCI cases caused by acts of violence and falls have increased steadily since 1973, while the percentage of cases due to motor vehicle crashes and sports injuries has been falling.

* These figures are for all injuries reported to the National Database since 1990.

Sports-Related Injury/Concussion

A patient with mild traumatic brain injury experiences a mild disruption of brain function due to a traumatic event. These injuries can be caused by someone’s head being hit, someone striking their head on an object or whiplash. The disruptions that can be caused by these factors may include one or more of the following:

  • Loss of consciousness for any period of time
  • Any loss of memory for events immediately before or after the accident
  • Any alteration in mental state at the time of the accident (e.g., feeling dazed, disoriented or confused)
  • Focal neurological deficit(s) that may come and go, but which do not exceed the following:
    • Loss of consciousness for approximately 30 minutes or less
    • An initial Glasgow Coma Scale (GCS) of 13-15
    • Posttraumatic amnesia (PTA) that lasts for 24 hours or less.

Common Symptoms

Symptoms of mild TBI can continue for varying lengths of time.  It is not unusual, for example, for a patient with mild TBI to have ongoing symptoms. These symptoms generally fall into one of the following categories:

  • Physical problems: Nausea, vomiting, dizziness, headache, blurred vision, sleep disturbance, easily fatigued, lethargy or other sensory loss that aren’t due to other causes
  • Cognitive issues: Difficulty paying attention or concentrating or problems with perception, memory, speech/language, or decision-making, which are not due to other causes
  • Behavioral issues: Changes in emotional state or stability. For example, a patient may be more irritable, become angry quickly, show less discretion in certain circumstances (inhibition) or simply seem emotionally disconnected (lability).
    Keep in mind that some patients may not become aware of the extent of their symptoms until they attempt to return to normal functioning.

Diagnosis

Specialists at the CNI NeuroTrauma Service utilize various diagnostic tests and tools to determine the type and severity of various patient injuries. The following provides an overview of each:

Glasgow Coma Scale

A standard test for a suspected head injury is the Glasgow Coma Scale. Typically performed by emergency medical personnel, this test assesses: eye opening, the ability to respond verbally and the ability to move the arms and legs. The scores of the three tests are added up to determine the patient’s overall condition. A total score of 3 to 8 indicates a severe head injury, 9 to 12 indicates a moderate head injury, and 13 to 15 indicate a mild head injury.  Anyone with signs of moderate or severe TBI should receive medical attention as soon as possible. Because little can be done to reverse the initial brain damage caused by trauma, medical personnel try to stabilize an individual with TBI and focus on preventing further injury.

Additional Tests

 A patient with a mild or moderate Glascow Coma score may receive skull and neck X-rays to check for bone fractures and any evidence of injury to the spine. CT scans are typically performed on patients with moderate to severe injuries. The CT scan can show bone fractures, hematomas, contusions, and brain swelling. An MRI may also be performed because it can reveal more detailed images of the brain. However, an MRI may not be the first test performed because it takes longer than a CT scan—and time is always critical when diagnosing these injuries.

CT scans and MRIs are standard tests used in the diagnosis of TBI; however, other imaging and diagnostic techniques may be used to confirm a particular diagnosis. These include cerebral angiography, electroencephalography (EEG), transcranial Doppler ultrasound, and single photon emission computed tomography (SPECT).

Treatment Options

Surgery
Approximately half of severe head-injured patients will need surgery to remove or repair hematomas (ruptured blood vessels) or contusions (bruised brain tissue). Patients may also need surgery to treat injuries in other parts of the body. These patients usually go to the intensive care unit after surgery. 

Relieving Intracranial Pressure
When the brain is injured, swelling sometimes occurs and fluids accumulate within the brain space. It is normal for bodily injuries to cause swelling and disruptions in fluid balance. However, when an injury occurs inside the skull-encased brain, there is no place for swollen tissues to expand and no adjoining tissues to absorb excess fluid. This increased pressure is called intracranial pressure (ICP). Specialists at the CNINeuroTraumaCenter measure a patient’s ICP using a probe or catheter. This involves inserting the instrument through the skull to the subarachnoid level so that the ICP can be measured. If a patient has high ICP, he or she may undergo a ventriculostomy, a procedure that drains cerebrospinal fluid (CSF) from the brain to bring the pressure down. Certain medications may also be used to decrease ICP.

Rehabilitation

The CNI NeuroTrauma Service works closely with and connects patients to comprehensive rehabilitation services to support and enhance recovery for moderate or severe injuries. Each rehabilitation program is tailored to each patient’s particular needs and may involve one or more of the following services:

  • Physical therapy
  • Occupational therapy
  • Speech/language therapy
  • Physiatry (physical medicine)
  • Psychology or psychiatry
  • Social support

Rehabilitation Partners

The CNINeuroTraumaCenter partners with the following centers of care to provide traumatic brain injury and spinal cord injury patients with the most advanced and comprehensive rehabilitative care and support available in order to achieve the best-possible outcomes:

CNI NeuroHealth Center
Many neurotrauma patients benefit from rehabilitation services at the CNINeuroHealthCenter. Located adjacent to Swedish Medical Center and Craig Hospital, the CNI NeuroHealth Center is an outpatient neuro-rehabilitation clinic offering speech, occupational and physical therapy, as well as patient navigation, social work and other support services. While homecare may be indicated initially, the CNINeuroHealthCenter is a good choice for longer-term rehabilitation in the outpatient setting. NeuroHealthCenter patients include those in need of rehabilitation therapy as as result of not only traumatic brain injury, but also Parkinson’s disease, Huntington’s disease, stroke, multiple sclerosis, peripheral neuropathy, brain tumors, gait abnormalities, progressive supranuclear palsy, and many other conditions. All services are delivered in one location, optimizing convenience and resources.

Dedicated to helping patients achieve their highest level of function, the CNINeuroHealthCenter emphasizes a team approach, wellness education and community reintegration. With a team of highly-trained therapists, the center participates in monthly clinics, research, and professional training in the area of neurological rehabilitation. Patients from across the RockyMountain region are referred to the CNINeuroHealthCenter for top-quality rehabilitation therapy.

Comprehensive services and resources at the CNINeuroHealthCenter include:

  • Physical, occupational and speech therapy by qualified therapists.
  • Services for patients with Medicare, most major insurance plans, and private pay.
  • Services to medically uninsured and underinsured patients through the generous support of our donors.
  • Social work services to evaluate current benefits, identify additional services available in the community and connect the client with these services.
  • Special programs and equipment, including LSVT Loud training for individuals with Parkinson’s Disease, Vital Stim training for swallowing disorders, LiteGait partial body weight support for individuals learning to walk and working on balance.
  • Scholarship assistance for neuro-optometry, neuropsychological and driving evaluations and the purchase of small durable medical equipment.
  • Education on disease processes as part of therapy treatment.
  • Multidisciplinary clinics with CNI physicians including Vision, Spasticity/Movement Disorders and Huntington’s disease.
  • Specialized seating and equipment evaluations.
  • Team communication and case management.

For an appointment at the CNINeuroHealthCenter, please call 303.788.4010.

Craig Hospital
CraigHospital, which is adjacent to CNI, has long-been recognized as a national center of excellence in specialty rehabilitation and research related to spinal cord and brain injury. CraigHospital is designated by the National Institute on Disability Rehabilitation and Research (NIDRR) as a ModelSystemCenter for both spinal cord injury and traumatic brain injury.

Swedish Medical Center
SwedishMedicalCenter, a Level 1 Trauma Center located directly adjacent to CNI, houses a Multi-Trauma Unit (MTU) that provides acute nursing care at a variety of stages from respiratory management, including ventilators, through the beginning phases of rehabilitation. One of only eight in the nation, the MTU provides aggressive therapy to prevent debilitation and complications that come with bed rest, the team works closely with patients who have experienced multiple trauma, spinal cord and column injuries, and head injuries.