Traumatic Brain Injury, Part I: Diagnosis and Treatment

Serious brain injuries are most often the result of either automobile crashes or falls, says Mark Klingbeil, MD, Medical College of Wisconsin Assistant Professor of Physical Medicine and Rehabilitation and Medical Director of Neurorehabilitation Medicine at Froedtert Hospital.

Traumatic Brain Injury (TBI) occurs when a sudden event damages the brain. The damage can be focal - confined to one area of the brain - or diffuse, involving more than one area of the brain. A closed injury occurs when the head suddenly and violently hits an object but the object does not break through the skull. A penetrating injury occurs when an object pierces the skull and enters brain tissue. Every year in the US, approximately 1.4 million people experience a traumatic brain injury, and approximately 50,000 people die.

"Traditionally, motor vehicle accidents have been responsible for the majority of serious head injuries, but lately we've seen more injuries from falls than motor vehicle accidents," notes Dr. Klingbeil. That doesn't necessarily mean that falls are becoming more frequent, he points out, but that the injury-preventing effects of airbags are becoming more apparent.

Diagnosis Based on Symptoms, Scans
Dr. Klingbeil says that diagnosis of a brain injury depends upon the patient's symptoms. "When there is an insult to the brain due to a blow to the head, there are a number of symptoms that can occur," says Dr. Klingbeil. "A loss or alteration in consciousness is the symptom that we see most often, and then a decline or impairment in physical abilities."

If there is a loss or alteration of consciousness, a CT scan is performed. "That's our best tool for early assessment of a patient with a head trauma," says Dr. Klingbeil. "Bleeding shows up very clearly on a CT scan, but is harder to recognize on an MRI scan." The MRI scan is more sensitive to the effects of head trauma after 24 to 48 hours, he says. "We might have a patient who has a diffuse injury to the brain that doesn't show up on a CT scan, but when we go back 24 to 48 hours after admission, an MRI will show signs of injury that didn't show up on the CT scan."

Physicians are also concerned about maintaining the patient's overall medical status. "The time constraint that we have with MRI scans is another reason we don't choose that as our initial tool - it just takes too long to scan someone who isn't medically stable," explains Dr. Klingbeil.

An MRI isn't always necessary, he says. "If there are gross abnormalities on the CT scan, typically the patient is given serial CT scans. But if trauma isn't obvious on the CT scan and the patient continues to show an alteration of consciousness, then we will do an MRI scan."

Treatment Depends on Severity
Treatment for TBI depends on the severity of the injury. "Patients who have a brief loss or alteration of consciousness, some amnesia, or problems remembering things from one moment to the next, might just be observed for 24 hours," says Dr. Klingbeil. This can be done in the emergency room, or patients can be sent home if they have family or friends who can watch them.

"Fortunately, the vast majority of people with head trauma fall into this category," Dr. Klingbeil says. "Most people are seen in an emergency room if necessary, then sent home. They're observed for a time, and they recover well."

Signs of a worsening condition, such as a deteriorating level of consciousness, nausea, vomiting, confusion, stupor, or seizures would warrant a return to the hospital for further studies, says Dr. Klingbeil. If the patient has been observed for a week without these symptoms, but still has some cognitive deficits, further imaging or neuropsychological testing might be required.

Patients with moderate brain injury might have a more persistent loss or alteration of consciousness, or a scan that shows a fracture or accumulation of blood in and around the brain. Dr. Klingbeil says, "These patients are typically admitted to the hospital for close observation, and serial CT scans are performed to make sure that the accumulation of blood doesn't worsen, and that there's no swelling of the brain or pressure on the brain. They might be hospitalized for another 24 to 48 hours until they can go home to be observed."

Patients with a severe injury to the brain, who have a persistent loss of consciousness of greater than an hour or are in a coma, need to be treated in the intensive care unit. Dr. Klingbeil says, "These patients often have more problems with swelling, edema, and bleeding that might need more aggressive management." This can include placement of an intercranial pressure monitor by a neurosurgeon, and measures to lower the pressure inside the head if needed.

"We might put patients into a chemically-induced coma, which helps lower the pressure in the head," Dr. Klingbeil explains. "We might also use cryotherapy, which is used quite a bit in our intensive care unit. We cool the patient's core temperature using a central line with a small balloon at the end; cold water is circulated in this way, rapidly cooling the patient's blood."

"If the swelling or the accumulation of blood inside the head is too great, more extreme measures are taken," says Dr. Klingbeil. "Neurosurgical approaches such as drainage of a hematoma (a collection of blood) inside the head might be necessary.

"The most common approach would be an open craniotomy, in which a piece of the skull is removed, blood and damaged brain tissue is removed, and the bone is replaced and secured in place. The most extreme approach would be a craniectomy, in which a portion of the skull is removed to relieve pressure inside the head and replaced after acute swelling has completely resolved."

Take Preventive Measures
More than 5 million Americans alive today have had a TBI resulting in a permanent need for help in performing daily activities. They are often left with significant cognitive, behavioral, and communicative disabilities, and some patients develop long-term medical complications, such as epilepsy.

Dr. Klingbeil says that preventive measures must consistently be taken to avoid TBI. Always wear a helmet when riding a bike or motorcycle, playing sports, skating or skateboarding, riding a horse, skiing, or snowboarding. Avoid falls by using a step-stool with a grab bar, installing handrails on stairways, installing window guards to keep young children from falling out of open windows, and using safety gates at the top and bottom of stairs when young children are around.

When driving or riding in a car, remember to wear a seatbelt and use child safety seats. Dr. Klingbeil emphasizes, "Never drive drunk, because 50% of all motor vehicle brain injuries are alcohol-related." By taking these important safety measures, you can lower your chances of a traumatic brain injury considerably.

P. J. Early
HealthLink Contributing Writer

This article contains information from the National Institutes of Health and the US Centers for Disease Control and Prevention (CDC).

For more information on this topic, see the second part of this interview, Traumatic Brain Injury: Therapy, Rehabilitation, and Recovery.

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.