Traumatic Brain Injuries

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What Are Traumatic Brain Injuries?

Traumatic brain injuries (TBIs) occur when an external force disrupts normal brain function, leading to physical, cognitive, and emotional impairments. These injuries can range from mild concussions to severe brain damage, impacting an individual’s quality of life. At the Advanced Brain and Spine Surgical Centre, we specialise in diagnosing and treating traumatic brain injuries with modern medical developments.

Types of Traumatic Brain Injuries

Traumatic brain injuries (TBI) refer to sudden injuries that cause brain damage. Such injury may arise following a blow or bump to the head. It can be grouped into 2 main types:

  • Penetrating (open head injury): These occur when an object pierces the skull and enters the brain tissue, causing localised damage.
  • Non-penetrating (close head injury): These occur when the brain is shaken within the skull, causing bruising, bleeding, or swelling. Concussions are the most common form of closed head injuries.

What are the symptoms of a traumatic brain injury?

The symptoms of a TBI also varies depending on the severity and cause of the injury. Symptoms of the injury might occur directly after a blow or at the time of impact but also may appear much later for very trivial cases.

At times, people especially the elderly, don’t feel the effects of the injury for a few days after the blow. Common signs include:

  • Behaviour and mood changes, irritability
  • Fainting, loss of consciousness
  • Confusion and disorientation
  • Memory problems, memory loss, amnesia
  • persistent Headaches
  • Early morning nausea and vomiting
  • Dizziness and loss of balance
  • Sensitive to bright light
  • Tremors, poor coordination
  • First onset of Seizures
  • Loss of smell
  • Dilated pupils or blurred/double vision
  • Slurred speech, difficulty speaking, reading, or writing
  • Sleep disturbances
  • Feelings of depression and mood changes
  • Cerebrospinal fluid (CSF) leaking from ears or nose


In children and infants, some other signs include:

  • Inconsolable, nonstop crying
  • Refusing to eat or drink
  • Drowsiness
  • Loss of interest in favourite activities

When should you see a doctor?

If you have experienced a blow to the head, especially accompanied by the symptoms mentioned above, it is always a good idea to visit a doctor. Even mild or moderate injuries may require medical attention and appropriate investigations so it is always best to see a doctor and get an accurate diagnosis.

How are traumatic brain injuries caused?

As previously mentioned, a traumatic brain injury is classified into 2 main types:

Non-penetrating/ closed head injury may be caused by:

  • Falls
  • Car crashes and/or other vehicle-related accidents
  • Sports injuries
  • Struck by an object
  • Child abuse
  • Blast injuries due to explosions


Penetrating injury
may be caused by:

  • Being hit by a weapon/ firearms
  • A head injury that causes a bone fragment to penetrate the skull
  • Severe industrial accidents


In cases of natural disasters such as an earthquake and other extreme events, it is also possible for someone to experience both penetrating and non-penetrating brain injury at the same time.

What complications can arise from an untreated brain injury?

If left untreated, a traumatic brain injury can cause long-term and even permanent damage and disabilities. The complications can be wide-ranging, affecting both physical and mental health. Some of the most common risks include:

Psychological and Neurological Risks

  • Mental Health Disorders: Anxiety, depression, and post-traumatic stress disorder (PTSD) are common psychological effects.
  • Traumatic Epilepsy: Seizures can develop due to the injury, increasing the risk of traumatic epilepsy.
  • Neurological Deficits: Weakness in the arms or legs and internal bleeding within the brain may occur.

 

Physical Complications

  • Hydrocephalus: Cerebrospinal fluid (CSF) buildup can lead to increased pressure and swelling in the brain.
  • Infections: Meningitis and other infections can develop, potentially spreading throughout the nervous system.
  • Vascular Damage: Blood vessel damage may result in stroke or blood clots.
  • Chronic Symptoms: Frequent headaches, vertigo, and cranial nerve damage, which can lead to facial muscle paralysis, swallowing difficulties, and sensory loss.

 

Cognitive and Communication Challenges

  • Cognitive Impairments: Memory loss, difficulties with learning, reasoning, judgement, and problem-solving, as well as impaired attention and concentration.
  • Mood Disorders: Changes in mood and emotional regulation.
  • Communication Difficulties: Problems with speaking, writing, understanding information, and organising thoughts and ideas.

 

While unlikely for mild to moderate traumatic brain injuries, severe cases can also increase the risks of developing early onset of Alzheimer’s disease, dementia, or movement disorders later in life.

What can I expect during my first consultation?

When a patient with a traumatic brain injury arrives in the emergency room, the initial assessment is crucial. The doctor will evaluate the patient’s condition by examining symptoms, understanding the cause of the injury, and conducting a series of tests to determine the severity of the brain injury.

One of the primary tools used to assess the level of consciousness is the Glasgow Coma Scale (GCS). This test assesses the patient’s ability to:

  • Open their eyes: Spontaneously, in response to speech, or in response to pain.
  • Respond appropriately to orientation questions: Such as identifying their name, location, and the current date.
  • Follow commands: Such as simple movements like squeezing a hand or moving a limb.
  • Respond to pain stimulation: Particularly important if the person is unconscious or unable to follow verbal commands.

 

Each of these categories is scored, and the total score is calculated to determine the severity of the traumatic brain injury:

  • Mild TBI: GCS score of 13 – 15
  • Moderate TBI: GCS score of 9 – 12
  • Severe TBI: GCS score of 8 and below

How are traumatic brain injuries diagnosed?

Following a GCS test, other diagnostic imaging tests will be done. These may include:

Computed Tomography (CT)

This is the first line of investigation in the diagnosis of head injury., A CT scan is a non-invasive imaging test that helps identify skull and skull base fractures, bleeding in the brain, blood clots, and the overall extent of brain injury and underlying brain swelling. CT scans will be taken a few times throughout the recovery process to observe the progression of the injury and treatment.

Magnetic Resonance Imaging (MRI)

A non-invasive test that utilises a magnetic field to visualise the soft tissues of the brain. The test may show subtle changes that are not seen in a CT scan, but as the test takes longer than a CT scan, it is usually only done after the patient has stabilised. It can give more detailed information about the brain after the injury and treatment.

Magnetic Resonance Spectroscopy (MRS)

A test to find information about the metabolism of the brain. By analysing the chemical composition of brain tissue, MRS can help identify abnormalities and assess potential complications or consequences related to a traumatic brain injury. This test is particularly useful in ruling out specific conditions and guiding the development of a more targeted treatment plan.

Cerebrospinal Fluid (CSF) Analysis

Above that, a cerebrospinal fluid (CSF) analysis may also be done. The CSF is collected through a procedure called a spinal tap. This involves inserting a thin, hollow needle between two vertebrae in the lower spine. The CSF analysis in traumatic brain injury is done to diagnose:

  • Infections, including meningitis and encephalitis
  • To measure the CSF pressures

How are traumatic brain injuries treated?

The treatment for a TBI will depend on the severity of the condition. For mild cases, the treatment may include symptomatic medications and subsequent clinical assessment with physiotherapy. Surgery may be necessary for those with severe head injuries and bleeding or swelling inside the brain.

Medications

This treatment works to limit secondary damage immediately after the injury. This may include:

Anti-seizure drugs

A TBI increases the risk of seizures which may cause additional brain damage. The use of this drug may be continued if seizures continue to happen.

Coma-inducing drugs

The drug is used to put people to sleep, which is called temporary coma that will help the injured or swollen brain requires less oxygen to function and temporary rest.

Diuretics

To reduce the amount of fluid in tissues, thus reducing the pressure inside the brain.


Surgery

In some cases, emergency surgery may be necessary to minimise additional damage to the brain. The surgery may be done to:

• Remove blood clots
• Repair skull fractures
• Stop bleeding in the brain
• Relieve pressure inside the skull (by draining CSF or creating a window in the skull)

Treatment of severe traumatic brain injury

Referred to as neurocritical care, the intensive care of patients with severe TBI may include:

Monitoring

• Intracranial pressure (ICP) monitor
• Brain oxygen monitor (Licox)
• Ventilator
• Feeding tube
• Seizures and EEG monitoring

Medication

• Sedation and pain
• Controlling brain pressure (hypertonic saline)
• Preventing seizures (levetiracetam or phenytoin)
• Preventing infection

Advanced Surgical Treatment

Surgery

This involves cutting a hole in the skull to remove a bone flap. The surgeon can then access the brain through the bone flap  to remove the blood clot and repair the damaged brain membrane to prevent brain fluid leak.

Decompressive craniectomy

Performed when the pressure inside the brain increases to a life-threatening level. The surgery involves removing a large section of bone to allow the brain to swell and expand. The removed bone flap will be stored in a freezer and 1-3 months after the swelling has resolved, the bone flap will be replaced (called cranioplasty).

Evacuation of a cerebral blood clot (Burr hole drainage)

Either a small hole (burr hole) or craniotomy (larger bone opening) is created through the skull to suction out the blood clot, stop the bleeding areas and relieve brain pressure.

CSF leak repair

Involves using a synthetic graft, a piece of the patient’s own tissue, or a tissue flap to seal damaged or torn areas in the skull base to prevent CSF leak.

Summary

The diagnosis, treatment, and management of traumatic brain injuries differ greatly depending on the severity and cause of injury. While some cases might be mild and come with few symptoms, other cases might be much more severe and even life-threatening.

If you experienced a blow to the head or any of the symptoms mentioned above, it is always a good measure to visit a doctor. An accurate diagnosis is the start to effective treatment and recovery.

Dr Sein Lwin Author

Dr Sein Lwin

Senior Consultant Neuro & Spine Surgeon
MBBS, MSc Surgery, MRCS (Edin), MMed. Sc (Gen Surg) (S'pore), FRCS. Surgical Neurology (UK)

Dr Sein Lwin is an experienced Senior Consultant Neuro & Spine Surgeon and the Neurosurgical Director at the Advanced Brain and Spine Surgical Centre.

He is highly experienced in spine surgery and in minimally invasive approaches for spinal cord tumours and degenerative spine surgery. His specialised interests lie in endoscopic endonasal and open skull base surgery, pituitary tumours, vascular surgery, cranial nerve disorders and peripheral nerve conditions.

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