Traumatic Brain Injury (TBI)
This is damage to the brain caused by a trauma to the head (head injury). There are many possible causes, including road traffic accidents, assaults, falls and accidents at home or at work.
A brief period of unconsciousness, or just feeling sick and dizzy, may result from the accident which according to research account for 80% of all head injuries that are reported
A moderate head injury is usually viewed where there has been a loss of consciousness for between 15 minutes and six hours, or a period of post-traumatic amnesia of up to 24 hours.
Often in these cases an injured person maybe kept in hospital overnight for observation, and then discharged if there are no further obvious medical injuries.
The effects of a moderate head injury are such that a person is likely to suffer from a number of residual symptoms. Please see the case study of Jamie Pinkerton for the effect a modertae brain injury has had on this man.
The effects of a traumatic brain injury on an individual depends on a number of factors such as the type, location and severity of injury. Symptoms can be wide-ranging, from physical effects such as balance problems, headaches and dizziness to cognitive, emotional and behavioural effects such as memory problems and anger.
A head injury is classed as Severe where someone has been in unconscious for a number of hours or more, or they suffer from a post-traumatic amnesia of 24 hours or more. These people are likely to need to stay in hospital for at least a few days but probably more and in some cases months and go on to receive rehabilitation once the acute phase has passed. Depending on the length of time in coma, these patients tend to also have more serious physical problems usually as a result of what is known as hemipareis where one side of the brain has been damaged and this effects the opposite of the body and can cause mobility and speech problems.
Closed head injuries and Diffuse axonal injuries
Closed head injury
This is a type of brain injury in which the skull and dura mater remain intact. Closed-head injuries are the leading cause of death in children under 4 years old and the most common cause of physical disability and cognitive impairment in young people. Brain injuries such as closed-head injuries may result in lifelong physical, cognitive, or psychological impairment.
Diffuse axonal injury
This is a brain injury in which damage occurs over a widespread area. This is one of the most common and devastating types of brain injury and is a major cause of unconsciousness It occurs in about half of all cases of severe damage to the head and may be the primary damage that occurs in concussion. Sometimes this can result in coma with over 90% of patients with severe injury never regaining consciousness. Those who do wake up often remain significantly impaired.
Diffuse axonal injury is the result of shearing forces that occur when the head is rapidly accelerated or decelerated and the brain moves about in the closed confines of the skull coming in cointact with the interior of the skull and shearing against the chamber. It usually results from rotational forces or severe deceleration. Car accidents are the most frequent cause and it can also occur as the result of child abuse such as in shaken baby syndrome.
The major cause of damage is the disruption of axons, the neural processes that allow one neuron to communicate with another. Acceleration causes shearing injury: damage inflicted as tissue slides over other tissue. When the brain is accelerated, parts of differing densities and distances from the axis of rotation slide over each other, stretching axons that traverse junctions between areas of different density, especially at junctions between white and grey matter.Two thirds of DAI lesions occur in areas where grey and white matter meet.
A contrecoup injury
This occurs under the site of impact with an object, and a contrecoup injury occurs on the side opposite the area that was hit. Coup and contrecoup injuries are associated with cerebral contusions, in which the brain is bruised. Coup and contrecoup injuries can occur individually or together. When a moving object impacts the stationary head, coup injuries are typical, while contrecoup injuries are produced when the moving head strikes a stationary object.
Coup and contrecoup injuries are considered focal brain injuries, those that occur in a particular spot in the brain, as opposed to diffuse injuries, which occur over a more widespread area.
The exact mechanism for the injuries, especially contrecoup injuries, is a subject of much debate. In general, they involve an abrupt deceleration of the head, causing the brain to collide with the inside of the skull. It is likely that inertia is involved in the injuries, e.g. when the brain keeps moving after the skull is stopped by a fixed object or when the brain remains still after the skull is accelerated by an impact with a moving object.
Professor Michael vloeburghs ( Consultant paediatric Neurosurgeon)
Summary brain injury:
Traditionally brain injuries are classified as minor, moderate and severe based on a generally accepted score for head injury, the Glasgow Coma Score. In general this scoring guides the management of the individual and gives and preliminary outlook on the outcome.
Severe head injuries equate to severe disability, moderate head injuries haves variable outcomes and minor head injuries are usually considered to have little or no long term consequences.
In severe head injuries the consequences are generally obvious such as physical impairment or neurocognitive problems. In moderate and minor head injuries the spectrum is wider and harder to interpret, even more so when there are no physical signs of injury.
The recent literature has a number of substantial papers showing this general concept is to be interpreted with caution and the clinical presentation of the individual is more significant than the level of trauma as indicated by a scoring system.
In descriptive anatomy of the 19th and 20th century, the brain is subdivided in sectors that have their own role. As time went this “sectoring” was increasingly questioned; also the brain repairs itself and regenerates but not to the extent of replacing lost structures.
The brain essentially functions as a unit in the sense that every area has a role and influences the other areas, which helps explain why for example perception of pain has an impact on performance or behaviour.
This is more than pertinent in brain injuries in children. When a brain injury occurs at young age, the brain is in full development and significant consequences are seen from minor/moderate head injuries in young children. Even with normal CT scans and MRIs there can be non- detectable damage to the “white matter tracks”, the connective wiring of the brain, which results in impaired function. Recently alternative MRI sequences early after injury have shown “white matter” changes in these circumstances.
The same applies to adult head injury where the issues are confounded by the “psychological” consequences of the trauma, which leads to different clinical interpretations of the individual’s problems as in strict terms “psychology” is still related to brain function.
Children’s head injuries were previously thought to have a better prognosis than adult head injuries but further assessments have disproven this. Young injured children aim to become active as soon as they can and have a drive to get back to their former activities. Depending on the significance of the injury, their abilities will plateau at some point, the child grows, matures in a sense, which is when the discrepancy with their peers becomes obvious.
The process is more “binary” in adults. An injured adult may have a family, may need to provide an income and there is pressure to get back to the former lifestyle as soon as possible.
Because of the head injury this may not be possible. In fact after the head injury the injured individual may not be entirely the same person as before the injury and can’t deal with the return to their former lives and thing that were considered normal or common may no longer be acceptable.
A cautious summary is that the effect of a head injury is generally related to the severity of the head injury; the clinical presentation of the injured individual overrides a scoring system and the individual and their environment must be kept in mind when doing clinical or expert witness assessments.
Prof. Michael Vloeberghs, MD, PhD
Consultant Paediatric Neurosurgeon
Nottingham University Hospital
Visiting Professor Nottingham Trent University
Dr Bruce Scheepers ( Consultant Neuropsychiatrist ) –
An injury to certain parts of the brain can cause devastating emotional and behavioural difficulties including the inability to foresee the consequences of actions, problems regulating emotions, impulsivity, disinhibition or loss of drive or motivation. What is most troubling to the person and more often to their loved ones is the fundamental change of personality; the essence of who they were, their personality, sense of humour, attitudes, empathy, preferences, and interests. These impairments usually cause a greater disability than any physical dysfunction, but are largely ignored by the services provided within the NHS and by statutory services. Unsurprisingly the focus for financially strapped statutory services is on managing risks, containment, and management. All challenging behaviour can readily be temporarily managed by medication and an induced coma if necessary! Unfortunately, most ‘medical’ management leads to restrictions, isolation, discrimination, and an impoverished life for many people with a brain injury. Despite the rhetoric, services are very often not person-centred and the interventions are not necessarily the least restrictive option or in the best interests of the brain injured person who has challenging behaviour.
Mental Health and Care Services for brain injured people with complex needs and challenging behaviour have repeatedly been criticised for their reliance on physical intervention, control and restraint and medication. In recent years, there has been widespread acknowledgement that many behaviours cannot readily be fixed, controlled, or modified, but people can be assisted to lead active and purposeful lives despite their challenging behaviour if they have appropriate support and environments that are capable of meeting their complex needs. This requires a different approach, philosophy and often a paradigm shift in thinking.
The Civil Procedure Rules in the UK legal system establish that the purpose of compensation in personal injury claims is to try and place people as close as possible to the position they might have expected but for the incident or accident. This is not about managing risk, or merely controlling and managing problem behaviours however challenging they may be. Personal injury claims provide a unique opportunity to design, create and fund environments that can meet the complex needs of people who have a brain injury and challenging behaviour. It requires individuals like us who are ‘choice architects’ to have the appropriate attitudes and skills to accept the challenge.
Professor Wang ( Consultant Neuropsychologist)-
Traumatic brain injury can have devastating consequences which, at first sight, are not always obvious to the uninitiated. There are often hidden handicaps of which only family, friends and employers become aware. And yet these difficulties with memory, concentration and what neuropsychologists call executive function (ability to plan ahead, organise, understand the consequences of actions, manage unforeseen circumstances) have a major impact on a person’s independence and quality life. The person may appear to the outside world to be quite normal: they seem to be able to walk and talk like everyone else. But what is not always seen is the extent of supervision (often by family and friends) required to ensure the person’s safety and welfare. Typically a person with frontal lobe injury will not be safe alone in the kitchen because of the risk of them causing a fire or burning themselves; typically they will not be safe walking in the street alone since they will have no sense of danger from traffic; they may leave their home open for opportunistic burglars; they may be impulsive with spending and run up large debts if there is no oversight. But there are strategies for managing these problems and cognitive rehabilitation can improve function despite permanent underlying brain damage, in addition to the need for supervision.