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Mild
Traumatic Brain Injuries (MTBI) are common and most
often result in complete recovery. However, sometimes
the effects can linger, causing physical, cognitive,
and behavioral problems. When that happens, expert,
comprehensive care is needed.
An
automobile passenger takes a glancing blow to the head
during a fender bender. A wide receiver briefly loses
consciousness after being tackled. An elderly woman
slips in the bathroom and bumps her head on the sink.
While most people recover well after such minor incidents,
about 15 percent of patients with a mild traumatic brain
injury (MTBI) have lingering problems such as headache,
pain, sleep disturbances, cognitive or memory loss,
and personality change. The symptoms can last for as
long as one year after the trauma.
About
1.5 million Americans sustain traumatic brain injuries
(TBI) each year, most of which - 75 percent - are considered
mild, according to the Centers for Disease Control and
Prevention (CDC). An MTBI begins with the mishap itself;
motor vehicle accidents account for about half of all
brain injuries, but violence, falls, and sports-related
trauma are common causes. A recent study by University
of Pittsburgh researchers found that mild concussions
had lingering effects among high school athletes playing
contact sports. Additionally, alcohol use is often an
underlying factor in these traumas; for example, a drunk
driver causes an automobile accident during which a
brain injury is sustained.
It's
estimated that traumatic brain injuries account for
1 million emergency room visits, 230,000 hospitalizations,
and 50,000 deaths each year in America, with direct
and indirect costs of $56 billion. MTBIs alone cost
the nation an estimated $17 billion.
A
Scalable Solution
Doctors use an assessment tool, the Glasgow Coma Scale
(GCS), to categorize brain injuries. "The scale
runs from 3 to 15 based on the patient's motor response,
verbal response, and ability to open his or her eyes,
with 3 being the lowest," explains Dr.
Allen Maniker, associate professor of neurosurgery
at New Jersey Medical School and director of neurotrauma
at University Hospital. "With a score below 8,
the patient is considered comatose, meaning that he
or she is unresponsive to external stimuli and has a
50 percent or greater chance of sustaining permanent
neurological injury. A person who is assessed between
13 to 15 on the Glasgow Coma Scale has an MTBI, which
carries a 50 percent or greater chance of sustaining
no permanent neurological injury."
The
symptoms of an MTBI can include disorientation, lethargy,
irritability, headache, dizziness, seizures or vomiting.
In some cases, the patient loses consciousness. A brief
loss of consciousness has been termed a concussion .
Newer grading scales have been designed to further define
concussion, but no one scale is universally accepted.
When
brain injury patients come to the hospital, they typically
are evaluated using the Glasgow Coma Scale and other
physical and neurological assessments. Once the patient
has been stabilized and all acute injuries have been
cared for, Dr. James Hill, an assistant professor of
clinical psychiatry at New Jersey Medical School and
director of neuropsychology for University Hospital,
is often called in to administer neuropsychological
tests that gauge a patient's cognitive abilities and
memory.
The
Big Picture
Imaging
is an important part of the diagnostic workup. "A
CT scan will reveal whether there's an actual injury
such as a blood clot or contusion within the brain that
requires operative intervention. It can also reveal
if there is increased intracranial pressure within the
skull that may require treatment with medications such
as mannitol," says Dr. Maniker.
"Sometimes
the CT may show nothing unusual, but the patient is
still in bad condition neurologically. We may then use
MRI to look for evidence of diffuse axonal injury (DAI).
This is a situation where the axons, the long fibers
of the neurons that rapidly transmit nerve impulses,
are sheared or broken. DAI is a severe condition that
carries a very poor prognosis, and, unfortunately, there
are not many treatment options for the patient."
Says Dr. Maniker. The rapid acceleration-deceleration
that occurs during automobile accidents, high-speed
sports collisions, or when a baby is shaken can lead
to this severe type of brain injury.
Brain
injury patients with significant impairment are usually
discharged to a rehabilitation center once they are
medically stable. Most MTBI patients will not have to
be hospitalized and can return to their regular routines.
Yet, some will experience symptoms of post-traumatic
brain injury syndrome for as long as one year after
the trauma. Older patients who have the syndrome, especially
those with other neurological disorders or medical problems,
might progress more slowly. "The syndrome includes
personality changes, poor concentration, headache, and
short-term memory problems," says Dr. Maniker.
"The signs can be subtle, but generally, the syndrome
resolves over time."
But just because post-traumatic brain injury syndrome
eventually eases up, that doesn't mean it should be
ignored. "There are significant unmet needs among
MTBI patients," says Dr. Brian Greenwald, assistant
professor of physical medicine and rehabilitation at
New Jersey Medical School and director of trauma rehabilitation
and the Acquired Brain Injury Clinic at University Hospital.
"We can help these patients, yet many of them believe
they have to suffer with the headaches or sleep problems.
A brain injury might be mild, but that doesn't mean
it is trivial."
MTBI
patients who experience troubling physical, cognitive,
or behavioral symptoms are encouraged to seek a post-injury
evaluation, including a medical history and physical
exam. "The patient is given a comprehensive neurological
exam, along with an imaging study to look for such things
as complications of a brain injury or to evaluate its
resolving," says Dr. Greenwald, one of the relatively
few physical medicine and rehabilitation physicians
who specialize in brain injury.
Neuropsychological
tests are given to determine whether there are cognitive
deficits, as well; Dr. Greenwald frequently turns to
Dr. Hill to assess brain injury patients.
When
appropriate, medication can help ease some of the symptoms
of post-traumatic brain injury syndrome. "Certain
patients with headache get relief from something as
basic as Tylenol, while others benefit from medicines
typically used to treat migraines," says Dr. Greenwald.
"For people with hypoarousal or attention problems,
a stimulant such as Ritalin might be helpful."
MTBI
patients can also be taught ways to work around their
deficiencies. "A patient with memory loss could
be encouraged to make lists or use electronic data recording
devices," says Dr. Hill. "There are many strategies
that can help patients function well."
Another
important tool, Dr. Hill notes, is the support of family
and friends. "Sometimes the most major loss an
MTBI patient experiences is that of self image,"
he says. "The patient might look physically OK
and does a reasonable job making it through the day.
When cognitive problems or personality changes do occur,
friends and family might wrongfully assume that the
patient is 'faking.'"
At
University Hospital, there's a comprehensive continuum
of care for MTBI patients that encompasses the neurosciences,
psychology, and physical medicine and rehabilitation
specialties. "An MTBI can have significant effects
on a person's relationships and ability to work or study,"
says Dr. Greenwald. "It's important that these
patients don't slip through the cracks or needlessly
suffer with problems that can be treated."
An
Ounce of Prevention
Following
some basic safety rules can help eliminate the chance
of brain injury or reduce its severity. With so many
traumatic brain injuries resulting from motor vehicle
accidents, it makes sense to wear a seat belt or buckle
a youngster into a child safety seat. Adults and children
should wear properly fitting, protective headgear when
skiing, biking, horseback riding, or skateboarding,
or playing sports such as baseball and football. In
the home, handrails on stairways, safety gates, removing
clutter from the floor, and non-slip mats in the bathtub
or shower can help prevent falls, another cause of head
injury.
For
a consultation on Brain Injuries of all types, you may
contact Dr. Allen Maniker at (973) 972-2908 or Dr. Brian
Greenwald at (973) 972-7163.
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