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Category Archives: Brain Injury Treatment

Traumatic Brain Injury & Neurological Disorder Treatment …

Posted: December 16, 2017 at 7:43 pm

All brain injuries are serious. Some are life-threatening. But in many cases treatmentand healingis indeed possible. In fact, a high percentage of brain injury patients go on to lead productive and fulfilling lives. Long after rehabilitation has been completed, people with a brain injury need to sustain the gains made in rehabilitation to remain independent. Our goal is to make that outcome a reality.

The Neurologic Rehabilitation Institute (NRI) is an internationally recognized center for the treatment and rehabilitation of individuals over the age of 18 dealing with traumatic brain injuries and other neurological disorders.

Located on the park-like campus of Brookhaven Hospital in Tulsa, Oklahoma, NRI goes beyond traditional rehabilitation care to provide victims of traumatic brain injury with one of the most comprehensive and advanced treatment programs in America, offering complex care rehabilitation, intensive neurobehavioral rehabilitation and TBI dual diagnosis treatment.

This highly individualized treatment program, created by our interdisciplinary team of neurological specialists, is tailored to each patients unique set of needsbut the goal is always the sameto give individuals who have experienced a severe brain injury the highest level of independence possible.

NRI offers a wide range of treatment options and services including:

In addition, our Complex Care Rehabilitation Services include:

We are proud to announce our accreditation by the Commission on Accreditation of Rehabilitation Facilities, CARF International. CARF is an independent, nonprofit accreditor of health and human services.

The mission of CARF is to promote the quality, value, and optimal outcomes of services through a consultative accreditation process and continuous improvement services that center on enhancing the lives of persons served.

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Traumatic Brain Injury & Neurological Disorder Treatment …

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Traumatic brain injury – Wikipedia

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Traumatic brain injury (TBI), also known as intracranial injury, occurs when an external force injures the brain. TBI can be classified based on severity, mechanism (closed or penetrating head injury), or other features (e.g., occurring in a specific location or over a widespread area). Head injury is a broader category that may involve damage to other structures such as the scalp and skull. TBI can result in physical, cognitive, social, emotional, and behavioral symptoms, and outcome can range from complete recovery to permanent disability or death.

Causes include falls, vehicle collisions, and violence. Brain trauma occurs as a consequence of a sudden acceleration or deceleration within the cranium or by a complex combination of both movement and sudden impact. In addition to the damage caused at the moment of injury, a variety of events in the minutes to days following the injury may result in secondary injury. These processes include alterations in cerebral blood flow and the pressure within the skull. Some of the imaging techniques used for diagnosis include computed tomography and magnetic resonance imaging (MRIs).

Prevention measures include use of protective technology in vehicles, such as seat belts and sports or motorcycle helmets, as well as efforts to reduce the number of collisions, such as safety education programs and enforcement of traffic laws. Depending on the injury, treatment required may be minimal or may include interventions such as medications, emergency surgery or surgery years later. Physical therapy, speech therapy, recreation therapy, occupational therapy and vision therapy may be employed for rehabilitation. Counseling, supported employment, and community support services may also be useful.

TBI is a major cause of death and disability worldwide, especially in children and young adults. Males sustain traumatic brain injuries more frequently than do females. The 20thcentury saw developments in diagnosis and treatment that decreased death rates and improved outcome.

Traumatic brain injury is defined as damage to the brain resulting from external mechanical force, such as rapid acceleration or deceleration, impact, blast waves, or penetration by a projectile.[2] Brain function is temporarily or permanently impaired and structural damage may or may not be detectable with current technology.[3]

TBI is one of two subsets of acquired brain injury (brain damage that occur after birth); the other subset is non-traumatic brain injury, which does not involve external mechanical force (examples include stroke and infection).[4][5] All traumatic brain injuries are head injuries, but the latter term may also refer to injury to other parts of the head.[6][7][8] However, the terms head injury and brain injury are often used interchangeably.[9] Similarly, brain injuries fall under the classification of central nervous system injuries[10] and neurotrauma.[11] In neuropsychology research literature, in general the term “traumatic brain injury” is used to refer to non-penetrating traumatic brain injuries.

TBI is usually classified based on severity, anatomical features of the injury, and the mechanism (the causative forces).[12] Mechanism-related classification divides TBI into closed and penetrating head injury.[2] A closed (also called nonpenetrating, or blunt)[6] injury occurs when the brain is not exposed.[7] A penetrating, or open, head injury occurs when an object pierces the skull and breaches the dura mater, the outermost membrane surrounding the brain.[7]

Brain injuries can be classified into mild, moderate, and severe categories.[12] The Glasgow Coma Scale (GCS), the most commonly used system for classifying TBI severity, grades a person’s level of consciousness on a scale of 315 based on verbal, motor, and eye-opening reactions to stimuli.[14] In general, it is agreed that a TBI with a GCS of 13 or above is mild, 912 is moderate, and 8 or below is severe.[3][8][15] Similar systems exist for young children.[8] However, the GCS grading system has limited ability to predict outcomes. Because of this, other classification systems such as the one shown in the table are also used to help determine severity. A current model developed by the Department of Defense and Department of Veterans Affairs uses all three criteria of GCS after resuscitation, duration of post-traumatic amnesia (PTA), and loss of consciousness (LOC).[13] It also has been proposed to use changes that are visible on neuroimaging, such as swelling, focal lesions, or diffuse injury as method of classification.[2]Grading scales also exist to classify the severity of mild TBI, commonly called concussion; these use duration of LOC, PTA, and other concussion symptoms.[16]

Systems also exist to classify TBI by its pathological features.[12] Lesions can be extra-axial, (occurring within the skull but outside of the brain) or intra-axial (occurring within the brain tissue).[17] Damage from TBI can be focal or diffuse, confined to specific areas or distributed in a more general manner, respectively.[18] However, it is common for both types of injury to exist in a given case.[18]

Diffuse injury manifests with little apparent damage in neuroimaging studies, but lesions can be seen with microscopy techniques post-mortem,[18][19] and in the early 2000s, researchers discovered that diffusion tensor imaging (DTI), a way of processing MRI images that shows white matter tracts, was an effective tool for displaying the extent of diffuse axonal injury.[20][21] Types of injuries considered diffuse include edema (swelling) and diffuse axonal injury, which is widespread damage to axons including white matter tracts and projections to the cortex.[22][23] Types of injuries considered diffuse include concussion and diffuse axonal injury, widespread damage to axons in areas including white matter and the cerebral hemispheres.[22]

Focal injuries often produce symptoms related to the functions of the damaged area.[10] Research shows that the most common areas to have focal lesions in non-penetrating traumatic brain injury are the orbitofrontal cortex (the lower surface of the frontal lobes) and the anterior temporal lobes, areas that are involved in social behavior, emotion regulation, olfaction, and decision-making, hence the common social/emotional and judgment deficits following moderate-severe TBI.[24][25][26][27] Symptoms such as hemiparesis or aphasia can also occur when less commonly affected areas such as motor or language areas are, respectively, damaged.[28][29]

One type of focal injury, cerebral laceration, occurs when the tissue is cut or torn.[30] Such tearing is common in orbitofrontal cortex in particular, because of bony protrusions on the interior skull ridge above the eyes.[24] In a similar injury, cerebral contusion (bruising of brain tissue), blood is mixed among tissue.[15] In contrast, intracranial hemorrhage involves bleeding that is not mixed with tissue.[30]

Hematomas, also focal lesions, are collections of blood in or around the brain that can result from hemorrhage.[3]Intracerebral hemorrhage, with bleeding in the brain tissue itself, is an intra-axial lesion. Extra-axial lesions include epidural hematoma, subdural hematoma, subarachnoid hemorrhage, and intraventricular hemorrhage.[31] Epidural hematoma involves bleeding into the area between the skull and the dura mater, the outermost of the three membranes surrounding the brain.[3] In subdural hematoma, bleeding occurs between the dura and the arachnoid mater.[15] Subarachnoid hemorrhage involves bleeding into the space between the arachnoid membrane and the pia mater.[15] Intraventricular hemorrhage occurs when there is bleeding in the ventricles.[31]

Symptoms are dependent on the type of TBI (diffuse or focal) and the part of the brain that is affected.[33] Unconsciousness tends to last longer for people with injuries on the left side of the brain than for those with injuries on the right.[7] Symptoms are also dependent on the injury’s severity. With mild TBI, the patient may remain conscious or may lose consciousness for a few seconds or minutes.[34] Other symptoms of mild TBI include headache, vomiting, nausea, lack of motor coordination, dizziness, difficulty balancing,[35] lightheadedness, blurred vision or tired eyes, ringing in the ears, bad taste in the mouth, fatigue or lethargy, and changes in sleep patterns.[34] Cognitive and emotional symptoms include behavioral or mood changes, confusion, and trouble with memory, concentration, attention, or thinking.[34] Mild TBI symptoms may also be present in moderate and severe injuries.[34]

A person with a moderate or severe TBI may have a headache that does not go away, repeated vomiting or nausea, convulsions, an inability to awaken, dilation of one or both pupils, slurred speech, aphasia (word-finding difficulties), dysarthria (muscle weakness that causes disordered speech), weakness or numbness in the limbs, loss of coordination, confusion, restlessness, or agitation.[34] Common long-term symptoms of moderate to severe TBI are changes in appropriate social behavior, deficits in social judgment, and cognitive changes, especially problems with sustained attention, processing speed, and executive functioning.[27][36][37][38][39]Alexithymia, a deficiency in identifying, understanding, processing, and describing emotions occurs in 60.9% of individuals with TBI.[40] Cognitive and social deficits have long-term consequences for the daily lives of people with moderate to severe TBI, but can be improved with appropriate rehabilitation.[39][41][42][43]

When the pressure within the skull (intracranial pressure, abbreviated ICP) rises too high, it can be deadly.[44] Signs of increased ICP include decreasing level of consciousness, paralysis or weakness on one side of the body, and a blown pupil, one that fails to constrict in response to light or is slow to do so.[44]Cushing’s triad, a slow heart rate with high blood pressure and respiratory depression is a classic manifestation of significantly raised ICP.[3]Anisocoria, unequal pupil size, is another sign of serious TBI.[32]Abnormal posturing, a characteristic positioning of the limbs caused by severe diffuse injury or high ICP, is an ominous sign.[3]

Small children with moderate to severe TBI may have some of these symptoms but have difficulty communicating them.[45] Other signs seen in young children include persistent crying, inability to be consoled, listlessness, refusal to nurse or eat,[45] and irritability.[3]

The most common causes of TBI in the U.S. include violence, transportation accidents, construction, and sports.[35][46] Motor bikes are major causes, increasing in significance in developing countries as other causes reduce.[47] The estimates that between 1.6 and 3.8million traumatic brain injuries each year are a result of sports and recreation activities in the US.[48] In children aged two to four, falls are the most common cause of TBI, while in older children traffic accidents compete with falls for this position.[49] TBI is the third most common injury to result from child abuse.[50] Abuse causes 19% of cases of pediatric brain trauma, and the death rate is higher among these cases.[51] Although men are twice as likely to have a TBI. Domestic violence is another cause of TBI,[52] as are work-related and industrial accidents.[53] Firearms[7] and blast injuries from explosions[54] are other causes of TBI, which is the leading cause of death and disability in war zones.[55] According to Representative Bill Pascrell (Democrat, NJ), TBI is “the signature injury of the wars in Iraq and Afghanistan.”[56] There is a promising technology called activation database-guided EEG biofeedback, which has been documented to return a TBI’s auditory memory ability to above the control group’s performance[57][58]

The type, direction, intensity, and duration of forces all contribute to the characteristics and severity TBI.[2] Forces that may contribute to TBI include angular, rotational, shear, and translational forces.[30]

Even in the absence of an impact, significant acceleration or deceleration of the head can cause TBI; however in most cases a combination of impact and acceleration is probably to blame.[30] Forces involving the head striking or being struck by something, termed contact or impact loading, are the cause of most focal injuries, and movement of the brain within the skull, termed noncontact or inertial loading, usually causes diffuse injuries.[12] The violent shaking of an infant that causes shaken baby syndrome commonly manifests as diffuse injury.[60] In impact loading, the force sends shock waves through the skull and brain, resulting in tissue damage.[30] Shock waves caused by penetrating injuries can also destroy tissue along the path of a projectile, compounding the damage caused by the missile itself.[15]

Damage may occur directly under the site of impact, or it may occur on the side opposite the impact (coup and contrecoup injury, respectively).[59] When a moving object impacts the stationary head, coup injuries are typical,[61] while contrecoup injuries are usually produced when the moving head strikes a stationary object.[62]

A large percentage of the people killed by brain trauma do not die right away but rather days to weeks after the event;[63] rather than improving after being hospitalized, some 40% of TBI patients deteriorate.[64]Primary brain injury (the damage that occurs at the moment of trauma when tissues and blood vessels are stretched, compressed, and torn) is not adequate to explain this deterioration; rather, it is caused by secondary injury, a complex set of cellular processes and biochemical cascades that occur in the minutes to days following the trauma.[65] These secondary processes can dramatically worsen the damage caused by primary injury[55] and account for the greatest number of TBI deaths occurring in hospitals.[32]

Secondary injury events include damage to the bloodbrain barrier, release of factors that cause inflammation, free radical overload, excessive release of the neurotransmitter glutamate (excitotoxicity), influx of calcium and sodium ions into neurons, and dysfunction of mitochondria.[55] Injured axons in the brain’s white matter may separate from their cell bodies as a result of secondary injury,[55] potentially killing those neurons. Other factors in secondary injury are changes in the blood flow to the brain; ischemia (insufficient blood flow); cerebral hypoxia (insufficient oxygen in the brain); cerebral edema (swelling of the brain); and raised intracranial pressure (the pressure within the skull).[66] Intracranial pressure may rise due to swelling or a mass effect from a lesion, such as a hemorrhage.[44] As a result, cerebral perfusion pressure (the pressure of blood flow in the brain) is reduced; ischemia results.[32][67] When the pressure within the skull rises too high, it can cause brain death or herniation, in which parts of the brain are squeezed by structures in the skull.[44] A particularly weak part of the skull that is vulnerable to damage causing extradural haematoma is the pterion, deep in which lies the middle meningeal artery, which is easily damaged in fractures of the pterion. Since the pterion is so weak, this type of injury can easily occur and can be secondary due to trauma to other parts of the skull where the impact forces spreads to the pterion.

Diagnosis is suspected based on lesion circumstances and clinical evidence, most prominently a neurological examination, for example checking whether the pupils constrict normally in response to light and assigning a Glasgow Coma Score.[15] Neuroimaging helps in determining the diagnosis and prognosis and in deciding what treatments to give.[68]

The preferred radiologic test in the emergency setting is computed tomography (CT): it is quick, accurate, and widely available.[69] Follow-up CT scans may be performed later to determine whether the injury has progressed.[2]

Magnetic resonance imaging (MRI) can show more detail than CT, and can add information about expected outcome in the long term.[15] It is more useful than CT for detecting injury characteristics such as diffuse axonal injury in the longer term.[2] However, MRI is not used in the emergency setting for reasons including its relative inefficacy in detecting bleeds and fractures, its lengthy acquisition of images, the inaccessibility of the patient in the machine, and its incompatibility with metal items used in emergency care.[15] A variant of MRI since 2012 is High definition fiber tracking (HDFT).[70]

Other techniques may be used to confirm a particular diagnosis. X-rays are still used for head trauma, but evidence suggests they are not useful; head injuries are either so mild that they do not need imaging or severe enough to merit the more accurate CT.[69]Angiography may be used to detect blood vessel pathology when risk factors such as penetrating head trauma are involved.[2]Functional imaging can measure cerebral blood flow or metabolism, inferring neuronal activity in specific regions and potentially helping to predict outcome.[71]Electroencephalography and transcranial doppler may also be used. The most sensitive physical measure to date is the quantitative EEG, which has documented an 80% to 100% ability in discriminating between normal and traumatic brain-injured subjects.[72][73]

Neuropsychological assessment can be performed to evaluate the long-term cognitive sequelae and to aid in the planning of the rehabilitation.[68] Instruments range from short measures of general mental functioning to complete batteries formed of different domain-specific tests.

Since a major cause of TBI are vehicle accidents, their prevention or the amelioration of their consequences can both reduce the incidence and gravity of TBI. In accidents, damage can be reduced by use of seat belts, child safety seats[48] and motorcycle helmets,[74] and presence of roll bars and airbags.[30] Education programs exist to lower the number of crashes.[68] In addition, changes to public policy and safety laws can be made; these include speed limits, seat belt and helmet laws, and road engineering practices.[55]

Changes to common practices in sports have also been discussed. An increase in use of helmets could reduce the incidence of TBI.[55] Due to the possibility that repeatedly “heading” a ball practicing soccer could cause cumulative brain injury, the idea of introducing protective headgear for players has been proposed.[75] Improved equipment design can enhance safety; softer baseballs reduce head injury risk.[76] Rules against dangerous types of contact, such as “spear tackling” in American football, when one player tackles another head first, may also reduce head injury rates.[76]

Falls can be avoided by installing grab bars in bathrooms and handrails on stairways; removing tripping hazards such as throw rugs; or installing window guards and safety gates at the top and bottom of stairs around young children.[48] Playgrounds with shock-absorbing surfaces such as mulch or sand also prevent head injuries.[48] Child abuse prevention is another tactic; programs exist to prevent shaken baby syndrome by educating about the dangers of shaking children.[51] Gun safety, including keeping guns unloaded and locked, is another preventative measure.[77] Studies on the effect of laws that aim to control access to guns in the United States have been insufficient to determine their effectiveness preventing number of deaths or injuries.[78]

Recent clinical and laboratory research by neurosurgeon Julian Bailes, M.D., and his colleagues from West Virginia University, has resulted in papers showing that dietary supplementation with omega-3 DHA offers protection against the biochemical brain damage that occurs after a traumatic injury.[79] Rats given DHA prior to induced brain injuries suffered smaller increases in two key markers for brain damage (APP and caspase-3), as compared with rats given no DHA.[80] The potential for DHA to provide prophylactic benefit to the brain against traumatic injury appears promising and requires further investigation. The essential concept of daily dietary supplementation with DHA, so that those at significant risk may be preloaded to provide protection against the acute effects of TBI, has tremendous public health implications.[81]

Furthermore, acetylcysteine has been confirmed, in a recent double-blind placebo-controlled trial conducted by the US military, to reduce the effects of blast induced mild traumatic brain and neurological injury in soldiers.[82] Multiple animal studies have also demonstrated its efficacy in reducing the damage associated with moderate traumatic brain or spinal injury, and also ischemia-induced brain injury. In particular, it has been demonstrated through multiple studies to significantly reduce neuronal losses and to improve cognitive and neurological outcomes associated with these traumatic events. Acetylcysteine has been safely used to treat paracetamol overdose for over forty years and is extensively used in emergency medicine.

It is important to begin emergency treatment within the so-called “golden hour” following the injury.[83] People with moderate to severe injuries are likely to receive treatment in an intensive care unit followed by a neurosurgical ward.[84] Treatment depends on the recovery stage of the patient. In the acute stage the primary aim of the medical personnel is to stabilize the patient and focus on preventing further injury because little can be done to reverse the initial damage caused by trauma.[84] Rehabilitation is the main treatment for the subacute and chronic stages of recovery.[84] International clinical guidelines have been proposed with the aim of guiding decisions in TBI treatment, as defined by an authoritative examination of current evidence.[2]

Certain facilities are equipped to handle TBI better than others; initial measures include transporting patients to an appropriate treatment center.[44][85] Both during transport and in hospital the primary concerns are ensuring proper oxygen supply, maintaining adequate blood flow to the brain, and controlling raised intracranial pressure (ICP),[3] since high ICP deprives the brain of badly needed blood flow[86] and can cause deadly brain herniation. Other methods to prevent damage include management of other injuries and prevention of seizures.[15][68] Some data supports the use of hyperbaric oxygen therapy to improve outcomes.[87]

Neuroimaging is helpful but not flawless in detecting raised ICP.[88] A more accurate way to measure ICP is to place a catheter into a ventricle of the brain,[32] which has the added benefit of allowing cerebrospinal fluid to drain, releasing pressure in the skull.[32] Treatment of raised ICP may be as simple as tilting the patient’s bed and straightening the head to promote blood flow through the veins of the neck. Sedatives, analgesics and paralytic agents are often used.[44]Hypertonic saline can improve ICP by reducing the amount of cerebral water (swelling), though it is used with caution to avoid electrolyte imbalances or heart failure.[2]Mannitol, an osmotic diuretic,[2] appears to be equally effective at reducing ICP.[89][90][91] Some concerns; however, have been raised regarding some of the studies performed.[92]Diuretics, drugs that increase urine output to reduce excessive fluid in the system, may be used to treat high intracranial pressures, but may cause hypovolemia (insufficient blood volume).[32]Hyperventilation (larger and/or faster breaths) reduces carbon dioxide levels and causes blood vessels to constrict; this decreases blood flow to the brain and reduces ICP, but it potentially causes ischemia[3][32][93] and is, therefore, used only in the short term.[3] Administration of corticosteroids is associated with an increased risk of death, and so it is recommended that they not be given routinely.[94]

Endotracheal intubation and mechanical ventilation may be used to ensure proper oxygen supply and provide a secure airway.[68]Hypotension (low blood pressure), which has a devastating outcome in TBI, can be prevented by giving intravenous fluids to maintain a normal blood pressure. Failing to maintain blood pressure can result in inadequate blood flow to the brain.[15] Blood pressure may be kept at an artificially high level under controlled conditions by infusion of norepinephrine or similar drugs; this helps maintain cerebral perfusion.[95] Body temperature is carefully regulated because increased temperature raises the brain’s metabolic needs, potentially depriving it of nutrients.[96] Seizures are common. While they can be treated with benzodiazepines, these drugs are used carefully because they can depress breathing and lower blood pressure.[44] TBI patients are more susceptible to side effects and may react adversely or be inordinately sensitive to some pharmacological agents.[84] During treatment monitoring continues for signs of deterioration such as a decreasing level of consciousness.[2][3]

Traumatic brain injury may cause a range of serious coincidental complications that include cardiac arrhythmias[97] and neurogenic pulmonary edema.[98] These conditions must be adequately treated and stabilised as part of the core care for these patients.

Surgery can be performed on mass lesions or to eliminate objects that have penetrated the brain. Mass lesions such as contusions or hematomas causing a significant mass effect (shift of intracranial structures) are considered emergencies and are removed surgically.[15] For intracranial hematomas, the collected blood may be removed using suction or forceps or it may be floated off with water.[15] Surgeons look for hemorrhaging blood vessels and seek to control bleeding.[15] In penetrating brain injury, damaged tissue is surgically debrided, and craniotomy may be needed.[15] Craniotomy, in which part of the skull is removed, may be needed to remove pieces of fractured skull or objects embedded in the brain.[99]Decompressive craniectomy (DC) is performed routinely in the very short period following TBI during operations to treat hematomas; part of the skull is removed temporarily (primary DC).[100] DC performed hours or days after TBI in order to control high intracranial pressures (secondary DC) has not been shown to improve outcome in some trials and may be associated with severe side-effects.[2][100]

Once medically stable, people may be transferred to a subacute rehabilitation unit of the medical center or to an independent rehabilitation hospital.[84] Rehabilitation aims to improve independent function at home and in society and to help adapt to disabilities [84] and has demonstrated its general effectiveness, when conducted by a team of health professionals who specialise in head trauma.[101] As for any person with neurologic deficits, a multidisciplinary approach is key to optimising outcome. Physiatrists or neurologists are likely to be the key medical staff involved, but depending on the person, doctors of other medical specialties may also be helpful. Allied health professions such as physiotherapy, speech and language therapy, cognitive rehabilitation therapy, and occupational therapy will be essential to assess function and design the rehabilitation activities for each person. Treatment of neuropsychiatric symptoms such as emotional distress and clinical depression may involve mental health professionals such as therapists, psychologists, and psychiatrists, while neuropsychologists can help to evaluate and manage cognitive deficits.[84]

After discharge from the inpatient rehabilitation treatment unit, care may be given on an outpatient basis. Community-based rehabilitation will be required for a high proportion of people, including vocational rehabilitation; this supportive employment matches job demands to the worker’s abilities.[102] People with TBI who cannot live independently or with family may require care in supported living facilities such as group homes.[102]Respite care, including day centers and leisure facilities for the disabled, offers time off for caregivers, and activities for people with TBI.[102]

Pharmacological treatment can help to manage psychiatric or behavioral problems.[103] Medication is also used to control post-traumatic epilepsy; however the preventive use of anti-epileptics is not recommended.[104] In those cases where the person is bedridden due to a reduction of consciousness, has to remain in a wheelchair because of mobility problems, or has any other problem heavily impacting self-caring capacities, caregiving and nursing are critical. The most effective research documented intervention approach is the activation database guided EEG biofeedback approach, which has shown significant improvements in memory abilities of the TBI subject that are far superior than traditional approaches (strategies, computers, medication intervention). Gains of 2.61 standard deviations have been documented. The TBI’s auditory memory ability was superior to the control group after the treatment.[57]

Prognosis worsens with the severity of injury.[105] Most TBIs are mild and do not cause permanent or long-term disability; however, all severity levels of TBI have the potential to cause significant, long-lasting disability.[106] Permanent disability is thought to occur in 10% of mild injuries, 66% of moderate injuries, and 100% of severe injuries.[107] Most mild TBI is completely resolved within threeweeks, and almost all people with mild TBI are able to live independently and return to the jobs they had before the injury, although a portion have mild cognitive and social impairments.[77] Over 90% of people with moderate TBI are able to live independently, although a portion require assistance in areas such as physical abilities, employment, and financial managing.[77] Most people with severe closed head injury either die or recover enough to live independently; middle ground is less common.[2] Coma, as it is closely related to severity, is a strong predictor of poor outcome.[3]

Prognosis differs depending on the severity and location of the lesion, and access to immediate, specialised acute management. Subarachnoid hemorrhage approximately doubles mortality.[108] Subdural hematoma is associated with worse outcome and increased mortality, while people with epidural hematoma are expected to have a good outcome if they receive surgery quickly.[68] Diffuse axonal injury may be associated with coma when severe, and poor outcome.[2] Following the acute stage, prognosis is strongly influenced by the patient’s involvement in activity that promote recovery, which for most patients requires access to a specialised, intensive rehabilitation service. The Functional Independence Measure is a way to track progress and degree of independence throughout rehabilitation.[109]

Medical complications are associated with a bad prognosis. Examples are hypotension (low blood pressure), hypoxia (low blood oxygen saturation), lower cerebral perfusion pressures and longer times spent with high intracranial pressures.[2][68] Patient characteristics also influence prognosis. Factors thought to worsen it include abuse of substances such as illicit drugs and alcohol and age over sixty or under two years (in children, younger age at time of injury may be associated with a slower recovery of some abilities).[68] Other influences that may affect recovery include pre-injury intellectual ability, coping strategies, personality traits, family environment, social support systems and financial circumstances.[110]

Life satisfaction has been known to decrease for individuals with TBI immediately following the trauma, but evidence has shown that life roles, age, and depressive symptoms influence the trajectory of life satisfaction as time passes.[111]

Improvement of neurological function usually occurs for two or more years after the trauma. For many years it was believed that recovery was fastest during the first six months, but there is no evidence to support this. It may be related to services commonly being withdrawn after this period, rather than any physiological limitation to further progress.[2] Children recover better in the immediate time frame and improve for longer periods.[3]

Complications are distinct medical problems that may arise as a result of the TBI. The results of traumatic brain injury vary widely in type and duration; they include physical, cognitive, emotional, and behavioral complications. TBI can cause prolonged or permanent effects on consciousness, such as coma, brain death, persistent vegetative state (in which patients are unable to achieve a state of alertness to interact with their surroundings),[113] and minimally conscious state (in which patients show minimal signs of being aware of self or environment).[114][115] Lying still for long periods can cause complications including pressure sores, pneumonia or other infections, progressive multiple organ failure,[84] and deep venous thrombosis, which can cause pulmonary embolism.[15] Infections that can follow skull fractures and penetrating injuries include meningitis and abscesses.[84] Complications involving the blood vessels include vasospasm, in which vessels constrict and restrict blood flow, the formation of aneurysms, in which the side of a vessel weakens and balloons out, and stroke.[84]

Movement disorders that may develop after TBI include tremor, ataxia (uncoordinated muscle movements), myoclonus (shock-like contractions of muscles), and loss of movement range and control (in particular with a loss of movement repertoire).[84] The risk of post-traumatic seizures increases with severity of trauma (image at right) and is particularly elevated with certain types of brain trauma such as cerebral contusions or hematomas.[107] People with early seizures, those occurring within a week of injury, have an increased risk of post-traumatic epilepsy (recurrent seizures occurring more than a week after the initial trauma).[116] People may lose or experience altered vision, hearing, or smell.[3]

Hormonal disturbances may occur secondary to hypopituitarism, occurring immediately or years after injury in 10 to 15% of TBI patients. Development of diabetes insipidus or an electrolyte abnormality acutely after injury indicate need for endocrinologic work up. Signs and symptoms of hypopituitarism may develop and be screened for in adults with moderate TBI and in mild TBI with imaging abnormalities. Children with moderate to severe head injury may also develop hypopituitarism. Screening should take place 3 to 6 months, and 12 months after injury, but problems may occur more remotely.[117]

Cognitive deficits that can follow TBI include impaired attention; disrupted insight, judgement, and thought; reduced processing speed; distractibility; and deficits in executive functions such as abstract reasoning, planning, problem-solving, and multitasking.[118]Memory loss, the most common cognitive impairment among head-injured people, occurs in 2079% of people with closed head trauma, depending on severity.[119] People who have suffered TBI may also have difficulty with understanding or producing spoken or written language, or with more subtle aspects of communication such as body language.[84]Post-concussion syndrome, a set of lasting symptoms experienced after mild TBI, can include physical, cognitive, emotional and behavioral problems such as headaches, dizziness, difficulty concentrating, and depression.[3] Multiple TBIs may have a cumulative effect.[115] A young person who receives a second concussion before symptoms from another one have healed may be at risk for developing a very rare but deadly condition called second-impact syndrome, in which the brain swells catastrophically after even a mild blow, with debilitating or deadly results. About one in five career boxers is affected by chronic traumatic brain injury (CTBI), which causes cognitive, behavioral, and physical impairments.[120]Dementia pugilistica, the severe form of CTBI, affects primarily career boxers years after a boxing career. It commonly manifests as dementia, memory problems, and parkinsonism (tremors and lack of coordination).[121]

TBI may cause emotional, social, or behavioral problems and changes in personality.[122][123][124][125] These may include emotional instability, depression, anxiety, hypomania, mania, apathy, irritability, problems with social judgment, and impaired conversational skills.[122][125][126] TBI appears to predispose survivors to psychiatric disorders including obsessive compulsive disorder, substance abuse, dysthymia, clinical depression, bipolar disorder, and anxiety disorders.[127] In patients who have depression after TBI, suicidal ideation is not uncommon; the suicide rate among these persons is increased 2- to 3-fold.[128] Social and behavioral symptoms that can follow TBI include disinhibition, inability to control anger, impulsiveness, lack of initiative, inappropriate sexual activity, asociality and social withdrawal, and changes in personality.[122][124][125][129]

TBI also has a substantial impact on the functioning of family systems[130] Caregiving family members and TBI survivors often significantly alter their familial roles and responsibilities following injury, creating significant change and strain on a family system. Typical challenges identified by families recovering from TBI include: frustration and impatience with one another, loss of former lives and relationships, difficulty setting reasonable goals, inability to effectively solve problems as a family, increased level of stress and household tension, changes in emotional dynamics, and overwhelming desire to return to pre-injury status. In addition, families may exhibit less effective functioning in areas including coping, problem solving and communication. Psychoeducation and counseling models have been demonstrated to be effective in minimizing family disruption [131]

TBI is a leading cause of death and disability around the globe[133] and presents a major worldwide social, economic, and health problem.[2] It is the number one cause of coma,[134] it plays the leading role in disability due to trauma,[68] and is the leading cause of brain damage in children and young adults.[7] In Europe it is responsible for more years of disability than any other cause.[2] It also plays a significant role in half of trauma deaths.[15]

Findings on the frequency of each level of severity vary based on the definitions and methods used in studies. A World Health Organization study estimated that between 70 and 90% of head injuries that receive treatment are mild,[135] and a US study found that moderate and severe injuries each account for 10% of TBIs, with the rest mild.[64]

The incidence of TBI varies by age, gender, region and other factors.[136] Findings of incidence and prevalence in epidemiological studies vary based on such factors as which grades of severity are included, whether deaths are included, whether the study is restricted to hospitalized people, and the study’s location.[7] The annual incidence of mild TBI is difficult to determine but may be 100600 people per 100,000.[55]

In the US, the case fatality rate is estimated to be 21% by 30days after TBI.[85] A study on Iraq War soldiers found that severe TBI carries a mortality of 3050%.[55] Deaths have declined due to improved treatments and systems for managing trauma in societies wealthy enough to provide modern emergency and neurosurgical services.[96] The fraction of those who die after being hospitalized with TBI fell from almost half in the 1970s to about a quarter at the beginning of the 21stcentury.[68] This decline in mortality has led to a concomitant increase in the number of people living with disabilities that result from TBI.[137]

Biological, clinical, and demographic factors contribute to the likelihood that an injury will be fatal.[132] In addition, outcome depends heavily on the cause of head injury. In the US, patients with fall-related TBIs have an 89% survival rate, while only 9% of patients with firearm-related TBIs survive.[138] In the US, firearms are the most common cause of fatal TBI, followed by vehicle accidents and then falls.[132] Of deaths from firearms, 75% are considered to be suicides.[132]

The incidence of TBI is increasing globally, due largely to an increase in motor vehicle use in low- and middle-income countries.[2] In developing countries, automobile use has increased faster than safety infrastructure could be introduced.[55] In contrast, vehicle safety laws have decreased rates of TBI in high-income countries,[2] which have seen decreases in traffic-related TBI since the 1970s.[47] Each year in the United States, about two million people suffer a TBI,[13] approximately 675,000 injuries are seen in the emergency department,[139] and about 500,000 patients are hospitalized.[136] The yearly incidence of TBI is estimated at 180250 per 100,000 people in the US,[136] 281 per 100,000 in France, 361 per 100,000 in South Africa, 322 per 100,000 in Australia,[7] and 430 per 100,000 in England.[53] In the European Union the yearly aggregate incidence of TBI hospitalizations and fatalities is estimated at 235 per 100,000.[2]

TBI is present in 85% of traumatically injured children, either alone or with other injuries.[140] The greatest number of TBIs occur in people aged 1524.[5][30] Because TBI is more common in young people, its costs to society are high due to the loss of productive years to death and disability.[2] The age groups most at risk for TBI are children ages five to nine and adults over age 80,[105] and the highest rates of death and hospitalization due to TBI are in people over age 65.[106] The incidence of fall-related TBI in First-World countries is increasing as the population ages; thus the median age of people with head injuries has increased.[2]

Regardless of age, TBI rates are higher in males.[30] Men suffer twice as many TBIs as women do and have a fourfold risk of fatal head injury,[105] and males account for two thirds of childhood and adolescent head trauma.[141] However, when matched for severity of injury, women appear to fare more poorly than men.[86]

Socioeconomic status also appears to affect TBI rates; people with lower levels of education and employment and lower socioeconomic status are at greater risk.[7]

Head injury is present in ancient myths that may date back before recorded history.[142] Skulls found in battleground graves with holes drilled over fracture lines suggest that trepanation may have been used to treat TBI in ancient times.[143] Ancient Mesopotamians knew of head injury and some of its effects, including seizures, paralysis, and loss of sight, hearing or speech.[144] The Edwin Smith Papyrus, written around 16501550BC, describes various head injuries and symptoms and classifies them based on their presentation and tractability.[145]Ancient Greek physicians including Hippocrates understood the brain to be the center of thought, probably due to their experience with head trauma.[146]

Medieval and Renaissance surgeons continued the practice of trepanation for head injury.[146] In the Middle Ages, physicians further described head injury symptoms and the term concussion became more widespread.[147] Concussion symptoms were first described systematically in the 16thcentury by Berengario da Carpi.[146]

It was first suggested in the 18th century that intracranial pressure rather than skull damage was the cause of pathology after TBI. This hypothesis was confirmed around the end of the 19thcentury, and opening the skull to relieve pressure was then proposed as a treatment.[143]

In the 19thcentury it was noted that TBI is related to the development of psychosis.[148] At that time a debate arose around whether post-concussion syndrome was due to a disturbance of the brain tissue or psychological factors.[147] The debate continues today.

Perhaps the first reported case of personality change after brain injury is that of Phineas Gage, who survived an accident in which a large iron rod was driven through his head, destroying one or both of his frontal lobes; numerous cases of personality change after brain injury have been reported since.[24][26][27][36][37][41][149][150]

The 20th century saw the advancement of technologies that improved treatment and diagnosis such as the development of imaging tools including CT and MRI, and, in the 21st century, diffusion tensor imaging (DTI). The introduction of intracranial pressure monitoring in the 1950s has been credited with beginning the “modern era” of head injury.[96][151] Until the 20thcentury, the mortality rate of TBI was high and rehabilitation was uncommon; improvements in care made during World War I reduced the death rate and made rehabilitation possible.[142] Facilities dedicated to TBI rehabilitation were probably first established during World War I.[142] Explosives used in World War I caused many blast injuries; the large number of TBIs that resulted allowed researchers to learn about localization of brain functions.[152] Blast-related injuries are now common problems in returning veterans from Iraq & Afghanistan; research shows that the symptoms of such TBIs are largely the same as those of TBIs involving a physical blow to the head.[153]

In the 1970s, awareness of TBI as a public health problem grew,[154] and a great deal of progress has been made since then in brain trauma research,[96] such as the discovery of primary and secondary brain injury.[143] The 1990s saw the development and dissemination of standardized guidelines for treatment of TBI, with protocols for a range of issues such as drugs and management of intracranial pressure.[96] Research since the early 1990s has improved TBI survival;[143] that decade was known as the “Decade of the Brain” for advances made in brain research.[155]

No medication is approved to halt the progression of the initial injury to secondary injury.[55] The variety of pathological events presents opportunities to find treatments that interfere with the damage processes.[2]Neuroprotection methods to decrease secondary injury, have been the subject of interest follows TBI. However, trials to test agents that could halt these cellular mechanisms have met largely with failure.[2] For example, interest existed in cooling the injured brain; however, a 2014 Cochrane review did not find enough evidence to see if it was useful or not.[156] A 2016 review found that maintaining a normal or low normal temperature appeared useful in adults but not children.[157] High quality evidence to support targeted temperature management below normal however is poor.[158]

In addition, drugs such as NMDA receptor antagonists to halt neurochemical cascades such as excitotoxicity showed promise in animal trials but failed in clinical trials.[96] These failures could be due to factors including faults in the trials’ design or in the insufficiency of a single agent to prevent the array of injury processes involved in secondary injury.[96]

Other topics of research have included investigations into mannitol,[159]dexamethasone,[160]progesterone,[161]xenon,[162]barbiturates,[163]magnesium,[164]calcium channel blockers,[165]PPAR- agonists,[166][167]curcuminoids,[168]ethanol,[169]NMDA antagonists,[96]caffeine.[170]

In addition to traditional imaging modalities, there are several devices that help to monitor brain injury and facilitate research. Microdialysis allows ongoing sampling of extracellular fluid for analysis of metabolites that might indicate ischemia or brain metabolism, such as glucose, glycerol, and glutamate.[171][172] Intraparenchymal brain tissue oxygen monitoring systems (either Licox or Neurovent-PTO) are used routinely in neurointensive care in the US.[173] A non invasive model called CerOx is in development.[174]

Research is also planned to clarify factors correlated to outcome in TBI and to determine in which cases it is best to perform CT scans and surgical procedures.[175]

Hyperbaric oxygen therapy (HBO) has been evaluated as an add on treatment following TBI. The findings of a 2012 Cochrane systematic review does not justify the routine use of hyperbaric oxygen therapy to treat people recovering from a traumatic brain injury.[176] This review also reported that only a small number of randomized controlled trials had been conducted at the time of the review, many of which had methodological problems and poor reporting.[176] HBO for TBI is controversial with further evidence required to determine if it has a role.[177][176]

As of 2010, the use of predictive visual tracking measurement to identify mild traumatic brain injury was being studied. In visual tracking tests, a head-mounted display unit with eye-tracking capability shows an object moving in a regular pattern. People without brain injury are able to track the moving object with smooth pursuit eye movements and correct trajectory. The test requires both attention and working memory which are difficult functions for people with mild traumatic brain injury. The question being studied, is whether results for people with brain injury will show visual-tracking gaze errors relative to the moving target.[178]

The original version of this article contained text from the NINDS public domain pages on TBI

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Traumatic brain injury – Diagnosis and treatment – Mayo Clinic

Posted: at 7:43 pm

Diagnosis

Because traumatic brain injuries are usually emergencies and because consequences can worsen swiftly without treatment, doctors usually need to assess the situation rapidly.

This 15-point test helps a doctor or other emergency medical personnel assess the initial severity of a brain injury by checking a person’s ability to follow directions and move their eyes and limbs. The coherence of speech also provides important clues.

Abilities are scored numerically in the Glasgow Coma Scale. Higher scores mean less severe injuries.

If you observed someone being injured or arrived immediately after an injury, you may be able to provide medical personnel with information that’s useful in assessing the injured person’s condition.

Answers to the following questions may be beneficial in judging the severity of injury:

Tissue swelling from a traumatic brain injury can increase pressure inside the skull and cause additional damage to the brain. Doctors may insert a probe through the skull to monitor this pressure.

Mild traumatic brain injuries usually require no treatment other than rest and over-the-counter pain relievers to treat a headache. However, a person with a mild traumatic brain injury usually needs to be monitored closely at home for any persistent, worsening or new symptoms. He or she also may have follow-up doctor appointments.

The doctor will indicate when a return to work, school or recreational activities is appropriate. It’s best to avoid physical or thinking (cognitive) activities that make things worse until symptoms have resolved. Most people return to normal routines gradually.

Emergency care for moderate to severe traumatic brain injuries focuses on making sure the person has an adequate oxygen and blood supply, maintaining blood pressure, and preventing any further injury to the head or neck.

People with severe injuries may also have other injuries that need to be addressed. Additional treatments in the emergency room or intensive care unit of a hospital will focus on minimizing secondary damage due to inflammation, bleeding or reduced oxygen supply to the brain.

Medications to limit secondary damage to the brain immediately after an injury may include:

Anti-seizure drugs. People who’ve had a moderate to severe traumatic brain injury are at risk of having seizures during the first week after their injury.

An anti-seizure drug may be given during the first week to avoid any additional brain damage that might be caused by a seizure. Additional anti-seizure treatments are used only if seizures occur.

Emergency surgery may be needed to minimize additional damage to brain tissues. Surgery may be used to address the following problems:

Most people who have had a significant brain injury will require rehabilitation. They may need to relearn basic skills, such as walking or talking. The goal is to improve their abilities to perform daily activities.

Therapy usually begins in the hospital and continues at an inpatient rehabilitation unit, a residential treatment facility or through outpatient services. The type and duration of rehabilitation varies by individual, depending on the severity of the brain injury and what part of the brain was injured.

Rehabilitation specialists may include:

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this disease.

A number of strategies can help a person with traumatic brain injury cope with complications that affect everyday activities, communication and interpersonal relationships. Depending on the severity of injury, a family caregiver or friend may need to help implement the following approaches:

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Welcome to the Brain Injury Association of America

Posted: at 7:43 pm

Welcome to the Brain Injury Association of America (BIAA)

Brain injury is not an event or an outcome. It is the startof a misdiagnosed, misunderstood, under-funded neurological disease.People who sustain brain injuries must have timely access to experttrauma care, specialized rehabilitation, lifelong disease management,and individualized services and supports in order to live healthy,independent, and satisfying lives.

BIAA’s mission is to advanceawareness, research, treatment, and education and toimprove the quality of life for all people affected by brain injury. Weare dedicated to increasing access to quality health care and raisingawareness and understanding of brain injury. With a network of state affiliates, local chapters, and support groups, we are the voice ofbrain injury.

Please contact your elected officials and tell them that now is the time to permanently repeal the Medicare therapy cap. Congress needs to take action. What can you do? Call your electe.. Read More…

The Brain Injury Association of Ameirca (BIAA) is pleased to announce that Congressional Brain Injury Task Force, co-chaired by Reps. Bill Pascrell, Jr. (D-N.J.) and Thomas J. Rooney (R-Fla.), has.. Read More…

The latest edition of THE Challenge! is now available for free download. This issue, “Being Your Best Self,” features inspirational stories by brain injury survivors and informative articles by brain .. Read More…

GODSPEED: The Story of Page Jones, was released today on iTunes (https://itunes.apple.com/us/movie/godspeed-the-story-of-page-jones/id1292132095), Amazon (https://www.amazon.com/Godspeed-Story-Pag.. Read More…

Vienna, Va. The Brain Injury Association of America salutes the Trump Administration for directing the Department of Health and Human Services to declare the nations opioid crisis a pub.. Read More…

Please join us for an important briefing The Silent Epidemic in America Brain Injury and Domestic Violence Oct. 25 from 10-11 a.m. in the Congressional Meeting Room North in .. Read More…

Brain injury – including traumatic brain injury and stroke – is not an isolated event or an outcome. For many, the issues become chronic, requiring long-term management of multiple health conditio.. Read More…

The Graham-Cassidy-Heller-Johnson Proposal to Repeal the Patient Protection and Affordable Care Act is moving rapidly, and the Brain Injury Association of America is relying on you to take action .. Read More…

For the second year, the Brain Injury Association of America (BIAA) is proud to be collaborating with a New England student to educate the public on the impact of concussions. Brooke Mills, stud.. Read More…

The Law Offices of De Caro & Kaplen, LLP (https://brainlaw.com/) presented the inaugural De Caro & Kaplen, LLP Traumatic Brain Injury Scholarship on September 1, 2017 to Courtney Bruun-And.. Read More…

Award Winners Recognized for Contributions to Research and Clinical Care Vienna, Va. The Brain Injury Association of America (BIAA) has announced that Tessa Hart, Ph.D., has been named .. Read More…

The Brain Injury Association of America lost an important member of our family last month, Alice Demichelis. Alice was an extraordinary advocate for her son, Robert, and for all individuals who su.. Read More…

Click here for more News & Announcements…

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Rehabilitative Center Treatment – Traumatic Brain Injury

Posted: December 11, 2017 at 12:44 pm

The familiesof traumatic brain injury (TBI) victims often have many questions when their loved one is transferred to a rehabilitative care center.

What happens in rehabilitation?Similar tothe acute care facility, the TBI patient will be cared for by a team of professionals who specialize in the care of trauma victims.

Their goals are to:

Each day, the patient will participate in therapy. Initially, the patient may require staff assistance for even the most simple activities: brushing teeth, getting out of bed and eating. The patient also may require staff for safety because there is a risk of falling, eloping (trying to get out of the hospital to go home) or getting hurt. The patientmay be confused and forgetful.

The Rehabilitation Team

The Physiatrist is the team leader in the rehabilitation program. The physiatrist is a physician specializing in physical medicine and rehabilitation. Physiatrists treat a wide range of problems, including the changes after brain injury. The physiatristwill assess and prescribe the treatment and direct the team.

The Neuropsychologist is a key member of the rehabilitation team. The neuropsychologistwill assess the patients changesin thinking and behavior. Changes couldinclude:

Many patients areunaware of the changes in the brain and how those changesaffect their daily lives. A patient may not understand what has happened andmay bedistraughtby being away from home. Through education and counseling, the neuropsychologist can help assure the patient and the patientsfamily.

The Rehabilitation Nurse assists patients with brain injury and chronic illness in attaining maximum optimal health, and adapting to an altered lifestyle. The Rehabilitation Nurse provides care for the patient on the nursing unit. The focus of nursing care is on:

The Physical Therapistworks with people with orthopedic problems, such as low back pain, knee injuries or pain reduction. With traumatic brain injury, thePTsjob is to minimize or overcome paralyzing effects related to the brain injury.Physical therapistsare experts in the examination and treatment of musculoskeletal and neuromuscular problems that affectthe abilities to move and function indaily life.

Physical therapists help with transfers to and from the bed whena patientcannot walk alone. They train a person to begin to walk and move more normally. PTs will assess:

The Occupational Therapist assesses functions and potential complications related to the movement of upper extremities, daily living skills, cognition, vision and perception.OTS help determine, with the patient, the best ways to perform daily living skills including showering, dressing and personal hygiene.The OT willidentify equipment for eating, dressing and bathing.

The OT also will look at skills to prepare the patient for a return to the home. These skillsinclude:

The following sections explain:

Treatments for Traumatic Brain Injury HomepageInitial TreatmentRehabilitative Center TreatmentAcute TreatmentSurgical TreatmentSupportive Care ConcernsRecovery

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Traumatic brain injury Treatments and drugs – Mayo Clinic

Posted: at 12:44 pm

Diagnosis

Because traumatic brain injuries are usually emergencies and because consequences can worsen swiftly without treatment, doctors usually need to assess the situation rapidly.

This 15-point test helps a doctor or other emergency medical personnel assess the initial severity of a brain injury by checking a person’s ability to follow directions and move their eyes and limbs. The coherence of speech also provides important clues.

Abilities are scored numerically in the Glasgow Coma Scale. Higher scores mean less severe injuries.

If you observed someone being injured or arrived immediately after an injury, you may be able to provide medical personnel with information that’s useful in assessing the injured person’s condition.

Answers to the following questions may be beneficial in judging the severity of injury:

Tissue swelling from a traumatic brain injury can increase pressure inside the skull and cause additional damage to the brain. Doctors may insert a probe through the skull to monitor this pressure.

Mild traumatic brain injuries usually require no treatment other than rest and over-the-counter pain relievers to treat a headache. However, a person with a mild traumatic brain injury usually needs to be monitored closely at home for any persistent, worsening or new symptoms. He or she also may have follow-up doctor appointments.

The doctor will indicate when a return to work, school or recreational activities is appropriate. It’s best to avoid physical or thinking (cognitive) activities that make things worse until symptoms have resolved. Most people return to normal routines gradually.

Emergency care for moderate to severe traumatic brain injuries focuses on making sure the person has an adequate oxygen and blood supply, maintaining blood pressure, and preventing any further injury to the head or neck.

People with severe injuries may also have other injuries that need to be addressed. Additional treatments in the emergency room or intensive care unit of a hospital will focus on minimizing secondary damage due to inflammation, bleeding or reduced oxygen supply to the brain.

Medications to limit secondary damage to the brain immediately after an injury may include:

Anti-seizure drugs. People who’ve had a moderate to severe traumatic brain injury are at risk of having seizures during the first week after their injury.

An anti-seizure drug may be given during the first week to avoid any additional brain damage that might be caused by a seizure. Additional anti-seizure treatments are used only if seizures occur.

Emergency surgery may be needed to minimize additional damage to brain tissues. Surgery may be used to address the following problems:

Most people who have had a significant brain injury will require rehabilitation. They may need to relearn basic skills, such as walking or talking. The goal is to improve their abilities to perform daily activities.

Therapy usually begins in the hospital and continues at an inpatient rehabilitation unit, a residential treatment facility or through outpatient services. The type and duration of rehabilitation varies by individual, depending on the severity of the brain injury and what part of the brain was injured.

Rehabilitation specialists may include:

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this disease.

A number of strategies can help a person with traumatic brain injury cope with complications that affect everyday activities, communication and interpersonal relationships. Depending on the severity of injury, a family caregiver or friend may need to help implement the following approaches:

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Traumatic brain injury Treatments and drugs – Mayo Clinic

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About Brain Injury – BIAA

Posted: December 6, 2017 at 6:46 pm

ABOUT BRAIN INJURY

The Brain Injury Associationof America and its network of state affiliates striveto connect people with useful, accurate information and resources in their area.If you or a family member are struggling with the effects of a brain injury, or think you may have sustained a brain injury, there is help. Here are some useful first steps:

This page offers helpful definitions and terms you might hear used.Use this page to help you understand brain injury a little better. Use the resources on other pages as well.

DefinitionsTypes of brain injuryCausesOutcomesSeverity of brain injuryTips for recovery

Traumatic Brain Injury (TBI)TBI is defined as an alteration in brain function, or other evidence of brain pathology, caused by an external force.

Adopted by the Brain Injury Association Board of Directors in 2011. This definition is not intended as an exclusive statement of the population served by the Brain Injury Association of America.

Acquired Brain InjuryAn acquired brain injury is an injury to the brain, which is not hereditary, congenital, degenerative, or induced by birth trauma. An acquired brain injury is an injury to the brain that has occurred after birth.

There is sometimes confusion about what is considered an acquired brain injury.By definition, any traumatic brain injury (e.g. from a motor vehicle accident or assault)could be considered anacquired brain injury.In the field of brain injury, acquired brain injuries are typically considered any injury that is non traumatic.Examples of acquired brain injury include stroke, near drowning, hypoxic or anoxic brain injury, tumor, neurotoxins, electric shock or lightning strike.

Diffuse Axonal Injury (TBI)Concussion (TBI)Contusion (TBI)Coup-contre coup injury (TBI)Second Impact Syndrome (TBI)Open and Closed Head InjuriesPenetrating Injury (TBI)Shaken Baby Syndrome (TBI)Locked in Syndrome (TBI)Anoxic brain injury (ABI)Hypoxic brain injury (ABI)

Diffuse Axonal Injury

Concussion (TBI)

Contusion

Coup-Contrecoup Injury

Second Impact Syndrome “Recurrent Traumatic Brain Injury”

Penetrating Injury

Sources: Brumback R.Oklahoma Notes: Neurology and Clinical Neuroscience. (2nd ed.). New York: Springer; 2006. andCenter for Disease Control and Injury Prevention.

Shaken Baby Syndrome

Source:National Center on Shaken Baby Syndrome

Locked in Syndrome

Anoxic Brain Injury

Source: Zasler, N. Brain Injury Source, Volume 3, Issue 3, Ask the Doctor

Hypoxic Brain Injury

Source: Zasler, N. Brain Injury Source,Volume 3, Issue 3, Ask the DoctorColumn

Open Head InjuryThe following are terms used to describe types of skull fractures that can occur with open head injuries:

Closed Head InjuryWhen a person receives an impact to the head from an outside force, but the skull does not fracture or displace this condition is termed a “closed head injury”. Again, separate terminology is added to describe the brain injury. For example, a person may have a closed head injury with a severe traumatic brain injury.

According to theCenters for Disease and Control Injury Prevention Center, the leading causes of traumatic brain injury are:

Brain injury can result in a range of outcomes:

Among children ages 0 to 14 years, TBI results in an estimated

The number of people with TBI who are not seen in an emergency department or who receive no care is unknown.

Emergency personnel typically determine the severity of a brain injury by using an assessment called the Glasgow Coma Scale (GCS). The terms Mild Brain Injury, Moderate Brain Injury, and Severe Brain Injury are used to describe the level of initial injury in relation to the neurological severity caused to the brain.There may be no correlation between the initial Glasgow Coma Scale score and the initial level of brain injury and a persons short or long term recovery, or functional abilities.Keep in mind that there is nothing Mild about a brain injurythe term Mild Brain injury is used to describe a level of neurological injury. Any injury to the brain is a real and serious medical condition. There is additional information about mild brain injury on ourmild brain injury page.

This information is not intended to be a substitute for medical advice or examination. A person with a suspected brain injury should contact a physician immediately, go to the emergency room, or call 911 in the case of an emergency. Symptoms of mild TBIcan be temporary. The majority of people with mild TBIrecover, though the timetable for recovery can vary significantly from person to person.

A moderate TBI occurs when there is aloss of consciousness that lasts from a few minutes to a few hours, when confusion lasts from days to weeks, or when physical, cognitive, and/or behavioral impairments last for months or are permanent.Persons with moderate TBIgenerally can make a good recovery with treatment and successfully learn to compensate for their deficits.

Source: Defense and Veterans Head Injury Program & Brain Injury Association. Brain Injury and You. 1996.

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Brain Injury and Drug Addiction Treatment Program Overview

Posted: December 5, 2017 at 8:42 am

At NRI, we use the term dual diagnosis to describe the victim of a brain injury who is also struggling with substance abuse and addiction. Studies show that substance abuse is a key factor in more than a third of the accidents that result in a traumatic brain injuryand the use of alcohol or drugs prior to the injury often results in complications that require specialized treatment in a facility qualified to treat dual diagnosis patients. NRI is such a facility.

Most individuals who were addicted to alcohol or drugs prior to their brain injury continue to experience substance abuse issues during their recovery. Other individuals may become addicted to pain medications as a result of their injury. Substance abuse and addiction not only pose special mental health concerns for people who have experienced brain trauma, they pose substantial impediments to recovery as well.

As a facility uniquely capable of treating traumatic brain injury patients with dual diagnosis, NRI offers a non-judgmental and supportive environment that specifically addresses the challenges of recovery faced by those who are also struggling with alcohol or drug abuse. Our approach is based on respect for the dignity of the patients we serve and the belief that addiction is a treatable disease.

The Traumatic Brain Injury and Dual Diagnosis Programs at NRI offer specialized services such as:

To learn more about this groundbreaking program for victims of traumatic brain injury and addiction, call or request a free assessment today. The call will be kept strictly confidential.

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Brain Injury and Drug Addiction Treatment Program Overview

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Rehabilitative Center Treatment – TBI – Traumatic Brain Injury

Posted: December 3, 2017 at 12:42 am

The familiesof traumatic brain injury (TBI) victims often have many questions when their loved one is transferred to a rehabilitative care center.

What happens in rehabilitation?Similar tothe acute care facility, the TBI patient will be cared for by a team of professionals who specialize in the care of trauma victims.

Their goals are to:

Each day, the patient will participate in therapy. Initially, the patient may require staff assistance for even the most simple activities: brushing teeth, getting out of bed and eating. The patient also may require staff for safety because there is a risk of falling, eloping (trying to get out of the hospital to go home) or getting hurt. The patientmay be confused and forgetful.

The Rehabilitation Team

The Physiatrist is the team leader in the rehabilitation program. The physiatrist is a physician specializing in physical medicine and rehabilitation. Physiatrists treat a wide range of problems, including the changes after brain injury. The physiatristwill assess and prescribe the treatment and direct the team.

The Neuropsychologist is a key member of the rehabilitation team. The neuropsychologistwill assess the patients changesin thinking and behavior. Changes couldinclude:

Many patients areunaware of the changes in the brain and how those changesaffect their daily lives. A patient may not understand what has happened andmay bedistraughtby being away from home. Through education and counseling, the neuropsychologist can help assure the patient and the patientsfamily.

The Rehabilitation Nurse assists patients with brain injury and chronic illness in attaining maximum optimal health, and adapting to an altered lifestyle. The Rehabilitation Nurse provides care for the patient on the nursing unit. The focus of nursing care is on:

The Physical Therapistworks with people with orthopedic problems, such as low back pain, knee injuries or pain reduction. With traumatic brain injury, thePTsjob is to minimize or overcome paralyzing effects related to the brain injury.Physical therapistsare experts in the examination and treatment of musculoskeletal and neuromuscular problems that affectthe abilities to move and function indaily life.

Physical therapists help with transfers to and from the bed whena patientcannot walk alone. They train a person to begin to walk and move more normally. PTs will assess:

The Occupational Therapist assesses functions and potential complications related to the movement of upper extremities, daily living skills, cognition, vision and perception.OTS help determine, with the patient, the best ways to perform daily living skills including showering, dressing and personal hygiene.The OT willidentify equipment for eating, dressing and bathing.

The OT also will look at skills to prepare the patient for a return to the home. These skillsinclude:

The following sections explain:

Treatments for Traumatic Brain Injury HomepageInitial TreatmentRehabilitative Center TreatmentAcute TreatmentSurgical TreatmentSupportive Care ConcernsRecovery

Link:
Rehabilitative Center Treatment – TBI – Traumatic Brain Injury

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Spreading depolarizations trigger early brain injury after subarachnoid hemorrhage, researchers find – Medical Xpress

Posted: September 6, 2017 at 5:45 pm

The study of Hartings and colleagues found that bleeding onto the surface of the brain (a subarachnoid clot) can directly cause the death (infarct) of the affected brain gray matter the cerebral cortex. Progression to death is mediated by repetitive brain tsunamis (cortical spreading depolarizations), shown here by blue waves and arrows, that spread through the cortex. Brain tsunamis reduce blood supply to the brain (cortical spreading ischemia) and impair brain function, resulting in flatline (terminal depolarization) as the tissue dies. Brain tsunamis were first described in 1944 by Aristides Leo and today are measured in patients with electrodes placed on the brain surface. Credit: Illustration by Tonya Hines, Mayfield Clinic

The phrase “time is brain” could take on new meaning when applied to the treatment of subarachnoid hemorrhage, a type of bleeding stroke, thanks to research partially funded by the Mayfield Education & Research Foundation and the United States government.

Subarachnoid hemorrhage, caused by the rupture of a brain aneurysm, affects an estimated 10 to 15 of every 100,000 individuals each year. An international team of researchers has established that the blood from this type of hemorrhage launches deadly “brain tsunamis” within hours, leading to permanent brain damage. This damage, known as infarction, occurs in the cerebral cortex near the hemorrhage and can cause permanent disability and in some cases death.

Brain tsunamis, scientifically known as cortical spreading depolarizations, are travelling waves of brain dysfunction that spread out from an injury site and contribute to worse outcomes in patients. They affect patients who suffer trauma to the brain as well as those who suffer various types of stroke. In subarachnoid hemorrhage, blood from a ruptured aneurysm or shredded artery pools in the space between the arachnoid membrane and the brain itself.

A team of researchers led by Principal Investigator Jed Hartings, PhD, Research Associate Professor in the Department of Neurosurgery at the University of Cincinnati, used a novel animal model to study what happens immediately after a subarachnoid hemorrhage. The team also monitored 23 patients who were surgically treated for subarachnoid hemorrhage at hospital locations of Charit University Medicine in Berlin. Monitoring was accomplished by placing electrode strips on the surface of the brains of animal models as well as patients.

The team’s findings of secondary damage within 6 hours were published online today in the journal Brain.

“We found that patients who suffered brain damage in their frontal lobes were more likely to have experienced spreading depolarizations than those who had no damage,” Dr. Hartings says. “The animal studies showed that these pathological changes can arise as a direct result of the blood accumulation in the grooves of the brain that the presence of blood in the wrong place is toxic to the brain.”

In the past, researchers have focused primarily on delayed complicationssuch as the narrowing of major cerebral arteries known as vasospasm that occur 5 to 14 days after subarachnoid hemorrhage. Those complications account for only a minority of deaths (13 percent), however; the majority of deaths from subarachnoid hemorrhage (86 percent) occur in the early hours and days after an aneurysm rupture occurs. The present study sheds new light on these early events and suggests that they may be preventable.

“This is the first evidence that brain tsunamis are a clinical marker, and mechanism, of early brain injury,” Dr. Hartings says. “As such, they provide us with an opportunity to pursue therapeutic interventions that could improve outcomes for patients. By treating or preventing brain tsunamis, we could potentially stop many victims of bleeding stroke from suffering additional, often catastrophic, brain damage.”

The early damage caused by subarachnoid hemorrhage has been underappreciated, Hartings says, because it often cannot be observed with routine CT brain imaging. “There has also been a sense that early damage could not be prevented, but perhaps that perception is starting to change.”

Looking ahead, the researchers propose the investigation in animal models of therapies that target spreading depolarizations in an effort to interrupt or prevent secondary injury processes.

When a brain injury occurs, nerve cells in the brain (which act like batteries by storing electrical and chemical energy) malfunction and effectively short-circuit. Because all nerve cells in the brain are connected, this depolarization causes all the neighboring cells to short-circuit as well; this subsequent leakage of precious electrical charge moves like a tsunami through the brain, with the potential to cause additional permanent tissue damage.

To document the cascade of events that immediately follows subarachnoid hemorrhage, the research team used a novel swine model, whose brain, with grooves and fissures, more closely resembles the human brain than previously studied rodent models. The researchers found that clots that quickly formed in the grooves of the swine brain mirrored the results in the human brain; in both situations, the clots caused repetitive spreading depolarizations and lesions (infarcts) in the cerebral cortex shortly after an aneurysm rupture and subarachnoid hemorrhage.

The study’s collaborating scientists and clinicians are members of COSBID (Co-Operative Studies on Brain Injury Depolarizations.

Explore further: Subarachnoid hemorrhage and the need for expert treatment

More information: Ayata C, Lauritzen M. Spreading Depression, Spreading Depolarizations, and the CerebralVasculature. Physiological Reviews. 2015;95(3):953-93.

Baechli H, Behzad M, Schreckenberger M, Buchholz HG, Heimann A, Kempski O, et al. Blood constituents trigger brain swelling, tissue death, and reduction of glucose metabolism early after acute subdural hematoma in rats. J Cereb Blood Flow Metab. 2010;30(3):576-85.

Bosche B, Graf R, Ernestus RI, Dohmen C, Reithmeier T, Brinker G, et al. Recurrent spreading depolarizations after subarachnoid hemorrhage decreases oxygen availability in human cerebral cortex. Ann Neurol. 2010;67(5):607-17.

Bretz JS, von Dincklage F, Woitzik J, Winkler MKL, Major S, Dreier JP, et al. The Hijdra scale has a significant prognostic value for the functional outcome of Fisher grade 3 patients with subarachnoid hemorrhage. Clin Neuroradiol. 2016:in press

Hartings JA. Spreading depolarization monitoring in neurocritical care of acute brain injury. Curr Opin Crit Care. 2017;23(2):94-102.

Hartings JA, Shuttleworth CW, Kirov SA, Ayata C, Hinzman JM, Foreman B, et al. Thecontinuum of spreading depolarizations in acute cortical lesion development: Examining Leao’s legacy. J Cereb Blood Flow Metab. 2017;37(5):1571-94.

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Spreading depolarizations trigger early brain injury after subarachnoid hemorrhage, researchers find – Medical Xpress

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