Traumatic brain injury

Traumatic brain injury (TBI) is a mechanical damage to the skull and intracranial formations, namely the brain, vessels, cranial nerves, meninges of the brain.

Head injuries can be classified into open, in which cranial cavity has a contact with the external environment, and closed ones. The main clinical factors that determine the severity of injury include duration of loss of consciousness and amnesia, the degree of consciousness oppression at the time of hospitalization, neurological symptoms in the brainstem.

Causes

The most common causes of TBI are motor vehicle accidents and domestic accidents. For more information on the causes, statistics, and other general data, see the section Information about TBI

Effects, complications

• The mechanical damage can result in the formation of focal brain injury, which initially causes local damage to the areas of the cerebral cortex accompanied by the formation of its injury zone and (or) intracranial hemorrhage (intracranial hematoma) due to the damage of the vessels of the cerebral membranes or vessels that provide direct feeding to the brain.
• With the simultaneous influence of various factors of mechanical effect on all brain structures, a person develops a diffuse axonal injury. In particular,diffuse axonal injury is common in car accidents. The injury is characterized by either rupture or damage of long nerve cell appendages - axons, which distorts the transmission of a nerve impulse. The patients with diffuse axonal injury can experience breathing problems, impaired blood flow and disorders of other vital functions caused by a primary damage to the brainstem. The clinical manifestation of diffuse axonal injury is a state of coma that can last several weeks. According to statistics, the mortality rate accounts for 80-90%, while the surviving patients can develop a complication, namely – apallic syndrome, with subsequent transition to the vegetative state.
• The secondary hypoxic brain injuries can develop due to the late or inadequate treatment of the primary brain injury. They are characterized by the development of (ischemic lesions) of various parts of the brain (ischemic strokes). For example, a late removal of the intracranial hematoma leads to uncontrolled growth of intracranial pressure, edema (brain swelling), impaired blood circulation in various parts of the brain and development of secondary ischemic foci (strokes) in various parts of the brain.

The severity of the trauma is determined by such factors as the duration of amnesia, the degree of the patient's consciousness oppression during the hospitalization and can be aggravated in case of neurological symptoms in the brainstem.

The traumatic brain injury can lead to a coma. This is an extremely unfavorable consequence of the injury when the patient is unconscious, does not perceive the external effect and does not understand the state in which he/she is. Being in a coma is patient lieing soundly with eyes closed.

The outcome of TBI can be even more severe in the case when coma changes to the vegetative state. This condition can occur after a prolonged stay in a coma and in most cases it is observed when the patient wakes up from the traumatic coma. In the vegetative state, the body maintains blood pressure, blood supply, breathing and heart rhythm. A characteristic feature of the vegetative state is a periodic awakening of the patient, which they periodically experience after a period of sleep. However, while being awake, the patient remains unconscious, does not perceive the environment and cannot speak. The patient can manifest the condition, which is common for decortication, signs of pyramidal insufficiency, subcortical symptoms, primitive reflex motor phenomena, for example, a voluntary palmar grasp reflex, symptoms of oral automatism; chaotic movements as a reaction to painful stimuli. The vegetative state can last from several days to a year and even more.

The main signs of the vegetative state:

• Unconscious state of the patient.
• Inadequate and disorderly reaction to auditory, visual, tactile or painful stimuli.
• Change in the periods of awakening and sleep.
• Functional activity of the hypothalamus and brainstem sufficient to maintain spontaneous breathing and adequate hemodynamics.
• Spontaneous blinking, normal pupil response to light and corneal reflexes.
• The patient cannot focus their eyes and cannot perceive the movement of objects.
• Urinary and fecal incontinence.

The patients who have suffered a trauma with direct damage to the cerebral cortex, as well as secondary ischemic strokes, may develop post-traumatic encephalopathy with characteristic symptoms,

• Motor disorders, weakness or paralysis, which can cause difficulty in moving, walking and loss of coordination. Hemiparesis or hemiplegia are the terms used to denote movement disorders affecting only one side of the body.
• Swallowing disorder. If the person develops impaired swallowing, both food and liquid can get into the respiratory tract or lungs but not into the esophagus. The person can therefore develop severe lung inflammation. Swallowing disorder can also cause constipation and dehydration.
• Speech disorder. Damage to the left hemisphere of the brain results in impaired speech production and understanding, including difficulty reading, writing and counting.
• Problems of perception. Even with normal vision, the sufferer is unable to understand what he/she sees. Perceptual disorders make it difficult for the person to use everyday objects. For example, the person cannot take a glass and pour water into it and drink it.
• Cognitive disorders. In these disorders the person’s ability to mental perception and processing of external information becomes impaired. The patient lacks clear and logical thinking, their memory gets worse, they lose their ability to learn, make decisions and plan ahead.
• Behavioral disorders. The person can experience aggression, slow response, fearfulness, emotional instability and disorganization.
• Bowel and bladder problems. Stroke can cause a variety of different problems, resulting in either bowel or bladder dysfunction (fecal or urinary incontinence or retention).
• Psychological disorders. These include mood swings, depression, irritability, episodes of laughing or crying without an evident reason. Depression is a very common problem for people who have suffered stroke. It is often accompanied by loss of appetite, episodes of causeless laughing or crying, insomnia, low self-esteem and an increased sense of anxiety.
• Post-traumatic Epilepsy.

Rehabilitation

In Germany and other the countries of the European Union, patients with the traumatic brain injury start their rehabilitation directly in the intensive care unit. Then, depending on the degree of the primary brain lesion, doctors develop rehabilitation programs and determine the further direction of the patient’s treatment.

With an early recovery and rehabilitation, millions of people who have suffered TBI can return to their normal life.

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