By Matt Lalande in Brain Injuries on July 31, 2021
Traumatic brain injury (TBI) occurs when a blow to the head causes brain damage. TBI includes anything from mild concussions up to severe brain damage. Treatment can range from rest only to intensive care and emergency surgery. Survivors can face a lifetime of disruptions, physical and mental impairment severe cognitive changes. Many persons who suffer serious head trauma will undergo long-term rehabilitation, and some might even need to relearn basic skills.
In the Canada, the most common causes of TBI include falls (35.2%), motorcycle and car accidents, automobile accidents involving pedestrians (17.3%) and assaults (10%) with or without a weapon. Athletics and sports also cause significant TBI injuries. NBIA.ca tells us that in Canada, one person is injured with a traumatic brain injury every 3 minutes and that brain injury occurs at a rate of 500 out of 100,000 individuals yearly in Canada. In fact, they say that the annual incidence of acquired brain injury in Canada is 44 times more common than spinal cord injuries, 30 times more common than breast cancer, and 400 times more common than HIV/AIDS. In fact, brain injury occurs at a rate greater than that of all known cases of Multiple Sclerosis, Spinal Cord Injury, HIV/AIDS and Breast Cancer per year combined.
Traumatic brain injuries are typically classified into three main categories, depending on severity: a mild TBI, a moderate TBI and a Severe TBI.
Mild TBI (MTBI) is another name for a concussion. MTBI can happen without the person's awareness. No loss of consciousness has to occur, and no physical signs of a head injury have to be present. Normally MTBI does not lead to any significant brain injury.
MTBI is caused by rapid acceleration or deceleration of the brain after a bump, blow or jolt to the head, or a sudden change of direction causes the brain to rapidly move within the skull. The resultant bruising this causes can cause a temporary disruption of brain function – meaning the brain will not work as well as it is supposed to for a while — only 50% of persons with MTBI experience any symptoms. The appearance of symptoms is no cause for worry though, as it is normal. It is important to note that symptoms might only appear hours, even days, after the injury.
A moderate head injury will lead to loss of consciousness between twenty minutes and six hours. The person will be sluggish and inert, but the eyes will open to stimulation. A degree of brain swelling or bleeding will present, and this will lead to sleepiness. But, a person will be able to wake up when prompted.
A severe head injury is a TBI that leads to unconsciousness for longer than six hours. The eyes will respond to any stimulation and will not open.
Yes, the brain is divided into two halves. The two halves (hemispheres) work together to command our thoughts and behaviors. The left hemisphere controls movements of the right side of the body. It also controls reasoning, speaking, writing and numerical skills. The right side controls the left side of the body’s movements and is the center of insight and imagination, awareness of the multi-dimensional nature of reality (three dimensions), creativity and musical ability as well as our interpretation skills.
The frontal lobe is responsible for the most important movements of the eyes, the trunk, and the extremities. This is where memory is located, judgment as well as the control mechanisms to moderate behavior. if the frontal lobe is damaged, one would experience changes such as behavior and emotional life, impaired language skills, impaired judgment, memory loss, loss of motivation, loss of inhibition, impaired mental capacity or paralysis (on the left or right side of the body).
The parietal lobe controls the remaining movements and the senses, as well as our perception and sense of space. Damage to the parietal lobe can cause such symptoms as impaired reading, writing, and vocabulary. Impaired hand-eye coordination and loss of mathematical reasoning can also be affected.
The temporal lobes are co-responsible for memory, controls language and are crucial in the experience and control of emotions. Damage to the occipital lobe can cause such symptoms as visual impairment, hallucinations and the impaired ability to read and write.
The cerebellum controls our coordination and timing. If the cerebellum is damages, one could experience such symptoms as slurred speech, dizziness, tremors, loss of dexterity or difficulty walking.
The brainstem – also popularly known as the reptile brain – is responsible for the automatic functions in the body. This includes breathing, blood pressure and arousal. The slightest injury to the the brainstem can lead to coma or a very low level of consciousness as well as other serious symptoms such as vertigo, dizziness, Impaired balance and difficulty of movement, difficulty in swallowing, changes in breathing.
A concussion is a mild injury to the head that can cause a brief loss of consciousness but does not normally bring about permanent brain injury. A concussion is a diffuse injury, which means it is spread over a large area and cannot be pinpointed to a specific location. Normally a concussion will present as an overall decrease in levels of consciousness.
The post-concussive symptoms, also known as the Post-Concussive Syndrome (PCS), are a part of the normal healing process and no cause for worry. Most of these symptoms will disappear without any treatment at all.
A recent pubmed study from 2017 listed the prevalence of post concussive syndromes as: attention deficit 71%, confusion 57%, depression 63%, disrupted sleep 80%, exhaustion 64%, forgetfulness 59%. headaches 59%, impaired vision 45%, moodiness 66%, nervousness 58%, sensitivity to Bright Light 40% and vertigo 52%.
When an impact to the head leaves a bruise to a specific area of the brain. This is also known as coup or counter-coup injuries. In coup injuries, the brain is injured directly under the point of impact while in countercoup injuries the brain it is injured on the opposite side of the impact. Contusions are focal injuries – that is to say, the injury is not spread out (diffuse), but it is specific to a location.
A diffuse axonal injury is a very serious brain injury. Axons, which compose what is also known as the white matter of the brain, connect nerve cells throughout the brain. When the brain reverberates (quickly moves back and forth inside the skull), the nerve axons are torn and damaged. During automobile accidents, for example, rapid rotation or deceleration of the brain causes stretching of these nerve cells on a cellular level, the brain’s normal transmission of signals (information) is disrupted, and this can dramatically impact the person’s alertness and wakefulness.
Ischemia is another form of diffuse injury. This happens when certain parts of the brain are cut off from an adequate supply of blood. A marked decrease in blood supply is especially perilous for a person with TBI because the brain becomes extremely sensitive even the smallest decreases in blood supply after a traumatic injury. Changes in blood pressure during the first-week post-head injury can have adverse effects.
When a blood vessel in the brain is ruptured, bleeding starts and the blood naturally clots. Sometimes these hematomas are very small. When a hematoma is large, it might compress the brain. Symptoms will depend on the location of the hematoma and hematomas are named for their location. A hematoma that forms between the skull and the dura (the tough outermost membrane enveloping the brain and spinal cord) is named an epidural hematoma. When the hematoma forms between the brain and the dura, it is named a subdural hematoma. When the hematoma forms deep inside the brain, it is named an intracerebral hematoma. Under fortunate circumstances, the body will reabsorb the hematoma. Large clots (hematomas) are periodically removed by surgery.
SIS causes the brain to swell catastrophically. SIS is not strictly speaking a type of injury, rather an extreme response of the brain to a second blow to the head/brain (even a very mild blow) after a first impact (seconds up to days after the first blow) already changed the brains functioning and left it in a vulnerable state. A second blow to the head during concussion unleashes a series of metabolic events that might start within 15 seconds. One of the ramifications is a very large increase in blood flow due to a loss of autoregulation of the brain’s blood vessels. Huge increases in intracranial pressure follow, and this might cause cerebellar herniation (the brain is squeezed past structures within the skull) which is very often fatal.
Linear skull fractures are simple cracks or breaks in the skull. The bigger concern when this happens is the fear that the underlying force that created the fracture might have caused damage to the brain itself. Fractures to the base of the skull can be very problematic because it may cause damage to arteries, nerves and other structures. If a fracture reaches down to the sinuses, this may cause cerebrospinal fluid to leak from the nose and ears. Sometimes this might require intervention to insert a lumbar drain. Depressed skull fractures are more problematic. These fractures happen when a part of the bone presses on or into the brain itself. This more often than not requires surgical intervention. The specific damage caused will be dependent upon the region where this fracture happens as well as its interaction/coexistence with any diffuse brain injuries.
When an escape of blood from a ruptured blood vessel leaks into the space that surrounds the brain, this kind of stroke caused by an external impact on the brain, is described as a subarachnoid hemorrhage. The subarachnoid space is the fluid-filled space around the brain between the arachnoid membrane and the pia mater (the delicate innermost membrane enveloping the brain and spinal cord) through which major blood vessels pass. The cerebrospinal fluid in this space forms a floating cushion the brain hovers in for protection. When an injury causes some of the small arteries to tear, the blood flow spreads all over the surface of the brain, causing widespread traumatic effects.
After the initial injury to the brain, swelling can occur for up to five days. The swelling often happens gradually because of the body’s reaction to the primary injury. In order to heal the initial injury, the body accumulates extra fluid and nutrients to the site of the injury to attempt to heal itself. Such inflammation in the brain can be quite dangerous. The skull is rigid, and space for extra fluid and nutrients is limited. As the brain swells, the pressure inside the skull is increased, and this can result in brain cell damage as well as blood flow interruption (ischemia).
If there is a hematoma (clot) large enough to damage the brain, a cerebral edema, or a pooling of blood, surgery will be required. A flap of bone is removed from the skull over the site of the clot. The clot is removed, and the arteries will be repaired. The skull heals rapidly, and the operation is usually straightforward and without much risk. If the skull was penetrated and the wound goes through to the brain, surgery will also take place. With proper treatment, these wounds normally heal very well. A future tendency to develop epileptic seizures (post-traumatic epilepsy) can occur. This can be treated with medication to reduce the risk. Neurosurgery is very time-consuming, and recovery can take a long time because of the injury to the brain. The severity of the brain injury, rather than the skill of the surgeon, is often the main determinant of success.
If a person undergoes brain surgery, he or she will then be moved to the intensive care unit (ICU) where treatment and condition will be monitored 24-hours per day. Heart rate, blood pressure, brain function, food, and fluid intake will be monitored continually. Intracranial pressure will be monitored by the insertion of an intracranial pressure monitor (ICP). A brain oxygen monitor (Licox) is placed through a small hole in the skull and positioned in the brain tissue. The oxygen levels and the temperature of the brain are constantly monitored. Oxygen is optimized for the brain to heal.
A cerebral blood flow monitor (Hemedex) is placed next to the Licox to evaluate blood flow throughout the brain. For some personz, a ventilator might be needed to help them to breathe. It is connected to the person via an endotracheal tube placed into the person’s mouth and down the windpipe. The machine can then push air in and out of the lungs. A feeding tube will be added to persons on a ventilator and with decreased alertness. A nasal gastric feeding tube may be inserted and passed down the throat to the stomach for delivery of liquid nutrition and medication delivery. To monitor the person for seizures due to abnormal electrical discharge from the brain, all TBI persons will be monitored with an EEG (electroencephalogram) for 72 hours after the injury.
Coma is a state of deep unconsciousness in which the eyes remain closed, and the patient cannot be aroused at all. The brain waves of a person in a coma are very different from the waves of a sleeping person. Movements of the eyes during a coma are just basic reflexes or automatic responses to stimuli. When the person starts to wake up, self-protection is turned on, and the person will often move away from any stimuli and tend to try and remove any attachments that irritate them. The person is most likely not aware of his surroundings yet and may respond in the same way to all stimuli. Signs might be an increased breathing rate, moaning, moving and sweating, as well as an increased blood pressure level. When the person starts to wake up, their interactions will become more purposeful. They might look at and follow visitors with their eyes or respond to simple commands. Confusion, inappropriate and agitated behavior are very likely.
A vegatative state (VS) can be described as the absence of any behavioral evidence of self-awareness or awareness of the environment when there is evidence of the restoration of the reticular activating system (eyes are opening, or patient is awake). In these circumstances, there is a complete absence of purposeful responses to visual stimuli, touch or unpleasant prodding (pinprick), and an apparent lack of understanding of language or the expression of language.
According to pubmed, head injury victims who remain in a VS for more than one year after suffering a seriuos brain injury has a lowered probability of recovering awareness. However, miracles happen very often. According to studies more than 20% of people in a VS for between 14 and 28 months after injury onset will progress to a minimally conscious state or will regain consciousness. Outcomes for younger persons are on average, more favorable. Persons who remain in VS can live for five years, and even ten years and miracles revive some of these persons years later, too.
For most TBI persons that have been discharged home, years of therapy and rehabilitation will follow. It is entirely possible to return home and still receive the full complement of therapy and treatments available from a TBI day hospital or outpatient program. Sometimes these facilities are not part of a hospital outpatient program as such but are formed by the aggregation of various therapy programs and practitioners at a specific location.
These facilities are often more than adequate for the less-severe TBI patient that might only require specific rehabilitation and treatment that can be accessed either in the traditional hospital outpatient department or via the office or home-based treatments. For severe TBI patients, some hospitals offer one-stop facilities provided by outpatient clinics that employ nurse practitioners, rehab nurses and rehab technicians that work with the outpatient therapy team. These clinics aid in the development of home programs for the patient and their caregivers and family members.
Outpatient therapy is often a long-term process that will last much longer than inpatient treatment. The team of outpatient healthcare providers will coordinate and develop a set of goals for the rehabilitation of the patient to optimize the patient’s recovery. It is important for the family members and caregivers to closely coordinate with the health care providers to ensure that they not only understand these goals but that they remain realistic about what can be achieved over a given period of time.
Generally speaking, outpatient rehabilitation will involve at least two to three sessions per week. During these sessions, the TBI patients might be required to do up to one hour each of physical, occupational and speech therapy with the goal of improving the patient’s life by making him/her more independent, improving their skills for a return to school or work, and allowing them more freedom to participate in in recreational activities of their preference.
Sometimes they will – especially if the brain trauma is accompanied by physical injury. As mentioned above, most TBI patients will require up to three therapy sessions per week, and these might include various types of therapy for an hour each, all in series. Physiotherapists and physical therapists treat disorders of the human body by physical means rather than by prescribing drugs. At the beginning of the treatment, the physical therapist will work in conjunction with the medical team treating the TBI patient, especially when assessing the treatment objectives for the patient.
One of their functions is to prevent the deterioration of the patient’s condition that might result from their existent injuries. These physical therapists (PT) are specialists in human movement dysfunctions and trained to treat the patient in order to strengthen their physical abilities. For this purpose, they use therapeutic exercise, electrical stimulation, heat and cold and the application and provision of devices such as braces. They achieve their aims by helping the patient to improve their coordination, endurance, and impairments.
While physiotherapy is mainly aimed at treating disorders of the body in relation to movement dysfunction, occupational therapy is different. After brain injury, a person may be impaired from the things that are important to their life and functioning such as the ability to care for themselves, the ability to work, the ability to participate in hobbies, sports or family events. All of this might contribute to a person’s failing sense of self and belief in the future. Occupational therapists intervene by teaching a person new skills and strategies, new ways of doing things, by adapting and redesigning the materials and equipment used, and by adapting the person’s environment to negotiate flexibility from employers, reorganizing work and living space, and by educating and training caregivers and family members about the person’s abilities and impairments.
After a serious head injury, many people develop severe cognitive and communication impairments. Many people have serious trouble swallowing and speech and language impairments might torment that person and their loved ones and caregivers. A speech therapist will help assess a person for various signs and symptoms, including poor concentration, confusion, disorientation, word repetition, stuttering, verbal confabulation and lack of verbal reasoning skills.
The long-term impact of a brain injury is notoriously difficult to predict. Every brain injury is unique. Our experts have explained to us that the amount of force, the direction of the force, the location of impact, to health and strength of the person, the speed and quality of treatment of the injury all of these factors determine the severity of the long-term effects of a head injury to some degree.
At best, we have learned our cases that predicting the outcome of a brain injury is a very complex and uncharted. Early education by both family and medical personnel, accompanied by psychosocial support improves long-term outcome. It's important that every person with a brain injury received continued support from family, clinicians and institutions. It's important that vocational and occupational therapy training be implemented. It's important that our social supports realize that emotionally, many brain injured victims remain vulnerable and they cannot deal with normal family and relationship issues. Many have impaired social skills which make relationships a challenge.
Remember, people that suffer from traumatic brain injuries often suffer tremendously. Substance abuse, hostility and aggression are not uncommon. People with brain injuries need emotional support, patience and understanding. Often, we have seen our brain injury clients also suffer from anxiety and anxiety -related disorders. It's important that family members and caregivers continue to play an important role in helping a brain injured person manage their fears and anxieties.
if you or your loved one has suffered a serious traumatic brain injury because someone was careless, call our brain injury lawyers today no matter where you are on Ontario at 1-844-LALANDE or local in the Hamilton / GTA / Niagara area at 905-333-8888. Alternatively, you can send a confidential email through our website and we promise that we will get right back to you.
Remember, it’s always free to talk to us, and we never ask our clients for money upfront. If you are in the Southern Ontario region we offer in person consultations or in the alternative, we are always happy to discuss your case and advise you of your legal rights via ZOOM.
*This article was research and written with the help of peer reviewed medical journals located at pubmed.