Understanding The Traumatic Brain Injury Better!

Traumatic brain injury (brain injury triggered by an external event such as a fall or a road accident) can be quite a harrowing experience for the patient and their loved ones. While most people recover from the injury, the duration and extent of recovery may vary from individual to individual.

Some patients may simply suffer from a temporary amnesia, while others may remain comatose for months. The recovery time and extent of neurological deficits in traumatic brain injury is determined by the severity and location of the brain injury. The traumatic brain injury can be

Open or closed

• Open injury: There is an opening up of the skin and other layers leading to direct contamination of the brain from external debris and the risk of brain infection is high in such a case.
• Closed injury: here, the brain is not contaminated, but the impact may cause various degrees of injury to parts of the brain.

Primary or secondary injury:

Primary injury: it is damage caused to the brain at the time of the injury. The damage can be

• A crack or fracture in the skull.
• Bleeding into the layers between skull and brain, like a EDH (Extra Dural Hematoma), SDH (Subdural Hematoma) or SAH (Sub-Arachnoid hemorrhage). These are potential emergencies, especially an EDH, where timely Neurosurgical intervention can decide between life and death.
• Due to violent shaking of the brain inside the skull cavity, there can be a damages to the entire brain including the axons and neurons without any visible hemorrhage on CT scans (Diffuse Axonal Injury). The outcome can be quiet unpredictable. It is dangerous if the brain starts swelling up excessively after a DAI.
• A person can also suffer from brain hemorrhages and contusions within the brain matter. Large contusions may need surgical evacuation to control brain pressure. Smaller ones are treated without surgery. Deep seated contusions towards the centre of the brain cause more morbidity even if small in size.

The secondary brain injury may develop gradually (within few hours or days from the primary brain injury), further aggravating the brain tissues. This is brought about by inflammation, altered blood supply, high brain pressure, brain edema or swelling, and programmed cell death. Sometimes, even though the primary insult is small, patients may succumb due to secondary injuries which are highly unpredictable and difficult to treat.

Estimating the extent of the brain damage

The damage inflicted to the brain is assessed by the combined assessment of the following:

1. The mode of injury, especially velocity of impact.

2. How long the person has been unconscious.

3. How bad are the visible external injuries. Is it an open or closed injury?

4. Whether there was any convulsions, vomiting, ear or nose bleeding?

5. Assessment of eye opening, verbal response and movement. This is assessed and recorded by the GCS (Glasgow coma scale).A score of 15 implies the person is fully conscious, a score of 9 indicates the person is in a semi-alert state, while a score of 3 indicates a deep state of coma.

6. Brain imaging through CT or MRI. This gives a more direct information about the physical damages to the brain, and guides the decision about Neurosurgical intervention.

Treatment of traumatic brain injury:

• Medical : medicines are administered to control brain pressure and limit the secondary injuries. It also attempts to control events like convulsions and infections.
• Surgical: surgery becomes necessary when there are depressed fractures impinging into the brain, or large hematoma or brain swelling causing rise of brain pressure or a shift of the brain to one side. Other indications are uncontrolled CSF (cerebrospinal fluid) leakage from nose. Sometimes shunts need to be put to drain out CSF in hydrocephalus (accumulation of excess water in the brain ventricles). During surgery, parts of the skull may need to be removed (Craniectomy) temporarily to allow brain expansion and control brain pressure.
• Accessory surgeries: smaller procedures like a tracheostomy (bypass of the windpipe) or PEG (stomach tube) may need to be done for long term care in comatose patients.
• Rehabilitation: tireless care by nursing and physiotherapy are necessary to help patients recover faster and avoid complications like bed sore, deep vein thrombosis, spasticity and weakness of limbs.
• Recovery: Recovery from traumatic brain injury may be time taking (weeks, months to even years). In addition to the initial treatment and medications, patients may need Brain Injury Rehabilitation. The rehabilitation aims at enabling the person to lead a normal life as early as possible. There are medications, activities, and exercises to improve one's cognitive power.

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