Understanding TBI

Traumatic brain injury (TBI) is a complex injury with a broad spectrum of symptoms and disabilities. The impact on a person and his or her family can be devastating.

Traumatic brain injury, often referred to as TBI, is most often an acute event similar to other injuries. That is where the similarity between traumatic brain injury and other injuries ends. One moment the person is normal and the next moment life has abruptly changed.

In most other aspects, a traumatic brain injury is very different. Since our brain defines who we are, the consequences of a brain injury can affect all aspects of our lives, including our personality. A brain injury is different from a broken limb or punctured lung. An injury in these areas limit the use of a specific part of your body, but your personality and mental abilities remain unchanged. Most often, these body structures heal and regain their previous function.

Brain injuries do not heal like other injuries. Recovery is a functional recovery, based on mechanisms that remain uncertain. No two brain injuries are alike and the consequence of two similar injuries may be very different. Symptoms may appear right away or may not be present for days or weeks after the injury.

One of the consequences of brain injury is that the person often does not realize that a brain injury has occured.

Most people are unaware of the scope of TBI or its overwhelming nature. TBI is a common injury and may be missed initially when the medical team is focused on saving the individual's life. Before medical knowledge and technology advanced to control breathing with respirators and decrease intracranial pressure, which is the pressure in the fluid surrounding the brain, the death rate from traumatic brain injuries was very high. Although the medical technology has advanced significantly, the effects of TBI are significant.

TBI is classified into two categories: mild and severe

A brain injury can be classified as mild if loss of consciousness and/or confusion and disorientation is shorter than 30 minutes. While MRI and CAT scans are often normal, the individual has cognitive problems such as headache, difficulty thinking, memory problems, attention deficits, mood swings and frustration. These injuries are commonly overlooked.  Even though this type of TBI is called "mild", the effect on the family and the injured person can be devastating. 

Severe brain injury is associated with loss of consciousness for more than 30 minutes and memory loss after the injury or penetrating skull injury longer than 24 hours. The deficits range from impairment of higher level cognitive functions to comatose states. Survivors may have limited function of arms or legs, abnormal speech or language, loss of thinking ability or emotional problems. The range of injuries and degree of recovery is very variable and varies on an individual basis.

The effects of TBI can be profound. Individuals with severe injuries can be left in long-term unresponsive states. For many people with severe TBI, long-term rehabilitation is often necessary to maximize function and independence.  Even with mild TBI, the consequences to a person's life can be dramatic. Change in brain function can have a dramatic impact on family, job, social and community interaction.

Mild TBI Symptoms

A traumatic brain injury (TBI) can be classified as mild if loss of consciousness and/or confusion and disorientation is shorter than 30 minutes. While MRI and CAT scans are often normal, the individual has cognitive problems such as headache, difficulty thinking, memory problems, attention deficits, mood swings and frustration. These injuries are commonly overlooked.  Even though this type of TBI is called "mild", the effect on the family and the injured person can be devastating.

Other Names For Mild TBI

• Concussion
• Minor head trauma
• Minor TBI
• Minor brain injury
• Minor head injury

Mild Traumatic Brain Injury is:

• Most prevalent TBI
• Often missed at time of initial injury
• 15% of people with mild TBI have symptoms that last one year or more.
• Defined as the result of the forceful motion of the head or impact causing a brief change in mental status (confusion, disorientation or loss of memory) or loss of consciousness for less than 30 minutes.
• Post injury symptoms are often referred to as post concussive syndrome.

Common Symptoms of Mild TBI

• Fatigue
• Headaches
• Visual disturbances
• Memory loss
• Poor attention/concentration
• Sleep disturbances
• Dizziness/loss of balance
• Irritability-emotional disturbances
• Feelings of depression
• Seizures

Other Symptoms Associated with Mild TBI

• Nausea
• Loss of smell
• Sensitivity to light and sounds
• Mood changes
• Getting lost or confused
• Slowness in thinking

These symptoms may not be present or noticed at the time of injury.  They may be delayed days or weeks before they appear.  The symptoms are often subtle and are often missed by the injured person, family and doctors.

The person looks normal and often moves normal in spite of not feeling or thinking normal.  This makes the diagnosis easy to miss.  Family and friends often notice changes in behavior before the injured person realizes there is a problem.  Frustration at work or when performing household tasks may bring the person to seek medical care.

Brain injuries can range in scope from mild to severe.  Traumatic brain injuries (TBI) result in permanent neurobiological damage that can produce lifelong deficits to varying degrees.  Moderate to severe brain injuries typically refer to injuries that have the following characteristics:

• Moderate brain injury is defined as a brain injury resulting in a loss of consciousness from 20 minutes to 6 hours and a Glasgow Coma Scale of 9 to 12
• Severe brain injury is defined as a brain injury resulting in a loss of consciousness of greater than 6 hours and a Glasgow Coma Scale of 3 to 8

The impact of a moderate to severe brain injury depends on the following:

• Severity of initial injury
• Rate/completeness of physiological recovery
• Functions affected
• Meaning of dysfunction to the individual
• Resources available to aid recovery
• Areas of function not affected by TBI

The impact of a moderate to severe brain injury can include:

Cognitive deficits including difficulties with:

• Attention
• Concentration
• Distractibility
• Memory
• Speed of Processing
• Confusion
• Perseveration
• Impulsiveness
• Language Processing
• "Executive functions"

Speech and Language

• not understanding the spoken word (receptive aphasia)
• difficulty speaking and being understood (expressive aphasia)
• slurred speech
• speaking very fast or very slow
• problems reading
• problems writing

Sensory

• difficulties with interpretation of touch, temperature, movement, limb position and fine discrimination

Perceptual

• the integration or patterning of sensory impressions into psychologically meaningful data

Vision

• partial or total loss of vision
• weakness of eye muscles and double vision (diplopia)
• blurred vision
• problems judging distance
• involuntary eye movements (nystagmus)
• intolerance of light (photophobia)

Hearing

• decrease or loss of hearing
• ringing in the ears (tinnitus)
• increased sensitivity to sounds

Smell

• loss or diminished sense of smell (anosmia)

Taste

• loss or diminished sense of taste

Seizures

• the convulsions associated with epilepsy that can be several types and can involve disruption in  consciousness, sensory perception, or motor movements

Physical Changes

• Physical paralysis/spasticity
• Chronic pain
• Control of bowel and bladder
• Sleep disorders
• Loss of stamina
• Appetite changes
• Regulation of body temperature
• Menstrual difficulties

Social-Emotional

• Dependent behaviors
• Emotional ability
• Lack of motivation
• Irritability
• Aggression
• Depression
• Disinhibition
• Denial/lack of awareness

The number of people with Traumatic Brain Injury (TBI) is difficult to assess accurately but is much larger than most people would expect.  According to the CDC (United States Centers for Disease Control and Prevention), there are approximately 1.5 million people in the U.S. who suffer from a traumatic brain injury each year.  50,000 people die from TBI each year and 85,000 people suffer long term disabilities.  In the U.S., more than 5.3 million people live with disabilities caused by TBI.  Patients admitted to a hospital for TBI are included in this count, while those treated in an emergency room or doctor's office are not counted.

The causes of TBI are diverse.  The top three causes are: car accident, firearms and falls.  Firearm injuries are often fatal: 9 out of 10 people die from their injuries.  Young adults and the elderly are the age groups at highest risk for TBI. Along with a traumatic brain injury, persons are also susceptible to spinal cord injuries which is another type of traumatic injury that can result out of vehicle crashes, firearms and falls. Prevention of TBI is the best approach since there is no cure.

Mechanisms of Injury

These mechanisms are the highest causes of brain injury: Open head Injury, Closed Head Injury, Deceleration Injuries, Chemical/Toxic, Hypoxia, Tumors, Infections and Stroke.

1. Open Head Injury

• Results from bullet wounds, etc.
• Largely focal damage
• Penetration of the skull
• Effects can be just as serious as closed brain injury

2. Closed Head Injury

• Resulting from a slip and falll, motor vehicle crashes, etc.
• Focal damage and diffuse damage to axons
• Effects tend to be broad (diffuse)
• No penetration to the skull

3. Deceleration Injuries (Diffuse Axonal Injury)

The skull is hard and inflexible while the brain is soft with the consistency of gelatin.  The brain is encased inside the skull.  During the movement of the skull through space (acceleration) and the rapid discontinuation of this action when the skull meets a stationary object (deceleration) causes the brain to move inside the skull.  The brain moves at a different rate than the skull because it is soft.  Different parts of the brain move at different speeds because of their relative lightness or heaviness.  The differential movement of the skull and the brain when the head is struck results in direct brain injury, due to diffuse axonal shearing, contusion and brain swelling.

Diffuse axonal shearing: when the brain is slammed back and forth inside the skull it is alternately compressed and stretched because of the gelatinous consistency.  The long, fragile axons of the  neurons (single nerve cells in the brain and spinal cord) are also compressed and stretched.  If the impact is strong enough, axons can be stretched until they are torn.  This is called axonal shearing.  When this happens, the neuron dies.  After a severe brain injury, there is massive axonal shearing and neuron death.

4. Chemical / Toxic

• Also known as metabolic disorders
• This occurs when harmful chemicals damage the neurons
• Chemicals and toxins can include insecticides, solvents, carbon monoxide poisoning, lead poisoning, etc.

5. Hypoxia (Lack of Oxygen)

• If the blood flow is depleted of oxygen, then irreversible brain injury can occur from anoxia (no oxygen) or hypoxia (reduced oxygen)
• It may take only a few minutes for this to occur
• This condition may be caused by heart attacks, respiratory failure, drops in blood pressure and a low oxygen environment
• This type of brain injury can result in severe cognitive and memory deficits

6. Tumors

• Tumors caused by cancer can grow on or over the brain
• Tumors can cause brain injury by invading the spaces of the brain and causing direct damage
• Damage can also result from pressure effects around an enlarged tumor
• Surgical procedures to remove the tumor may also contribute to brain injury

7. Infections

• The brain and surrounding membranes are very prone to infections if the special blood-brain protective system is breached
• Viruses and bacteria can cause serious and life-threatening diseases of the brain (encephalitis) and meninges (meningitis)

8. Stroke

• If blood flow is blocked through a cerebral vascular accident (stroke), cell death in the area deprived of blood will result
• If there is bleeding in or over the brain (hemorrhage or hematoma) because of a tear in an artery or vein, loss of blood flow and injury to the brain tissue by the blood will also result in brain damage