Traumatic brain injury. Diagnostics & Therapy
How is traumatic brain injury identified and treated?
How traumatic brain injury is treated very much depends on the severity of the trauma. If the traumatic brain injury is mild, then headaches or neck pain can be treated with medication or physiotherapy. If the trauma is severe, swelling or haemorrhages often occur and these frequently require surgery. So that the degree of severity and the injuries can be defined, various diagnostic steps are carried out. The most important examinations are the CT scan where the patient's head is X-rayed or imaging using an MRI scan. Skull fractures and haemorrhages in the brain are easy to detect.
Traumatic brain injury. Diagnostics, Therapy & Rehabilitation
Diagnostics. How is traumatic brain injury identified?
First important steps.
- Patient history: As far as is possible, details of prior illnesses, medications taken (particularly any medications that inhibit blood clotting) and what happened during the accident should be obtained from the patient.
- Examination: The examination initially focuses on determining the patient's state of consciousness (GCS) and taking the patient's vital signs (respiration, blood pressure and pulse). Concomitant injuries must then be identified. In case of a grade II or III traumatic brain injury, involvement of the cervical spine must be assumed until proven otherwise. Appropriate stabilisation measures must therefore be taken before the patient is mobilised. The neurological examination checks for the presence of signs of neurological deficits by examining the function of the cranial nerves, strength, sensitivity, tendon reflexes and coordination.
- Laboratory: Laboratory testing routinely includes assessment of blood clotting, a blood count, blood gases, liver and kidney function parameters, blood sugar, blood alcohol level (if applicable) and blood typing.
Diagnostic testing for suspected traumatic brain injury.
- X-rays: Fractures can be detected with the aid of an x-ray of the skull and cervical spine. Even patients with minor traumatic brain injury are found to have a fractured skull in approximately 10 percent of cases.
- Computed tomography (CT): Computed tomography of the brain provides x-ray images of the brain and bone structures in the form of slices. They are used to detect and differentiate haemorrhages. They can help to evaluate the space-occupying effect (i.e. the pressure on the brain from haemorrhages and thus to determine quickly whether neurosurgical intervention is necessary. They can also identify cerebral oedema, any enlargement of the spaces containing cerebrospinal fluid, complications associated with strokes and skull fractures. The detection of air inside the skull is indicative of an open-head traumatic brain injury. Whether computed tomography has to be performed even in the case of minor traumatic brain injury must be decided on a case-by-case basis and will be dependent on risk factors such as being aged over 65 years, the patient taking medications that inhibit blood clotting or accidents with an unclear mechanism. In cases of more severe traumatic brain injury, it may in certain circumstances be necessary to perform several follow-up CT scans, depending on the initial findings and clinical course.
- Magnetic resonance imaging (MRI): Magnetic resonance imaging is an imaging procedure that uses powerful magnetic fields to generate images in the form of slices. Unlike computed tomography, this procedure can also be used to detect diffuse axonal injury. Furthermore, the method permits more precise assessment of the brainstem. Special test procedures such as diffusion MRI techniques can be used to identify abnormal blood flows early on. Imaging blood vessels by means of a procedure known as MRA (magnetic resonance angiography) can be used to identify tears in the walls of blood vessels (dissection). However, because the procedure takes a long time and requires patients to remain still, MRI plays a secondary role in acute diagnostics.
- Neurosonography: Ultrasound procedures to detect the dissection of blood vessels and vasospasm.
- Electroencephalography (EEG): Procedures used to measure the electrical activity of the brain. These detect epileptic patterns of activity - an epileptic seizure resulting from traumatic brain injury may be the cause of impaired consciousness. EEG is also valuable to a certain degree for prognosis in cases of severe traumatic brain injury.
- Evoked potentials: Evoked potentials are a test method used to check whether the optic, acoustic and sensory nerve tracts are intact from the peripheral areas to their central representative areas in the brain. This method is also of value for prognostic purposes in cases of severe traumatic brain injury.
Therapy. Treatment of the traumatic brain injury
Treatment: Mild traumatic brain injury
High-risk patients (e.g. aged over 65, patients with coagulation disorders, an unclear trauma history, evidence of a fractured skull) should be observed on the ward for at least 24 hours. A large proportion of patients with slight traumatic brain injury develop what is known as post-traumatic syndrome. The symptoms consist of
- Head and neck pain
- Depressive mood
- Light and sound sensitivity.
Treatment involves medication with painkillers together with physiotherapy and relaxation techniques. For about 10% of these patients, the symptoms are still there for more than a year. This is then known as 'chronic post-traumatic syndrome'. In addition to psychosocial care, treatment is given with a special pain-relieving antidepressant.
Treatment: Moderately severe / severe traumatic brain injury
Patients with moderately severe traumatic brain injury have to be admitted to a special observation ward. In the case of severe disorders of consciousness half of the patients with moderately severe traumatic brain injury will show unusual findings in the computer tomography - most frequently cortical contusions. In almost 30% of these cases neurosurgical intervention is necessary. With severe traumatic brain injury, it is of utmost importance in the first instance to ensure that breathing and the circulatory system are safeguarded. Patients with severe traumatic brain injury are provided with a breathing tube and are mechanically ventilated. This should avoid oxygen deficiency and drops in blood pressure. Observation takes place in an intensive care unit. The next step will depend on the findings from imaging of the brain. In particular intracranial pressure therapy and the question about the necessity for neurosurgery are of prime importance. Whether a haemorrhage has to be relieved, i.e. suctioned off or removed, depends on how much effect its space-occupying effect has. If the CT shows a shift of more than 5mm of the midline structure towards the opposite side, a conservative procedure is usually unsuccessful. To record intracranial pressure, a pressure measurement probe can be introduced into the brain if need be, normally in to the internal spaces of the brain's cerebrospinal fluid, in order to lower intracranial pressure by releasing cerebrospinal fluid. Further treatment options for raised intracranial pressure consist of administering diuretic medication, lowering the brain's metabolism by means of certain narcotic drugs and elevating the upper body by 30°.
Rehabilitation after traumatic brain injury.
Rehabilitation from phase A to D.
Patients in the intensive care phase (phase A) are usually unconscious, bed-ridden, needing full-time care without continence control. The Barthel Index score is 0 for such severely injured patients because in all the identified areas they rely on outside help. As soon as the patient is vitally stable, i.e. no longer dependent on the Intensive Care Unit, he enters in to early rehabilitation phase B.
During early rehabilitation (phase B), the lost functions of the brain are restored. This usually begins when the patient is in a state of unconsciousness or coma vigil and continues if things go well into the continuing rehabilitation phases (Phase C and D). Patients who are still needing a high degree of care, but are mobile in a wheelchair and usually continent with over 30 points are included in phase C. If patients are assessed as having a score of more than 65, this means they still need a considerable degree of care but can do many activities independently, such as eating. As early as Phase D, the patient is often discharged to other clinics for further treatment or for care at home.
The Barthel Index is used to measure the degree of independence in important areas of life and so to record the patient's progress, for instance with moving about, eating, getting dressed, washing, urination and personal hygiene.
The sooner rehabilitation begins, the better the chances of recovery.
Clinical experience has shown that the sooner neurological early rehabilitation is started, the better the chances for the best possible recovery. Therefore at the Schön Klinik we get started with our patients as soon as possible. Getting started with our patients means strongly stimulating the vestibular system; also the flow of information from the activated sensors relating to static equilibrium and position sensors of the limbs leads to general activation. Technical aids are tilting tables, „standing“equipment and sophisticated equipment such as the Erigo (tilting table with passive leg movement). Gerstenbrand coined the term „'bed rest syndrome'“ for the sufferers of many different types of secondary brain damage resulting from inadequate mobilisation out of bed. To improve recovery of patients with the most severe traumatic brain injury, attempting therapy with certain stimulating medications is an option. Overall around 50% of patients with apallic syndrome (coma vigil) following traumatic brain injury regain consciousness. Further rehabilitation is individually tailored according to the deficits and includes - in addition to physiotherapy and ergotherapy - speech and swallowing therapy as well as neuropsychological therapy.
Swallowing and speech therapy
A particular speciality of the Schön Klinik is swallowing therapy and speech therapy. Many patients come to our clinic with severe swallowing and breathing disorders and have to be artificially ventilated and fed. One of the aims of the Schön Klinik is therefore to facilitate independent breathing for the patient through special swallowing and speech therapy. We succeed here so well that 90%* of all neurological rehabilitation patients, who leave the Schön Klinik, are able to breathe independently again. 89%* of patients are able to swallow better at the end of their stay in the clinic.
*Note: internal Quality Assurance system
Physiotherapy and robot-assisted therapy.
Our therapists mobilise our early rehab. patients at Schön Klinik. They move arms and legs and because of this passive conduction of natural movements, the brain could possibly remember capabilities that were thought of as forgotten and regenerate them. The therapists are supported at Schön Klinik by the very latest robots and device technology. For instance paralysed arms, or arms with restricted functions can be trained using special arm robots. Nerve cells are stimulated, muscle building promoted and coordination improved. Once the patient is able to carry out movements independently, work is carried out on their fine motor skills. Our clinics have the following device technology available:
- Arm robots such as Armeo or MIT Manus
- Animal therapy
- Ergotherapy with the provision of medical aids
- Neuropsychological training
- Psychological therapy
- Music therapy
- Physiotherapy according to Vojta- and Bobath
Apallic syndrome or coma vigil
After severe traumatic brain injury 1 – 14% of comatose patients develop what is knows as apallic syndrome or coma vigil. Unlike with a coma, the eyes are open, but the patient is unable to communicate, makes no movements whatsoever, does not obey commands and neither fixes his gaze nor makes any directional eye movements. The mouth moves automatically, the sleep-wake rhythm is disturbed, the patient is often restless, functions of the autonomous nervous system are uninhibited for example the heart, circulatory functions and sweating.
This is caused by the intact brain stem function being disconnected from the damaged cerebrum. It is during this phase that intensive rehabilitation measures become necessary, such as physiotherapy and ergotherapy, especially to avoid secondary complications such as joint stiffness. Furthermore it is known that long periods of being bed-ridden without moving the body or sitting up leads to a variety of side effects. The omission of weight bearing leads to osteoporosis. Moreover a decline in heart activity has been observed, digestive disturbances, susceptibility to infection and a tendency to the formation of blood clots.
Stimulate perception with specific stimuli.
Perception is stimulated using specific sensory stimuli, basal stimulation. Touch, movements, certain smells or even music should animate patients and create a contact with the world around them. Meanwhile it is known that coma vigil patients are more aware than previously thought. This knowledge also affects how coma vigil patients are treated. At Schön Klinik doctors, nurses and therapist talk to patients. On entering the room patients are greeted and are told if they are going to be touched. They take care not to startle patients and are only touched with warm hands.
What can I do as a family member?
Even patients with impaired consciousness or lying in a coma are often capable of perceiving and making contact with close family, even if the injured person is not answering. Short but regular visits by a few (1-2) important relatives or friends are therefore important. Physical contact, speaking calmly and bringing familiar objects, pictures or music can have a favourable effect. Avoid having many different relatives repeatedly asking the same questions of nursing staff and doctors. Specify the primary points of contact.