Traumatic brain injury

Traumatic brain injury is damage to the bone (or bones) of the skull, soft tissues, including the meninges, nerves and blood vessels. All traumatic brain injuries are divided into two large categories: open and closed. According to another classification, they talk about penetrating and not, about concussion and bruises of the brain.

The content of the article:
Principles of classification of traumatic brain injury
The following clinical forms of TBI are distinguished
Concussion of the brain
Mild brain injury
Moderate brain injury
Severe brain injury
Diffuse axonal brain injury
Compression of the brain
Treatment of traumatic brain injury
Prognosis for traumatic brain injury
Traumatic brain injury
The TBI clinic will be different in each case — it all depends on the severity and nature of the disease. Among the typical symptoms are:

headache;
vomiting;
nausea;
dizziness;
memory impairment;
loss of consciousness.
For example, an intracerebral hematoma or brain injury is always expressed by focal symptoms. It is possible to diagnose the disease on the basis of the anamnestic indicators obtained, as well as during a neurological examination, X-ray, MRI or CT.

Principles of classification of traumatic brain injury
According to biomechanics , the following types of TBI are distinguished
From the point of view of biomechanics, they talk about the following types of traumatic brain injuries:

shock-shock (when a shock wave passes from the place of collision of the head with an object through the entire brain, up to the opposite side, while a rapid pressure drop is observed);
acceleration-deceleration trauma (in which the large hemispheres move from a less fixed to a more fixed brain stem);
combined trauma (in which there is a parallel effect of the two mechanisms listed above).
By type of damage
According to the type of TBI damage , there are three types:

Focal: they are characterized by so-called local damage to the basis of the brain substance of a macrostructural nature; usually damage to the brain substance occurs throughout its thickness, except for places of small and large hemorrhage in the area of impact or shock wave.
Diffuse: they are characterized by primary or secondary axon ruptures located in the semioval center or corpus callosum, as well as in subcortical areas or the brainstem.
Injuries that combine focal and diffuse injuries.
By the genesis of the defeat
Regarding the genesis of the lesion, traumatic brain injuries are divided into:

Primary (these include focal type bruises, diffuse axonal injuries, primary intracranial hematomas, trunk rupture, significant intracerebral hemorrhages);
Secondary:
secondary lesions resulting from intracranial factors of a secondary type: impaired cerebrospinal fluid circulation or hemocirculation due to intraventricular hemorrhage, cerebral edema or hyperemia;
secondary lesions caused by extracranial factors of secondary type: hypercapnia, anemia, hypertension, etc.
By type of TBI
By type, traumatic brain injuries are usually divided into:

closed — a type of damage that does not violate the integrity of the skin of the head;
open non-penetrating TBI, which is not characterized by damage to the hard membranes of the brain;
open penetrating TBI, which is characterized by damage to the hard membranes of the brain;
fractures of the bones of the cranial vault (with no damage to adjacent soft tissues);
fractures of the base of the skull with further development of liquorrhea or ear (nasal) bleeding.
According to another classification , there are three types of TBI:

Isolated appearance — the presence of extracranial injuries is not characteristic.
Combined appearance — characterized by the presence of extracranial type of damage, as a result of mechanical influence.
Combined view — it is inherent in the combination of different types of damage (mechanical, radiation or chemical, thermal).
By nature
The severity of the disease is of three degrees: mild, moderate and severe. If we evaluate the severity of the disease on the Glasgow coma scale, then a mild TBI falls under 13-15 points, a moderate TBI is 9-12 points, and a severe one is 8 points or less.

According to its symptoms, a mild degree of TBI is similar to a mild brain injury, a moderate one is a moderate brain injury, while a severe one is a more severe brain injury.

According to the mechanism of occurrence of TBI
If we classify TBI by the mechanism of its occurrence, then there are two categories of injuries:

Primary: when no cerebral (or extra-cerebral) catastrophe precedes the traumatic energy of a mechanical nature directed at the brain.
Secondary: when a cerebral (or extra-cerebral) catastrophe usually precedes a traumatic energy of a mechanical type.
It should also be said that traumatic brain injuries with characteristic symptoms can be both for the first time and repeatedly.

The following clinical forms of TBI are distinguished
In neurology, there are several forms of TBI that are bright in their symptomatology, including:

brain contusions (mild, moderate and severe stages);
concussion;
brain compression;
diffuse axonal injury.
The course of each of these forms of TBI has acute, intermediate and long-term periods. According to the time, each of the periods lasts differently, it all depends on the severity and type of injury. For example, the acute period can last from 2 to 10-12 weeks, while the intermediate period lasts up to six months, and the long-term period sometimes lasts up to several years.

Concussion of the brain
Concussion of the brain is considered the most common injury among TBI. It accounts for more than 80% of all cases.

Diagnosis
It is not so easy to make an accurate diagnosis of a concussion from the first time. Usually, a traumatologist and a neurologist are involved in the diagnosis. The main indicator in the diagnosis is a subjectively collected anamnesis. Doctors ask the patient in detail about how the injury was received, determine its nature, and conduct a survey of possible witnesses of this injury.

A significant role is assigned to the examination by an otoneurologist, who determines the presence of symptoms that are an irritant factor for the vestibular analyzer in the apparent absence of signs of so-called prolapse.

Due to the fact that the nature of the concussion is usually mild, and the cause of its occurrence may be one of the pre-traumatic pathologies, during diagnosis, great importance is paid to changes in clinical symptoms.

This diagnosis can be finally confirmed only after the disappearance of typical symptoms, which usually occurs 3-5 days after receiving a TBI.

As you know, concussion is not inherent in fractures of the bones of the skull. At the same time, the indicator of craniocerebral pressure, as well as the biochemical composition of the liquor, remain unchanged. CT or MRI are considered an accurate diagnostic method, but they do not allow to identify intracranial spaces.

Clinical picture
The main indicator of the clinical picture of traumatic brain injury is depression of consciousness, which can last from a few seconds to a minute or more. In some cases, the oppression of consciousness is completely absent.

In addition, the patient may develop retrograde, antegrade or congrade amnesia. Another characteristic symptom accompanying TBI is vomiting and rapid breathing, which quickly recovers. Blood pressure also normalizes quickly, except in cases when the anamnesis is complicated by hypertension. At the same time, the body temperature remains normal.

After the patient regains consciousness, he begins to complain of headache, dizziness and general weakness. Cold sweat appears on the patient’s skin, cheeks turn red, sound hallucinations may appear.

If we talk specifically about the neurological status, then it is characterized by asymmetry of tendon reflexes of a mild type, as well as a horizontal type of nystagmus in the corners of the eyes and mild meningial symptoms, which may disappear after the first week of the disease.

In the case of a concussion of the brain, the cause of which was TBI, after two weeks the patient feels healthy, but some asthenic phenomena may persist.

Treatment
As soon as a person who has received a traumatic brain injury recovers, he needs to immediately provide first aid. To begin with, lay him down, giving a horizontal position, while slightly raising his head.

That patient with a traumatic brain injury who is not yet conscious should be laid on his side (preferably on the right), turning his face to the ground, and bending his arms and legs at right angles, but only if there are no fractures in the knee or elbow joints. It is this pose that helps the air to pass freely, reaching the lungs, and at the same time, not allowing the tongue to sink or choke with its own vomit.

If the patient has open wounds on the head, then it is necessary to apply an aseptic bandage. It is best to immediately transport a person with a traumatic brain injury to a hospital, where they can diagnose TBI and prescribe bed rest on an individual basis (it all depends on the clinical features of each patient’s course).

If, after CT and MRI, the results of the examination do not show any signs of focal-type brain lesions, then medication is not prescribed and the patient is almost immediately discharged home for outpatient treatment.

In the case of a concussion, active medication is usually not prescribed. The main goal of the initial treatment is to normalize the state of the brain, restoring its functionality, as well as relieving headaches and normalizing sleep. To do this, various analgesics and sedatives are used.

Forecast
In the case of a concussion of the brain and compliance with the doctor’s instructions, the process ends with recovery and return to working capacity. After a while, all signs of concussion (depression, anxiety, irritability, loss of attention, etc.) completely disappear.

Mild brain injury
Diagnostics
If we talk about a moderate brain injury, CT helps to detect and identify various kinds of focal changes, which include poorly located areas with reduced density and small-sized areas, on the contrary, with increased density. Along with CT, in this case, an additional diagnostic method may be required: lumbar puncture, electroencephalography, and others.

Clinical picture
It should be noted that the main characteristic of a brain injury of this degree is the duration of loss of consciousness, which manifests itself after the injury. Loss of consciousness with moderate severity of injury will be longer than with mild.

The loss of consciousness may continue for the next 30 minutes. In some cases, the duration of such a condition reaches several hours. At the same time, the congrade, retrograde or anterograde types of amnesia are particularly pronounced. The patient may have severe vomiting and headache. In some cases, there may be a violation of important vital functions.

A moderate brain injury is manifested, first of all, by loss of consciousness with varying duration. Vomiting, headache, abnormalities in the cardiovascular and respiratory systems occur.

Among other possible symptoms:

tachycardia;
bradycardia;
tachypnea (no change in breathing);
increase in body temperature;
occurrence of enveloped features;
the manifestation of pyramidal signs;
nystagmus;
the possibility of dissociation of meningeal symptoms.
Among the most pronounced focal signs in a separate category are: various types of pupillary disorders, speech disorder, sensitivity disorder. All these signs can regress 5 weeks after the onset of occurrence.

After the injury, patients often complain of severe headaches and vomiting. In addition, the manifestation of mental disorders, bradycardia, tachycardia, tachypnea and high blood pressure is not excluded. Meningeal symptoms are very often expressed. In some cases, doctors note a fracture of the skull bones and a subarachnoid hemorrhage.

Moderate brain injury
Usually, mild brain contusions are detected in 15% of people who have received a traumatic brain injury, while the average severity of the injury is diagnosed in 8% of the victims, and severe bruising in 5% of people.

Diagnosis
The main technique in the diagnosis of brain injury is CT. It is this method that helps to determine the area of the brain that has a reduced density. In addition, CT scans can reveal a fracture of the skull bones, as well as determine subarachnoid hemorrhage.

In the case of a severe injury, CT scans can reveal areas of heterogeneously increased density, while, as a rule, perifocal edema of the brain is pronounced with a significant hypodensive path passing into the area of the near section of the lateral ventricle. It is through this place that the release of fluid is observed along with various decay products of brain tissue and plasma.

Clinical picture
If we talk about the clinic of a mild brain injury, then loss of consciousness is inherent in it a couple of minutes after injury. After the victim regains consciousness, he complains of a strong characteristic headache, nausea and dizziness. Congrade and anterograde amnesia are also very often noted.

Vomiting may occur periodically with repetitions. At the same time, all vital functions are preserved. Very often, victims have tachycardia and bradycardia, blood pressure can sometimes be elevated. As for breathing, it remains unchanged, as well as the body temperature, which remains normal. Individual symptoms of a neurological nature may regress after 2 weeks.

Severe brain injury
Regarding severe brain injury, it is accompanied by loss of consciousness, which can be up to two weeks. Very often, such a bruise can be combined with a fracture of the bones of the base of the skull, as well as with severe subarachnoid hemorrhage.

At the same time , the following disorders of human vital functions may be noted:

violation of the respiratory rhythm;
increased blood pressure;
bradiarrhythmia;
tachyarrhythmia;
violation of the patency of the respiratory tract;
severe hyperthermia.
Interestingly, focal symptoms of the affected hemisphere are often hidden behind other symptoms (eye paresis, ptosis, nystagmus, dysphagia, mydriasis and decerebration rigidity). In addition, changes in tendon and foot reflexes may occur.

In case of severe brain injury, the patient’s condition is considered critical. For a person, a comatose state is inherent, lasting from several hours to several days. The patient may be in a state of psychomotor agitation, followed by a depressed mood.

As to where the affected brain tissues will be concentrated, they talk about certain manifestations of symptoms, such as a violation of the swallowing reflex, changes in the work of the respiratory and cardiovascular systems.

The duration of loss of consciousness in severe brain injury is very long and can be up to several weeks. In addition, there may be prolonged excitation of the motor apparatus. The dominance of neurological symptoms (such as nystagmus, swallowing failures, myosis, bilateral mydriasis) is also inherent in patients with this severity of traumatic brain injury.

Often severe bruises lead to death.

Diagnostics
The diagnosis is made after evaluating the following criteria — general condition, condition of vital organs, neurological disorders.

Diagnosis of severe traumatic brain injury is usually carried out using CT and MRI.

Diffuse axonal brain injury
If we talk about the diffuse type of axonal damage to the GM, then it is characterized, first of all, by the manifestation of a comatose state that arose after receiving a traumatic brain injury. In addition, stem symptoms are often expressed.

Coma is usually accompanied by symmetrical or asymmetric decerebration (or decortication). It can also be provoked by ordinary irritations, for example, pain.

The change in the muscle state is always variable: both diffuse hypotension and gormetonia can be observed. Very often, pyramidal extrapyramidal paresis of the limb can manifest itself, including asymmetric tetraparesis. In addition to gross changes in the work of the respiratory system (violations of the rhythm and frequency of habitual breathing), vegetative disorders are also observed, which include increased body temperature, increased blood pressure, hyperhidrosis.

The most striking sign of diffuse axonal brain damage is considered to be the transformation of the patient’s condition, flowing from a coma into a vegetative state of a transient nature. The beginning of such a state is indicated by suddenly opening eyes, however, all possible signs of eye tracking and gaze fixation may be absent.

Diagnosis
With the help of CT diagnostics, with axonal damage to the affected brain, an increase in the volume of the brain is traced, due to which the lateral ventricles, as well as subarachnoid convexital areas or so-called cisterns of the base of the brain can be squeezed. Hemorrhages of a small focal nature, located on the white matter of the cerebral hemispheres and in the corpus callosum, as well as on the subcortical structures of the brain, can very often be detected.

Compression of the brain
Approximately 55% of all cases of TBI patients are characterized by compression of the brain. Usually its cause is an intracranial hematoma that has arisen. In this case, the greatest danger to human life is the rapid growth of focal, stem and cerebral symptoms.

Diagnosis
With the help of CT, a biconvex or flat-convex limited zone can be identified, which is characterized by increased density, adjacent to the cranial vault or located within the boundaries of one or even two lobes. If several sources of bleeding have been identified, then the zone of increased density may acquire an even larger size, differing in its crescent shape.

Treatment of traumatic brain injury
As soon as a patient who has received a TBI is admitted to the hospital, doctors carry out the following measures:

inspection;
x-ray of the skull;
Ultrasound of the chest and abdominal cavity;
laboratory tests;
ECG;
urine tests and consultations with various specialists.
Examination at TBI
So, for example, a body examination includes the detection of abrasions and bruises, the detection of joint deformities and a change in the shape of the chest or abdomen. In addition, during the initial examination, nasal or ear bleeding may be detected. In special cases, during examination, a specialist also detects internal bleeding occurring in the rectum or urethra. The patient may have bad breath.

X-ray of the skull
With the help of an X-ray, the patient’s skull is scanned in two projections, doctors look at the condition of the cervical and thoracic spine, the condition of the chest, pelvic bones and limbs.

Laboratory tests
Laboratory tests include general clinical analysis of blood and urine, biochemical analysis of blood, determination of blood sugar levels and analysis of electrolytes. In the future, such laboratory tests should be carried out regularly.

Additional diagnostic measures
If we talk about an ECG, then it is prescribed for three standard and six thoracic leads. Among other things, additional blood and urine tests may be prescribed in order to detect alcohol in them. If necessary, consult a toxicologist, traumatologist and neurosurgeon.

One of the main methods of diagnosing a patient with this diagnosis is CT. There are usually no contraindications for its implementation. However, it should be known that with obvious hemorrhagic or traumatic shock or poor hemodynamics, CT may not be prescribed. However, it is CT that helps to identify the pathological focus and its localization, the number and density of hyperdensive areas (or, conversely, hypodensive), the location and level of displacement of the median structures of the brain, their condition and degree of damage.

In case of the slightest suspicion of meningitis, a lumbar puncture and a study of the cerebrospinal fluid are usually prescribed, which allows monitoring changes of an inflammatory nature.

If we talk about conducting a neurological examination of a person with TBI, then it should be carried out at least every 4-5 hours. In order to determine the degree of impaired consciousness, the Glasgow coma scale is usually used, which allows you to learn about the state of speech and the ability to react with your eyes to light stimuli. Among other things, the level of focal and oculomotor disorders can also be determined.

If the violation of consciousness on the Glasgow scale is 8 points for the patient, then doctors prescribe tracheal intubation, which helps to maintain normal oxygenation. If depression of consciousness to the level of coma was detected, then, as a rule, an additional ventilator is indicated, giving the patient up to 50% additional oxygen. With the help of a ventilator, the necessary level of oxygenation is usually maintained. However, patients who have been found to have a severe degree of TBI with characteristic hematomas and cerebral edema usually need to measure intracranial pressure, which should be maintained at a level below the 20 mm Hg mark. For this purpose, drugs from the category of mannitol or barbiturates are prescribed. In order to prevent septic complications, escalation (or, alternatively, de-escalation) antibacterial therapy is used.

Post-treatment therapy
For example, in order to treat post-traumatic meningitis, various antimicrobials are used, which, as a rule, doctors allow for endolumbar type of administration.

If we talk about proper nutrition of patients with such a serious injury, then it begins 3 days after the injury. The amount of nutrition will increase gradually, and at the end of the very first week, nutrition in its caloric content should be 100% of the human body’s need for it.

Speaking about the methods of nutrition, two of the most common should be distinguished: enteral and parenteral. In order to stop epileptic seizures, anticonvulsants are prescribed with a minimum dosage. Such drugs include, for example, levetiracetam and valproate.

The main indication for surgical intervention is an epidural hematoma, the volume of which is more than 30 cm3. The most effective method to eliminate it is transcranial removal. If we talk about a subdural hematoma, the thickness of which is more than 10 mm, then it is also surgically removed. Patients in a coma can have an acute subdural hematoma removed using a craniotomy, while the bone flap can be either removed or preserved. A hematoma with a volume of more than 25 cm3 should also be removed as soon as possible.

Prognosis for traumatic brain injury
In more than 90% of all cases of concussion, the patient recovers and his condition is fully restored. A small percentage of recovered people have post-comm syndrome, which manifests itself in a violation of cognitive functions, a change in the mood and behavior of the patient. A year later, all these residual symptoms disappear completely.

It is possible to give any prognosis for severe TBI based on the Glasgow scale. The lower the severity of a traumatic brain injury on the Glasgow scale, the higher the probability of an unfavorable outcome of this disease. When analyzing the prognostic significance of the age qualification, we can conclude about its impact on an individual basis. The most unfavorable symptomatic combination in TBI is hypoxia and hypertension.

Among other things, symptoms of oral automatism may be expressed, as well as paresis and focal epiprimes. It will be extremely difficult to restore the shattered functions. Very often, after recovery, patients have residual disorders in the motor apparatus and there may be obvious disorders of the mental sphere.

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