Brain Injuries
"Litigation can be a difficult process for the survivor to endure. While we advocate strongly for survivors, we ensure that they feel well protected and able to focus on their rehabilitation during the process"
M. Dee Rogers, Paralegal
Background
Traumatic Brain Injury (TBI) is an injury to the brain, and is a subset of "head injury". Not all head injuries result in a TBI. Sometimes "head injury" and "brain injury" are used incorrectly and interchangeably. Traumatic brain injuries occur as a result of external injuries (ie: car crash) while anoxic brain injuries are internal (ie: stroke).
The Injury
Most brain injuries are the result of bruising, bleeding, twisting or tearing of brain tissue. Damage may occur at the time of injury, or develop later as a result of swelling or bleeding within the head or other medical complications of the injury. Survivors may have more than one type of injury.
The Brain
The brain is a three pound, jellylike mass made up of millions of microscopic cells that are suspended in cerebrospinal fluid. The brain is composed of individual cells called neurons. TBI can cause these cells to malfunction or even die
There are three main areas in the brain: the cortex(cerebrum), the cerebellum and the brain stem (diancephalon).
The cortex is the largest. It is the center where most thinking functions occur. It has four lobes that control specific functions and skills, and two hemispheres: the right and the left. The left hemisphere is usually the dominant one and controls verbal functions such as speaking, writing, reading and calculating. The right controls visual-spacial functions such as visual memory, copying, drawing and rhythm.
The frontal lobe is often damaged because of its size and location near the front of the cranium, and is involved in many cognitive functions; it is considered to be our emotional and personality control center. Damage to temporal lobes has been associated with behavioural disorders.
The cerebellum is responsible for coordination, balance and posture.
Perhaps the most critical part of the brain is the brain stem. It connects the brain to the spinal cord and controls survival functions, such as breathing, heart rate, consciousness and alertness.
The brain is protected by the cranium or skull. The outside of the skull is smooth, but the inner surface contains ribbing and pronounced bony structures. When the brain moves inside the skull, it can be thrust into these bony protrusions, which tear or bruise the tissue, causing injury. The swelling and compression that follow this injury can cause long-term effects.
Neurological Imaging
Neurological imaging, beyond very obvious injuries from depressed skull fractures or obvious head injuries, occurs with the use of CT scans or CAT scans or MRI imaging.
Those complex machines can image (take pictures) of the inside of the brain. They are able to image blood in the brain, cell death (atrophy), swelling (edema) and other damage to the brain tissues.
Types of Brain Injury
Skull fracture
Skull fracture is a break in the bone that surrounds the brain. The fracture may heal on its own or, if there is tissue damage below the fracture, require remedial surgery. A skull fracture can be depressed, meaning part of the skull is pushed into the brain, but even a non-depressed skull fracture is very serious.
Anoxic brain injury
An anoxic brain injury is caused by a lack of oxygen to the brain. It usually results from lack of blood flow due to injury or bleeding and will cause the swelling of brain tissue.
Contusion/Concussion
Contusion or concussion is often mislabeled a "mild" injury to the brain resulting in bruising of brain tissue. This injury may cause headaches, vomiting, dizziness and problems remembering or concentrating. It does not require surgery. While there is little or no loss of consciousness, the long-term results certainly may not be "mild".
Coup-contrecoup
A coup injury is caused when the brain is propelled against one side of the skull. Because brain tissue is suspended in fluid, it often rebounds and collides with the opposite side of the skull. When it strikes both sides of the skull, the injury is sometimes called a contrecoup injury.
Diffuse Axonal Injury (DAI)
Diffuse axonal injury results when a rotational or shearing force is exerted on the nerve fibres. DAI may cause a loss of consciousness, or coma, which may last from a short time to an indefinite period.
The rotational force of this injury causes a shearing of the nerve connections and pathways. These pathways may tear and be lost, and once they are gone they cannot be rebuilt. The brain must then attempt to find alternate pathways to resume the functions of the severed paths.
DAI can be particularly devastating, because the brain stem is a critical relay station. It controls consciousness, alertness and basic bodily functions. Especially frustrating is that these injuries are microscopic and usually cannot be detected in radiographic studies, such as CT scans or MRI scans. Nonetheless, SPECT f-MRI and PET scans can sometimes pick them out.
Hematoma (Epidural and Subdural)
Epidural hematoma is an accumulation of blood between the skull and the top lining of the brain(dura). This clot may cause pressure changes in the brain, and emergency surgery may be necessary. The size of the clot will dictate the necessity of surgery.
This bleeding may increase pressure on the brain, causing it to be forced down the spinal column, compressing the brain stem and resulting in death. This is a neuro surgical emergency.
An intracerebral hemmorhage is a blood clot deep in the middle of the brain that is hard to remove. Pressure from this clot may cause tissue damage, and surgery may be needed to relieve the pressure.
A subdural hematoma refers to the formation of a blood clot between the brain tissue and the dura. If it occurs slowly over several weeks it is referred to as a subdural hematoma; if it occurs quickly it is referred to an acute subdural hematoma. The clot may cause pressure and require surgical removal.
Spinal cord injuries
Brain injury is the worst common other injury associated with spinal cord injuries (up to 58% concurrence.) The effects of impaired attention, concentration and memory can profoundly affect the rehabilitation process and outcome following spinal cord injury. It is essential that an expert in traumatic brain injury cases be employed to manage these exceptionally complex situations. For an introduction to the management of this combination injury see: Cynthia Perry Zejdlik, R.N., Management of Spinal Cord Injury, 2nd ed. (Boston: Jones & Bartlett, 1992).
More information can also be found at http://www.canparaplegic.org.
Pediatric brain injuries
The tragedy of traumatic brain injury knows no age barriers. Traumatic brain injury in children can add to the complexity of an already complex injury. Determining the true nature of any deficit is more difficult in a young person; a developing child may have no clear "before or after". The realization of problems caused by an early injury may not be obvious until years later. Families may be expected to undertake care (and be willing to do so) beyond their ability to provide it, and without proper respite or compensation.
Medical Terminology - Common Terms
Few people have comprehensive knowledge or understanding of the brain neuro-anatomy or the functions. Most people are forced to do a crash course on brain injury or rehabilitation when a family member or close friend is hurt. This section of our website is intended to assist the person with little or no background in brain injury, and who seeks a basic understanding of the terms often used in discussions concerning brain injury, and a quick glimpse of the future. For more comprehensive information on these subject areas, see the Resources, Articles and Links sections on this site.
Acquired brain injury
Acquired brain injury is an impairment of normal brain function, due to stroke, bleeding into the space between the brain and skull, loss of oxygen, tumours and other diseases of the brain.
Closed head injury
Some brain injuries are "closed head injuries", meaning that the skull has not been penetrated or fractured into brain tissue. Though survivors may not exhibit external signs of injury, a closed head injury can cause widespread damage and results in extensive, or "global", neurologic deficits. The injury can also be categorized as 'mild', 'moderate' or 'severe'. These deficits can range from partial to complete paralysis; cognitive, behavioural and memory dysfunction; a persistent vegetative state; or death.
Global disruption
Global disruption of D.A.I. (Diffuse Axonal Injury) is rarely detectable in a basic neurological examination of mental status, motor control, reflex, or sensation. Most often it is detected in the neuropsychological evaluation of cognitive function. In the worst injury, global disruption is obvious on MRI and is fatal. In its mild form, symptoms may be confused with chronic fatigue, depression, attention deficit disorder, somatiform disorder, hysteria or malingering.
Coma
Coma is a state of unconsciousness from which the injured survivor cannot be awakened or aroused by any means. Clinically described, it is an inability to follow a one-step command consistently. This term, as well as the description 'loss of consciousness' are used colloquially and incorrectly all the time. Commonly, court cases involve arguments about the legal definitions of these words.
Glasgow coma scale
The Glasgow Coma Scale (GCS) rates the survivor's ability to open his or her eyes and respond to verbal commands. Each level indicates a level of brain injury. The lowest possible cumulative score for the four sections is 3(no response); the alert and oriented survivor is rated at 15.
| Eyes | Score |
| Open spontaneously | 4 |
| Open to verbal command | 3 |
| Open to pain | 2 |
| No response | 1 |
| Best verbal response | |
| Oriented and converses | 5 |
| Disoriented and confused | 4 |
| Inappropriate words | 3 |
| Incomprehensible sounds | 2 |
| No response | 1 |
Glasgow outcome scale
The Glasgow outcome scale (GOS) was commonly used before other scales were developed. The five categories of the original scale are: dead, vegetative, severely disabled, moderately disabled, and good recovery. An extended version of the scale divides each of the latter three categories in two, making eight categories.
| Good Recovery | |
| Resumption of normal activities even though there may be minor neurological or psychological deficits | 5 |
| Moderate Disability | |
| Disabled but independent. Patient is independent as far as daily life is concerned. The disabilities found include varying degrees of dysphasia, hemiparesis, or ataxia, as well as intellectual and memory deficits and personality changes | 4 |
| Severe Disability | |
| Conscious but disabled. Patient depends upon others for daily support due to mental or physical disability, or both. | 3 |
| Persistent Vegetative State | |
| Patient exhibits no obvious cortical function | 2 |
| Death | |
| 1 | |
Mild brain injury
Unlike moderate or severe traumatic injury, where the deficits caused by the injury are rarely doubted, mild brain injury often goes unrecognized and is sometimes never detected. An injured survivor with mild traumatic brain injury suffers from a disruption of brain function, which may include a brief loss of consciousness, loss of memory of events immediately before or following the accident, an alteration of mental state at the time of the accident, or focal neurological deficits.
As in other brain injuries, mild traumatic brain injury may be the result of straining and shearing of anoxal connections or the release of excessive quantities of chemicals that the body produces. These chemicals may include glutamate, seratonin or acetylcholine, or prostaglandins, which in excess amounts can damage healthy tissue.
To the casual observer, the injured survivor may appear to be oriented and alert and most often evidence of the injury does not appear on radiographic images. Some injured survivors might not be aware of the extent of their symptoms until they attempt to return to normal living. Mild traumatic brain injury (MTBI) may also be overlooked in cases where other physical injury also occurs. Unfortunately, testiary care facilities sometimes focus on physical or orthopedic injuries, based upon a triage response system and MTBIs are overlooked.
Many people with mild brain injury "know" that something is wrong, but are not diagnosed, treated, counselled or rehabilitated. Determining and establishing the extent of the injury, whether it is permanent or temporary, and what difficulties will persist or worsen in the future, is very difficult. If not immediately diagnosed, the evidence for mild brain injury must be reconstructed. This is difficult but not impossible. More success occurs when the survivor has a strong, helpful family.
Often injured survivors recover fully, some in as little as three months after, others taking one to two years. Some survivors never recover. Litigation in these cases often revolves around 'causation' or other possible causes of the brain injury.
Open head injury
Open head injury results when an object has penetrated the skull and caused bleeding and other damage to brain tissue. It is generally more severe than closed head injury.
Traumatic brain injury
Traumatic brain injury is any injury to the brain that results in structural damage to brain tissue and/or disrupted brain function. The injury may be caused by a direct insult (e.g. blunt trauma) fracture or an indirect (whiplash or inhalation of toxic fumes) insult to the brain. TBI is commonly caused by car crashes, but may also result from falls, cycling, accidents, sports injury or a host of other incidents.
TBI leaves temporary or permanent impairment and partial-to-total functional disability. The damage may occur at the time of the injury or may develop later due to swelling and bleeding inside the head.
TBI may be immediately accompanied by a significant period of complete loss of consciousness (coma) and post-traumatic amnesia. Those who suffer skull fractures, loss of consciousness and coma are generally diagnosed with moderate to severe injuries, and their impairments are generally accepted as resulting from brain injury.
Mechanisms of TBI
The most dangerous mechanisms of trauma to the head and brain include:
- pedestrian struck by a vehicle
- occupant of MVA is ejected from vehicle
- a fall of 3 or more feet or 5 stairs
- high speed motor vehicle collisions
Brain Injury Symptoms
Injured survivors of traumatic brain injury manifest post-concussion syndrome. Symptoms include:
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Patients complain of trouble organizing thoughts, inability to express themselves, difficulty selecting and recalling words, short temper, learning and retaining new information, getting lost, confusion and agitation.
Early on, the survivor really must seek help dealing with the symptoms of traumatic brain injury. However, the symptoms themselves often interfere with that process.
Individuals sustaining mild brain injury manifest varied symptoms that may include the following:
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Traumatic Brain Injury and the Family
Advances in critical care
Advances in critical care medicine have led to the survival of a growing number of individuals who have sustained TBI. Many people now survive injuries that would once have been fatal. Though they remain alive, they often suffer a range of physical deficits. Despite the cause of the brain injury, attention must be focused on providing for survivor needs and rehabilitation.
At this point, society is seriously ill-equipped to deal with the needs of brain injury survivors, due to advances in critical care following brain injury, there are more survivors needing assistance. Family members often become caregivers that may mandate someone giving up their life to care for the injured survivor. Tremendous pressures are brought to bear on other family members, such as siblings who may end up leaving home early. Injured survivors without family or financial protection may be relegated to the streets, or misdiagnosed as mentally ill.
Survival also comes at great personal cost to the brain injury survivor. Living with the intuitive sense that something "wrong", painful rehabilitation, mental anguish and the general misery associated with loss; pressures of establishing communication, reconstructing a shattered life and building new relationships are but a few of the physical and emotional expenditures injured survivors must make. In general, society suffers, not only from the extraordinary costs of care for the seriously brain injured, but more critically in the lost potential. The collective loss of creative, societal, financial and other contributions which society never realizes compounds this tragedy.
Statistics and Facts
- 56,000 new cases of TBI occur each year; in 36,000 people the injury is severe enough to require hospitalization; of these, 2,500 will die. 9,000 injured survivors will require long-term rehabilitation; 6,000 of these will live with disability.
- Traumatic Brain Injury(TBI) is the leading cause of death and disability in children and young adults.
- Half of all brain injuries are the result of motor vehicle collisions. The remainder are caused by work-related injuries, falls, illness, sports injuries, firearms or assaults.
- TBI occurs mainly in young adults; approximately 70% of survivors are between age 18 and 28.
- Young men between 14 and 24 have the highest rate of injury; the risk of TBI among males is twice that of females.
- Children are at particular risk of bicycle-related brain injury and death; most injuries happen during the summer months and involve children aged 15 years and younger.
- Survivors of serious TBI may face five to ten years of rehabilitation services.
- Most TBI survivors will live a normal lifespan.
- After a TBI incident, the potential risk for subsequent multiple injury is extremely common. U.S. statistics report that among people with an initial TBI incident, the risk of a second injury is two to three times greater than that of the general population; after a second injury, the potential for a third increases to eight times the normal average.
The Aftermath of Brain Injury
Profound impact on couples
Probably the most profound impact of TBI is on a spousal union when a partner is injured. Partner relationships and family roles and responsibilities change and interpersonal communication becomes a major challenge and injured survivors and non-injured survivors deal with the intense feelings of shock, denial, anger, and depression that accompany the many losses resulting from TBI. TBI may lead to role changes, and with that changes in identity, because our role often defines who we are. Children are often troubled by the sudden helplessness of a parent, and may feel left out or forgotten. They require special support: the help of extended family and friends can help fill this need. The non-injured spouse may also at some time also feel an overwhelming need for support.
Sexual dysfunction
TBI survivors generally lose their sex drive, though in rare instances they experience a dramatic increase. Many non-injured spouses also experience a drastic reduction in libido, which may be linked to fatigue, worry, increased responsibility or the unfamiliarity of having a 'stranger', in bed - the changed injured survivor. It takes time for couples to adjust, and it is important to seek counseling if difficulties with intimacy and sexuality persist.
A swirl of emotions
Guilt is a common emotion among non-injured spouses. They may yearn for more personal space, but at the same time experience a need to do nearly everything for the survivor. They often report being torn between protecting the survivor and pushing them toward greater independence. They feel considerable emotional upheaval as a result of the dramatic shift in roles and circumstances. The non-injured spouse can be overwhelmed caring for a brain injured spouse, peer or parent who may have become almost infant-like. The staggering demands and loss of material, companionship and emotional support once provided by the injured survivor can result in a swirl of powerful emotions. Many non-injured spouses recall that at some point they lost confidence and began to question their own motives and judgment: were they holding the survivor back or were they pushing the survivor too hard? The key to finding balance seemed to come from open communication.
The challenge of communication
After trauma, everyone is vulnerable, so clear communication is particularly important; however communication with an injured survivor may be hampered by physical limitations or changes in their thinking patterns. It is not uncommon for misunderstanding and intense frustration to occur.
Many non-injured spouses recall that at some point they lost confidence and began to question their own motives and judgment: were they holding the survivor back or were they pushing the survivor too hard? The key to finding balance seemed to come from open communication. People close to the survivor who are burdened with new responsibilities also change after an incident resulting in brain injury. This may result when the injured survivor can no longer provide support for the spouse and family. The feelings of resentment, anger and guilt that arise often become stumbling blocks. Emotional stress and anxiety, and the struggle to deal with huge changes can mount enormous challenges.
To deal with these issues, the questions, can we do this together and are we able and willing to live with these changes must be resolved. Even after the decision has been made to make a go of it, the challenges of communicating with the injured survivor may require considerable adaptation. The many spouses whose relationships have succeeded have learned to avoid exchanges that lead to misunderstanding, and have found and use communication styles that work.
Feelings of loss
Personality changes in a TBI survivor often evoke the feeling of "having lost a loved one". Everyone who is affected by brain injury suffers loss, including the injured survivor and the non-injured family members. Injured survivors clearly suffer widespread loss on many fronts. Beyond the physical and cognitive losses, they often resent the loss of authority and responsibility they once held within the family. They may also experience a sense of bewilderment and feelings of being cheated out of something precious. These feelings may make it hard for them to place trust or plan for future, and for some, this readjustment is a lonely process. Non-injured survivors also suffer many of the same feelings of loss as they are affected when roles and relationships with the injured survivor change. All must adjust to a new world that include changes in lifestyle and responsibility; perhaps the loss of mobility and flexibility; and possibly a loss of connection to friends and activities in the "outside" world. These feelings of loss are quite common, and surface often.
Feelings of grief
When the shock of the injury has subsided, grieving begins and may last long after the initial injury. Grief may take the form of outrage or denial, or it may manifest as a profound sense of injustice. Many people experience depression as they come to realize that things will never again be the same. Clinical depression may set in, whose symptoms include low energy, apathy, disrupted sleeping habits, changes in appetite, decreased sexual interest, sadness, excessive self-criticism, and/or suicide. Every person reacts differently to traumatic brain injury, so the readjustment mechanism is different for each. Some may shy away from the deep feelings surrounding brain injury, and others withdraw from the family or become workaholics or resort to the use drugs or alcohol to "dull the pain". Even people not directly involved and who may want to help may find it difficult to relate. As a result, major problems in handling the stages of grief may prevent resolution and acceptance, creating obstacles that must be dealt with.
Coping
Those who have trouble coping may find that the problem creates difficulty at work or school, in friendships, changed attitudes or behaviors.
Extreme stress may cause irritability, feelings of being overwhelmed, increased physical tension. Legal problems and inappropriate sexual affairs may also be experienced by those whose lives have been seriously affected by TBI.
No matter how they cope, all survivors describe a long process of adjustment. Some families are torn apart, but others pull together and move forward. This approach often brings feelings of hope, and with time, things begin to make sense.
Experts recommend that you pay attention to how you feel and how your approach helps you, and those around you, get through each day. Name your coping device and use it in times of need. Recognize what you do to cope: some need to share their experience with others; some find release in a good cry and others take comfort from humour and laughter; and many find that focusing on solutions rather than problems is a great help.
Those who are best able to adjust to living with brain injury seem to be the ones who focus on the positive side of the experience. They tend to identify and welcome the positive changes that have been introduced into their lives. This is an attitude that unfolds naturally, and one that can be nurtured and developed.
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