Closed-head injury

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Closed-head injury is a type of traumatic brain injury in which the skull and dura mater remain intact. Closed-head injuries are the leading cause of death in children under 4 years old and the most common cause of physical disability and cognitive impairment in young people. [1] [2] Overall, closed-head injuries and other forms of mild traumatic brain injury account for about 75% of the estimated 1.7 million brain injuries that occur annually in the United States. [3] Brain injuries such as closed-head injuries may result in lifelong physical, cognitive, or psychological impairment and, thus, are of utmost concern with regards to public health. [4]

Contents

Symptoms

If symptoms of a head injury are seen after an accident, medical care is necessary to diagnose and treat the injury. Without medical attention, injuries can progress and cause further brain damage, disability, or death. [5]

Common symptoms

Because the brain swelling that produces these symptoms is often a slow process, these symptoms may not surface for days to weeks after the injury. [5] Common symptoms of a closed-head injury include:

Severe injury symptoms

Severe head injuries can lead to permanent vegetative states or death, therefore being able to recognize symptoms and get medical attention is very important. Symptoms of a severe closed-head injury include:

Secondary symptoms

Secondary symptoms are symptoms that surface during rehabilitation from the injury including social competence issues, depression, personality changes, cognitive disabilities, anxiety, and changes in sensory perception. More than 50% of patients who suffer from a traumatic brain injury will develop psychiatric disturbances. [6] Although precise rates of anxiety after brain injury are unknown, a 30-year follow-up study of 60 patients found 8.3% of patients developed a panic disorder, 1.7% developed an anxiety disorder, and 8.3% developed a specific phobia. [7] Patients recovering from a closed-head or traumatic brain injury often suffer from decreased self-esteem and depression. This effect is often attributed to difficulties re-entering society and frustration with the rehabilitation process. Patients who have suffered head injuries also show higher levels of unemployment, which can lead to the development of secondary symptoms. [8]

Causes

Closed-head injuries are caused primarily by vehicular accidents, falls, acts of violence, and sports injuries. [4] Falls account for 35.2% of brain injuries in the United States, with rates highest for children ages 0–4 years and adults ages 75 years and older. [3] Head injuries are more common in men than women across every age group. [3] Boys aged 0–4 years have the highest rates of brain injury related hospital visits, hospitalizations, and deaths combined. [3] Multiple mild traumatic brain injuries sustained over a short period of time (hours to weeks), often seen with sports-related injuries, can result in major neurological or cognitive deficits or fatality. [9]

Blast-related traumatic brain injuries are often closed-head injuries and result from rapid changes in atmospheric pressure, objects dislodged by the blast hitting people, or people being thrown into motion by the blast [10] Blast-related injuries have shown a recent increase in occurrence with the return of veterans from Iraq such that traumatic brain injury has been coined the "signature injury" of Operation Iraqi Freedom [11]

Closed-head injuries can range from mild injuries to debilitating traumatic brain injuries and can lead to severe brain damage or death. Common closed-head injuries include: [5]

Diagnosis

Classification

Glasgow Coma Scale

The Glasgow Coma Scale is commonly used to assess the severity of traumatic brain injuries, including closed-head injuries. The scale tests a patient's eye, verbal, and motor responses. The scale goes up to fifteen points; with fifteen being the most mild injury, less than eight being a severe brain injury, and three being a vegetative state. [12]

ASCOT

The ASCOT probability of survival encapsulates several of the variables measured in the Glasgow Coma Scale but also includes systolic blood pressure, respiration rates upon admission, and anatomic injuries. The ASCOT was found to be the most sensitive tool for determining severity of head injuries in children and is effective in predicting the outcome of injury. [1] [13]

Mechanism based

A mechanism-based TBI classification system divides traumatic brain injuries (TBI) into closed and penetrating head trauma; based on the way in which the person was injured. [14]

Treatments

There are several different types of treatment available to those who have suffered a closed-head injury. The treatment type chosen can depend on several factors including the type and severity of injury as well as the effects that injury has on the patient. [15] The course of treatment differs for each patient and can include several types of treatment, depending on the patient's specific needs. Early treatment is vital to recovering lost motor function after an injury, but cognitive abilities can be recovered regardless of time past since injury. [16]

Pharmacotherapy

Pharmacotherapy is the utilization of drugs to treat an illness. There are several different drugs that have been used to alleviate symptoms experienced after a head injury including anti-depressants such as amitriptyline and sertraline. Use of these drugs has been associated with a decrease in depression and increased functioning in social and work environments. [15] An antidiuretic called Desmopressin Acetate (DDAVP) has also been shown to improve memory performance in patients [15] Recent studies have examined the preventative effects of progesterone on brain injuries. Phase III trials are currently being conducted at 17 medical centers across the United States. Preliminary results have shown a 50% reduction in mortality in those treated with progesterone and showed an improved functional outcome. [17] Overall, the efficacy of pharmacotherapeutic treatments is dependent on the treatment being used and the symptoms being targeted by the treatment.

Patient education

Patient education has been shown to be one of the most effective ways to decrease secondary symptoms seen with closed-head injuries. Patient education often includes working with a therapist to review symptom management and learn about returning to regular activities. [15] Educational initiatives have also been shown to decrease the occurrence of PTSD in head-injury survivors. [15]

Cognitive rehabilitation

Many patients with severe injuries need therapy to regain basic motor and cognitive skills. Cognitive rehabilitation aims to improve attention, memory function, and cognitive-processing speed. The type of rehabilitation used is tailored to the patient's clinical needs depending on the severity and type of injury sustained. [15]

Other

Other types of rehabilitation focus on raising patient's self-esteem by giving him tasks that can be successfully completed despite any cognitive changes as a result of the brain injury. This process can help decrease secondary symptoms such as feelings of worthlessness, depression, and social anxiety. [18] Some rehabilitation programs use team-building exercises and problem-solving activities to help the patients learn to work with their disabilities. [15]

Prevention

Many closed-head injuries can be prevented by proper use of safety equipment during dangerous activities. Common safety features that can reduce the likelihood of experiencing a brain injury include helmets, hard hats, car seats, and safety belts. Another safety precaution that can decrease a person's risk for brain injury is not to drink and drive or allow oneself to be driven by a person who has been drinking or who is otherwise impaired. [19]

Helmets can be used to decrease closed-head injuries acquired during athletic activities, and are considered necessary for sports such as American "tackle" football, where frequent head impacts are a normal part of the game. However, recent studies have questioned the effectiveness of even American football helmets, where the assumed protection of helmets promotes far more head impacts, a behavior known as risk compensation. The net result seems to have been an increase, not decrease, in injuries. [20] The similar sports of Australian-rules football and rugby are always played helmetless, and see far fewer traumatic brain injuries. (See Australian rules football injuries.)

Bicycle helmets are perhaps the most promoted variety of helmet, based on the assumption that cycling without a helmet is a dangerous activity, with a large risk of serious brain injury. However, available data clearly shows that to be false. Cycling (with approximately 700 American fatalities per year from all medical causes) is a very minor source of fatal traumatic brain injury, whose American total is approximately 52,000 per year. [21] Similarly, bicycling causes only 3% of America's non-fatal traumatic brain injury.

Still, bicycle-helmet promotion campaigns are common, and many U.S jurisdictions have enacted mandatory bicycle-helmet laws for children. A few such jurisdictions, a few Canadian provinces, plus Australia and New Zealand mandate bicycle helmets even for adults. A bicycle-helmet educational campaign directed toward children claimed an increase in helmet use from 5.5% to 40.2% leading to a claimed decrease in bicycle-related head injuries by nearly 67%. [22] However, other sources have shown that bicycle-helmet promotion reduces cycling, often with no per-cyclist reduction in traumatic brain injury. [23] [24]

Estimates of bicycle-helmet use by American adults vary. One study found that only 25-30% of American adults wear helmets while riding bicycles, [25] despite decades of promotion and despite sport cyclists' adoption of helmets as part of their uniform.

Following the commercial (as opposed to public-health) success of bicycle helmets, there have been successful attempts to promote the sale of ski helmets. Again, results have been less than impressive, with great increases in helmet use yielding no reduction in fatalities, and with most injury reduction confined to lacerations, contusions, and minor concussions, as opposed to more serious head injuries. [26]

There have been rare campaigns for motoring helmets. [27] Unfortunately, just as people greatly overestimate the traumatic brain injury danger of bicycling, they greatly underestimate the risk of motoring, which remains the largest source of traumatic brain injury in the developed world, despite the protective effects of seatbelts and airbags.

See also

Related Research Articles

<span class="mw-page-title-main">Head injury</span> Serious trauma to the cranium

A head injury is any injury that results in trauma to the skull or brain. The terms traumatic brain injury and head injury are often used interchangeably in the medical literature. Because head injuries cover such a broad scope of injuries, there are many causes—including accidents, falls, physical assault, or traffic accidents—that can cause head injuries.

<span class="mw-page-title-main">Brain injury</span> Destruction or degeneration of brain cells

Brain injury (BI) is the destruction or degeneration of brain cells. Brain injuries occur due to a wide range of internal and external factors. In general, brain damage refers to significant, undiscriminating trauma-induced damage.

<span class="mw-page-title-main">Concussion</span> Medical condition

A concussion, also known as a mild traumatic brain injury (mTBI), is a head injury that temporarily affects brain functioning. Symptoms may include loss of consciousness; memory loss; headaches; difficulty with thinking, concentration, or balance; nausea; blurred vision; dizziness; sleep disturbances, and mood changes. Any of these symptoms may begin immediately, or appear days after the injury. Concussion should be suspected if a person indirectly or directly hits their head and experiences any of the symptoms of concussion. Symptoms of a concussion may be delayed by 1–2 days after the accident. It is not unusual for symptoms to last 2 weeks in adults and 4 weeks in children. Fewer than 10% of sports-related concussions among children are associated with loss of consciousness.

<span class="mw-page-title-main">Intracranial pressure</span> Pressure exerted by fluids inside the skull and on the brain

Intracranial pressure (ICP) is the pressure exerted by fluids such as cerebrospinal fluid (CSF) inside the skull and on the brain tissue. ICP is measured in millimeters of mercury (mmHg) and at rest, is normally 7–15 mmHg for a supine adult. This equals to 9–20 cmH2O, which is a common scale used in lumbar punctures. The body has various mechanisms by which it keeps the ICP stable, with CSF pressures varying by about 1 mmHg in normal adults through shifts in production and absorption of CSF.

<span class="mw-page-title-main">Bruise</span> Type of localized bleeding in tissues outside blood vessels

A bruise, also known as a contusion, is a type of hematoma of tissue, the most common cause being capillaries damaged by trauma, causing localized bleeding that extravasates into the surrounding interstitial tissues. Most bruises occur close enough to the epidermis such that the bleeding causes a visible discoloration. The bruise then remains visible until the blood is either absorbed by tissues or cleared by immune system action. Bruises which do not blanch under pressure can involve capillaries at the level of skin, subcutaneous tissue, muscle, or bone.

<span class="mw-page-title-main">Subdural hematoma</span> Hematoma usually associated with traumatic brain injury

A subdural hematoma (SDH) is a type of bleeding in which a collection of blood—usually but not always associated with a traumatic brain injury—gathers between the inner layer of the dura mater and the arachnoid mater of the meninges surrounding the brain. It usually results from tears in bridging veins that cross the subdural space.

<span class="mw-page-title-main">Intracranial hemorrhage</span> Hemorrhage, or bleeding, within the skull

Intracranial hemorrhage (ICH), also known as intracranial bleed, is bleeding within the skull. Subtypes are intracerebral bleeds, subarachnoid bleeds, epidural bleeds, and subdural bleeds.

<span class="mw-page-title-main">Traumatic brain injury</span> Injury of the brain from an external source

A traumatic brain injury (TBI), also known as an intracranial injury, is an injury to the brain caused by an external force. TBI can be classified based on severity ranging from mild traumatic brain injury (mTBI/concussion) to severe traumatic brain injury. TBI can also be characterized based on mechanism or other features. Head injury is a broader category that may involve damage to other structures such as the scalp and skull. TBI can result in physical, cognitive, social, emotional and behavioral symptoms, and outcomes can range from complete recovery to permanent disability or death.

<span class="mw-page-title-main">Cerebral contusion</span> Medical condition

Cerebral contusion, Latin: contusio cerebri, a form of traumatic brain injury, is a bruise of the brain tissue. Like bruises in other tissues, cerebral contusion can be associated with multiple microhemorrhages, small blood vessel leaks into brain tissue. Contusion occurs in 20–30% of severe head injuries. A cerebral laceration is a similar injury except that, according to their respective definitions, the pia-arachnoid membranes are torn over the site of injury in laceration and are not torn in contusion. The injury can cause a decline in mental function in the long term and in the emergency setting may result in brain herniation, a life-threatening condition in which parts of the brain are squeezed past parts of the skull. Thus treatment aims to prevent dangerous rises in intracranial pressure, the pressure within the skull.

Post-concussion syndrome (PCS), also known as persisting symptoms after concussion, is a set of symptoms that may continue for weeks, months, or years after a concussion. PCS is medically classified as a mild traumatic brain injury (TBI). About 35% of people with concussion experience persistent or prolonged symptoms 3 to 6 months after injury. Prolonged concussion is defined as having concussion symptoms for over four weeks following the first accident in youth and for weeks or months in adults.

<span class="mw-page-title-main">Blunt trauma</span> Trauma to the body without penetration of the skin

Blunt trauma, also known as blunt force trauma or non-penetrating trauma, describes a physical trauma due to a forceful impact without penetration of the body's surface. Blunt trauma stands in contrast with penetrating trauma, which occurs when an object pierces the skin, enters body tissue, and creates an open wound. Blunt trauma occurs due to direct physical trauma or impactful force to a body part. Such incidents often occur with road traffic collisions, assaults, and sports-related injuries, and are notably common among the elderly who experience falls.

<span class="mw-page-title-main">Chronic traumatic encephalopathy</span> Neurodegenerative disease caused by head injury

Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease linked to repeated trauma to the head. The encephalopathy symptoms can include behavioral problems, mood problems, and problems with thinking. The disease often gets worse over time and can result in dementia.

Second-impact syndrome (SIS) occurs when the brain swells rapidly, and catastrophically, after a person has a second concussion before symptoms from an earlier one have subsided. This second blow may occur minutes, days, or weeks after an initial concussion, and even the mildest grade of concussion can lead to second impact syndrome. The condition is often fatal, and almost everyone who is not killed is severely disabled. The cause of SIS is uncertain, but it is thought that the brain's arterioles lose their ability to regulate their diameter, and therefore lose control over cerebral blood flow, causing massive cerebral edema.

Post-traumatic amnesia (PTA) is a state of confusion that occurs immediately following a traumatic brain injury (TBI) in which the injured person is disoriented and unable to remember events that occur after the injury. The person may be unable to state their name, where they are, and what time it is. When continuous memory returns, PTA is considered to have resolved. While PTA lasts, new events cannot be stored in the memory. About a third of patients with mild head injury are reported to have "islands of memory", in which the patient can recall only some events. During PTA, the patient's consciousness is "clouded". Because PTA involves confusion in addition to the memory loss typical of amnesia, the term "post-traumatic confusional state" has been proposed as an alternative.

Post-traumatic seizures (PTS) are seizures that result from traumatic brain injury (TBI), brain damage caused by physical trauma. PTS may be a risk factor for post-traumatic epilepsy (PTE), but a person having a seizure or seizures due to traumatic brain injury does not necessarily have PTE, which is a form of epilepsy, a chronic condition in which seizures occur repeatedly. However, "PTS" and "PTE" may be used interchangeably in medical literature.

The Rivermead Post-Concussion Symptoms Questionnaire, abbreviated RPQ, is a questionnaire that can be administered to someone who sustains a concussion or other form of traumatic brain injury to measure the severity of symptoms. The RPQ is used to determine the presence and severity of post-concussion syndrome (PCS), a set of somatic, cognitive, and emotional symptoms following traumatic brain injury that may persist anywhere from a week, to months, or even more than six months.

Traumatic brain injury can cause a variety of complications, health effects that are not TBI themselves but that result from it. The risk of complications increases with the severity of the trauma; however even mild traumatic brain injury can result in disabilities that interfere with social interactions, employment, and everyday living. TBI can cause a variety of problems including physical, cognitive, emotional, and behavioral complications.

A sports-related traumatic brain injury is a serious accident which may lead to significant morbidity or mortality. Traumatic brain injury (TBI) in sports are usually a result of physical contact with another person or stationary object, These sports may include boxing, gridiron football, field/ice hockey, lacrosse, martial arts, rugby, soccer, wrestling, auto racing, cycling, equestrian, rollerblading, skateboarding, skiing or snowboarding.

Sleep disorder is a common repercussion of traumatic brain injury (TBI). It occurs in 30%-70% of patients with TBI. TBI can be distinguished into two categories, primary and secondary damage. Primary damage includes injuries of white matter, focal contusion, cerebral edema and hematomas, mostly occurring at the moment of the trauma. Secondary damage involves the damage of neurotransmitter release, inflammatory responses, mitochondrial dysfunctions and gene activation, occurring minutes to days following the trauma. Patients with sleeping disorders following TBI specifically develop insomnia, sleep apnea, narcolepsy, periodic limb movement disorder and hypersomnia. Furthermore, circadian sleep-wake disorders can occur after TBI.

A pediatric concussion, also known as pediatric mild traumatic brain injury (mTBI), is a head trauma that impacts the brain capacity. Concussion can affect functional, emotional, cognitive and physical factors and can occur in people of all ages. Symptoms following after the concussion vary and may include confusion, disorientation, lightheadedness, nausea, vomiting, blurred vision, loss of consciousness (LOC) and environment sensitivity. Concussion symptoms may vary based on the type, severity and location of the head injury. Concussion symptoms in infants, children, and adolescents often appear immediately after the injury, however, some symptoms may arise multiple days following the injury leading to a concussion. The majority of pediatric patients recover from the symptoms within one month following the injury. 10-30% of children and adolescents have a higher risk of a delayed recovery or of experiencing concussion symptoms that are persisting.

References

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  23. ↑ http://www.cyclehelmets.org/1041.html%5B%5D%5B%5D
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  25. ↑ Rosenkranz, Kari M.; Sheridan, Robert L. (2003). "Trauma to adult bicyclists: a growing problem in the urban environment". Injury. 34 (11): 825–9. doi:10.1016/S0020-1383(02)00389-3. PMID   14580814.
  26. ↑ "NSAA : National Ski Areas Association : Press". Archived from the original on 2007-02-08. Retrieved 2011-09-24.[ full citation needed ]
  27. ↑ http://casr.adelaide.edu.au/developments/headband/%5B%5D%5B%5D
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