Traumatic brain injury is a problem with increasing prominence largely because of its prevalence among soldiers and athletes. However, anybody can suffer from a head injury. Most head injuries are considered mild, and many people with mild TBI may never even see a doctor. Like injury to any other part of the body, the treatment of TBI depends on the severity of the injury.
Management of Mild TBI
About 75% of TBI cases are considered mild. The term mild TBI (mTBI) is often considered to be synonymous with a concussion. This involves a knock on the head with resulting change in neurological status, such as a period of confusion or amnesia. Unless there is loss of consciousness or other pronounced neurological deficit, imaging of the head with a CT or MRI is usually unnecessary for diagnosis.
In general, most people are able to recover from the symptoms of a concussion, though depending on how those symptoms are defined, the exact percentage varies widely in the scientific literature. Because the brains of concussion victims are at a higher risk of serious damage if the head is injured again, physical activity is restricted. Repeated concussions not only increase the risk of further concussion, but have also been associated with earlier onset of dementia like Alzheimer's disease.
In 1997, the American Academy of Neurology (AAN) released a set of guidelines for when an adult athlete could return to play following a concussion. For example, if an athlete lost consciousness for a minute or more, that athlete would be unable to play for at least two weeks. Some experts also recommend avoiding taxing mental exercises as well. These guidelines were recognized as being somewhat artificial, and are now being revised in order to highlight the individual nature of concussions and emphasize the importance of a clinician's judgment over a written protocol. "Any athlete who is suspected to have suffered a concussion should be removed from participation until he or she is evaluated by a physician with training in the evaluation and management of sports concussions," states the most recent statement from the AAN states:
When an athlete does return to the sport, a gradual re-introduction is advised, starting with light aerobic exercise, moving on to sport-specific exercises, non-contact drills, then practicing with contact before returning to competitive sports.
While most victims recover from a concussion without difficulty, others suffer from more prolonged problems, including headache, dizziness, insomnia, difficulty thinking, irritability and depression. This spectrum of symptoms is known as post-concussive syndrome. Treatment of these symptoms is tailored to the individual, and focuses on symptom management and recovery of any lost abilities. In more severe cases, occupational and physical therapy, speech and language therapy, and vestibular therapy all may play a role. Medications can help manage insomnia, pain, nausea, and depression.
Treatment of Moderate and Severe TBI
Moderate and severe TBI are serious medical conditions. Patients with these conditions need advanced treatment in a hospital or urgent care center, due to a prolonged loss of consciousness or other neurological deficit which can mimic the signs of stroke. While patients with moderate TBI are suffering from a serious medical problem, they may not need to be in an intensive care unit (ICU), whereas victims with severe TBI will require an ICU intubation to keep their airway open. Severe TBI requires transfer to a level one trauma center where the victim will be put on mechanical ventilation and be evaluated by neurosurgeons to see what further interventions may be necessary.
The management of moderate to severe TBI is complex, and focuses on controlling the second phase of injury. This phase involves swelling of damaged tissue as well neurons dying from lack of oxygen. Adequate oxygen supply to the brain will be delivered by ensuring the airway is open and the patient is breathing adequate supplies of oxygen. The blood pressure must be kept above a certain limit to ensure enough blood reaches the brain. Because patients with severe TBI often also have neck injuries, their neck may be placed in a cervical collar.
The victim will be evaluated closely to see if there are signs of brain swelling. If this swelling becomes too severe, it could increase the pressure in the skull (called intracranial pressure or ICP). This can lead to the brain moving through a small opening into a space to which it doesn't belong, a process called herniation, which has serious and often fatal consequences. For this reason, the victim may require an ICP monitor to be placed by a neurosurgeon into the skull, so that medications or other treatments can be given if the ICP becomes too high. The period of swelling is greatest from 48 to 96 hours after the injury, after which swelling begins to go down, and the victim should hopefully begin to improve. During this time, medical personnel will also work to ensure that the victim does not suffer from fever or seizures.
Each case of TBI is different, and it is often impossible to say with certainty how a patient will do after they leave the hospital. Even mild TBI can have severe consequences. In one study, 7% to 9% of patients with mTBI had residual symptoms three months after being injured and 2% to 3% could not return to their previous jobs. In the most severe cases of TBI, recovery may be prolonged and incomplete, with many victims not surviving more than one year. Recovery can involve intensive physical, occupational, and speech therapy, as well as tireless support from friends and family.
We are still learning a lot about how to best treat people with TBI. Despite all our medical advances, taking precautions to avoid head injury in the first place remains the most pragmatic approach. The best method of managing these injuries is to take appropriate caution to avoid the injury in the first place.
Quality Standards Subcommittee of the American Academy of Neurology, Practice Parameter: The Management of Concussion in Sports. Neurology 1997;48:581-585.
AAN Sports Neurology Section, Practice Committee, and Board of Directors, Position Statement on Sports Concussion, October 2010. www.aan.com/globals/axon/assets/7913.pdf
Jeffrey S. Kutcher, CC Giza; AG Alessi. Continuum: Traumatic Brian Injury, Sports Concussion Volume 16, Number 6, December 2010.
Geoffrey Ling, SA Marshall, DF Moore, Continuum: Traumatic Brian Injury, Diagnosis and Management of Traumatic Brain Injury Volume 16, Number 6,pp 27=40 December 2010.
World Health Organization. International statistical classification of diseases and related health problems, 10th revision. Geneva, Switzerland; World Health Organization, 1992.