Concussive Brain Trauma

Neurobehavioral Impairment & Maladaptation, Second Edition

Rolland S. Parker

• Publisher: CRC Press
• Year: 2016
• Print ISBN: 9780367452223
• eBook ISBN: 9781000654363
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Focusing on a public health problem affecting millions of people of all ages, the second edition of Concussive Brain Trauma: Neurobehavioral Impairment and Maladaptation reflects Dr. Rolland S. Parker's more than 25 years of neuropsychological practice and research in traumatic brain injury and stress, and his prior experience as a clinical psychol

1 Concussion
Not Always “Minor” Head Injury

OVERVIEW: “MILD” TBI (MTBI) MAY NOT BE SO “MILD”

THE EXPERIENCE OF CONCUSSION

Clinical example of a car/truck collision: A 34-year-old man was driving a car on a highway. “All of a sudden I got hit by a huge trailer truck.” He was going at 20 mph and was slowing down because of the traffic. His car was rear-ended by a truck; he did not know the speed of the truck. “I was hit several times.” He was shaking all over. His head hit the corner of the headrest, which was not totally padded. “It was a sunny day. I felt so good.” For hours he didn’t know what was going on. “I was totally shocked. I can’t describe how troubled I felt at the moment. I felt that this will never stop when this truck was hitting me. I felt like it was going to be forever.” He didn’t know how long it was before emergency assistance came. “I am totally different person. I can’t think straight. I can’t socialize with people. I am getting into arguments. I lost my friends. I broke up with my girl friend. I can’t do anything. I can’t go out to do sports.”

The outcome of the accident was that he was affected by central visual scotoma due to parietooccipital lesion. He never returned to work, abandoned plans for a graduate degree, suffered from chronic pain, required a cane, and so forth.

OVERVIEW OF COMORBID TBI AND SOMATIC INJURY

CONCUSSION

Concussion is the acute psychological experience of trauma incurred through head impact, acceleration, or both: an alteration or limited loss of consciousness (LOC). Generally, it is without sufficient neurotrauma to be detected by neuroimaging procedures. The limit of “lesser” LOC is about 20 min. The postconcussion syndrome (PCS) occasionally occurs without documented LOC. This may be due to the geometry of the accident: Impact and acceleration of the head and neck may not affect those central nervous system (CNS) centers and tracts maintaining awareness. Persistent postconcussion symptoms are caused directly by neural injury (CNS, cranial nerves, peripheral nerves, and brachial plexuses), unhealed somatic injuries, and physiological disruption.

The postconcussion syndrome (PCS) describes the multiple consequences of mechanical injuries to the brain that frequently result in comorbid traumatic brain injury (TBI) and somatic injuries. Its definition derives from common, but not universal, alterations of consciousness (AOC) after impact and/or acceleration and deceleration of the head and neck. Understanding TBI and AOC is enhanced by the examiner’s attempted reconstruction of the accident: geometric configuration of the head and body; the physical environment; and the size, direction, and nature of the injuring physical force and surface. Characteristic AOC includes retrograde and anterograde amnesia, a limited interval of unconsciousness, and confusion or disorientation varying from minutes to years with unpredictable disappearance. Injuries are caused by physical forces (impact; acceleration/deceleration) from injuries in motor vehicle accidents (MVAs), assault, falls, falling objects, blast, and also electrical accidents.

VARIED OUTCOMES

PCS (Parker, 2001), a so-called “mild” TBI, is a major public health problem. Trauma refers to the anatomical and emotional damage incurred by the person, and it is a multisystem reaction (Zellweger et al., 2001). Concurrent generalized brain effects occur due to mechanical forces, accompanied by brain and somatic physiological reactions to the trauma. These cause varying functional and injury-related behavioral changes. The nature of the event creates varied modal physical forces, and within each type of injury are different patterns of TBI.

The range of potential chronic disorders is frequently minimized in research and clinical practice. The range of potential neurobehavioral disorders after an accident is presented as a “taxonomy of neurobehavioral disorders.” A cerebral disorder (“concussion”) is frequently comorbid with significant somatic injuries. Thus, the clinician should consider a wide range of disorders, extending beyond the personal specialty. Concussion reflects a heterogeneous and complex spectrum of brain and somatic pathologies, clinical severity, and baseline prognostic risk (Maas et al., 2007). Neglect of particular domains in the acute injury period may miss significant signs of a potentially significant and chronic disorder. Thus, concussive-level injury may be both undiagnosed and untreated. Symptoms predicting a negative outcome have been described.

Concussive accidents result in varied comorbid psychological and anatomical conditions. Previously reported outcome markers have not been replicated in the literature. Further, typical outcome studies have concentrated upon a narrow range of cognitive, neurological, and physiological symptoms, without comparing posttraumatic functioning with an adaptive baseline. Therefore, there are varying patterns of neurobehavioral outcomes. A wide range of documented neurobehavioral disorders and symptoms is presented as a taxonomy of neurobehavioral disorders. This will be useful in planning an examination of a patient, preparing a report, and assessing the clinical outcome after an accident. Psychological and injury-related stress represent different, although overlapping, syndromes, whose effects are genetic, cellular, systemic, neurological, physiological, and mental.

“Head injuries” (without fracture or surgical involvement) have highly varied outcomes, from apparent loss of symptoms (so-called “minor TBI”) to significant chronic impairment. Millions in the United States suffer “polytrauma” (comorbid brain and somatic injury), resulting in complex impairment interfering with safety, employment, family and social relationships, and quality of life. A high proportion is disabled and impoverished, and cannot obtain services due to inability to obtain transportation, lack of insurance, or denial of the necessity for treatment.

Errors of assessing the PCS are common: (1) No record of head examination after an accident. (2) The patient is not alerted to potential long-term consequences or the need for follow-up. (3) Negative radiological or neurological findings are misinterpreted to mean that no diffuse TBI has occurred. (4) Dysfunctioning is attributed to an “emotional overlay” without competent personality examination. (5) Practitioners may deny the attribution of persistent TBI symptoms based upon the stereotype that “minor” head injuries “resolve” in 3 months. Complainers are considered the “miserable minority,” and are suspected of malingering, factitious disorders, or secondary gain. (6) Status is assessed prematurely, not considering interference with adaptive capacity or possible late-developing symptoms.

IGNORING THE RANGE OF POSSIBLE PCS DISORDERS

Clinical example: Emergency room (ER) personnel disregarding the actual accident: The patient was a man in his late 40s who was referred for study to confirm whether he was qualified for disability. Nine years earlier he had fallen from a height estimated at 40 to 45 feet while attempting to enter his own apartment when he was locked out. This vignette is based upon an intensive interview and review of the hospital records. The reader is directed to the height of the fall, the lack of close attention of the emergency squad, the patient’s misleading description of his own condition, and the hospital’s unawareness that his dysregulated behavior prognosticated a severe personality disorder. His discharge was described as “routine” a week after the accident. There had been an incorrect statement by his insurer that his policy had lapsed.

Observations: He was alert, cooperative, and did not appear to exaggerate or mislead concerning his condition. His affect was somewhat flat; despite a significant history of injury and emotional distress, he did not clearly exhibit anxiety, depression, or anger. The examiner had the impression that he was a reliable historian. Pain and orthopedic injury were apparent.

Record review: The patient was described as undomiciled, evicted from his apartment, and living alone. He was stated to withhold personal information, to display strange affect, and to be alert and oriented × 3 (time, place, person); memory appears to be intact. He had a skill in the construction industry, and was unemployed about 6 months.

His Glasgow Coma Score (GCS) was 8, which is usually categorized as a moderate brain injury. He denied LOC and was assessed as alert and oriented in three modalities. His statement at the accident scene that “I feel fine” is surprising in the context of the characteristics of the accident. It may indicate actual lack of orientation or denial. His examination revealed a bruise to his forehead, that is, a small abrasion with a hematoma on the left forehead.

Computed tomography (CT) of brain indicated mild enlargement of all the cerebrospinal fluid-containing spaces, consistent with cerebral atrophy.

Psychiatric consultation: Depression; alcohol-induced anxiety disorder; apparently he took the back brace off, which was dangerous, and could risk injury to his spine and spinal cord.

Velocity of his body upon striking the ground in feet per second was estimated: If the fall height was 40 feet, it was 50.8 feet/sec, and 53.8 if the height was 45 feet.

Abstract of interview: He stated that he graduated from a technical high school known for its high standards. He had an associate degree. He progressed to more skilled construction work over the years.

His description of the scene asserted that the emergency personnel did not recognize that he was injured. He asserted that he was dazed for about an hour. In the hospital he experienced pain, confusion, and fear. Self-described as disoriented and disorganized. (This self-description is consistent with hospital records, which indicated a level of cognitive or emotional disturbance anticipating later behavioral disorganization. The hospital record describes his discharge as “routine.” This examiner’s review suggested that apart from his documented injuries, there was significant evidence of impulsivity and possible disorientation, which indicated the need for postdischarge counseling and rehabilitation.)

He described his condition following his release from the hospital: “very little memory; began living on the street; I can’t completely remember where I was or who I was talking to; began drinking because I was in pain. I was redeeming cans.” He met his present lady companion 3 years after the accident.

• Preexisting conditions: Significant accidents or illness not reported.

• Subsequent conditions: Alcohol addiction, which he attributes to pain.

Complaints of impairment:

Sensory—close vision; dizziness; tinnitus; headaches; pain in wrists, ankles, elbow; disturbed sleep (nightmares; wakes up several times); oversensitivity to cold and loud sounds; partial-seizure like sensory phenomena (sound and somesthetic; electroencephalogram [EEG] recommended); physiological (fatigability; treated for a thyroid condition); affect (increased anxiety; more sensitive to anger; depressed but denies suicidal thoughts); memory and grasp of reality not completely recovered; could not work (fear of heights with use of a ladder; trouble steadying an electrical saw with his right hand); identity (asserts that he was a member of the high-IQ group Mensa). He wonders why he behaves the way that he does and is pessimistic about the future.

Status—Unemployed; is reliant upon his companion for some assistance. Asserts that their relationship is firm.

Diagnostic impression: PCS, severe, chronic.

Recommendations: Further neuropsychological study; internal medicine study; neurological consultation; orthopedic examination.

COMORBID SOMATIC AND NEUROLOGICAL TRAUMA

PCS is the consequence of a mechanical injury, often ignored by clinicians, or treated without awareness of its wide range of disorders, discomforts and dysfunctions, or chronic outcome. A person with possible TBI usually has comorbid somatic trauma in other parts of the body (polytrauma) and frequently experiences acute or chronic stress, anxiety, or depressive disorder. “The unhealed wound” creates neurobehavioral effects in the postconcussive syndrome, overlapping with dysfunctions directly due to mechanical brain and head injuries, musculoskeletal trauma, and pain. Lateralized dysfunctions such as restriction of range of movement, adaptive difficulties, and interruption with nerve pathways including muscular, ligaments, and bone occur. Vascular Injury and stress results, creating vasospasm affecting the arteries of the neck and skull base leading to dizziness and faintness, and hypoperfusion of the brain parenchyma and basal ganglia and thalamus (lesions detected by single photon emission computerized tomography [SPECT] and other imaging procedures).

Consequently, the use of mTBI as a nomenclature frequently contributes to an inaccurate assessment of the actual traumatic basis of the patient’s adaptive disorder. This leads to reduced quality of professional service. It is necessary in clinical and formal diagnosis to differentiate between anatomical findings, for example, without definite radiological or CNS neurological evidence, and the neurobehavioral consequences, which can be disabling. Accuracy is enhanced by giving extensive consideration to the noncerebral injuries and their disabling and physiological consequences. A useful clinical guideline is: “If the patient has an accident, and is examined for a head injury, closely examine the body. If the patient is examined for somatic injury, don’t forget about the head.” Examination of records frequently reveals that there is no evidence for injury victims that while in acute care any examination of the head was performed.

POSTTRAUMATIC SYNDROME : INITIAL EXAMINATION

The posttraumatic syndrome may be seen when the posttraumatic examination of the patient as incomplete. Thus, ER physicians caring for patients with a head injury should conduct a thorough examination, including radiological examination if indicated, and reassure the patient that no serious damage has been caused (Boes et al., 2008). The present writer would modify this advice: since patients and family may fear a skull fracture or brain injury, the reassurance should be restricted to the current medical findings. If the history of the accident and/or head injury is sufficient to warrant an ER examination, the patient should be counseled concerning frequent symptoms of the PCS and advised to consult a neurologist or other practitioner with head injury experience for examination. Further, at any time in the future when presenting a history, the facts of the accident should be reported.

If in the acute or chronic phase the possible contribution of an accident to a given disorder ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Preface
• Acknowledgments
• Chapter 1 Concussion: Not Always “Minor” Head Injury
• Chapter 2 Introduction to the Postconcussion Syndrome
• Chapter 3 The Central Nervous System: Organization of Behavior
• Chapter 4 Acute Alterations of Consciousness
• Chapter 5 The Internal Milieu: Brain and Body
• Chapter 6 Biomechanics and Tissue Injuries
• Chapter 7 Acute Brain and Somatic Injury
• Chapter 8 The Acute Stress Response
• Chapter 9 Chronic Posttraumatic Stress: Injury, Disease, and Burnout
• Chapter 10 Comorbid Posttraumatic Stress Disorder and Concussion
• Chapter 11 Disorders of Sensation, Motion, and Body Schema
• Chapter 12 Vocal Motor Disorders
• Chapter 13 Chronic Pain and Posttraumatic Headaches
• Chapter 14 Chronic Posttraumatic Disorders of Consciousness
• Chapter 15 Cognition, Language, and Intelligence
• Chapter 16 Posttraumatic Personality Disorders
• Chapter 17 Children’s Brain Trauma
• Chapter 18 Outcome and Treatment: Concussive Trauma
• Chapter 19 Biomechanical Perspective on Blast Injury: Comorbid Brain and Somatic Trauma
• Glossary
• References
• Index