Brain

A Traumatic Brain Injury (TBI) is an injury to the brain caused by trauma to the head from an outside force. The effects can be wide-ranging and depend on a variety of factors such as type, location and severity of injury caused, but also on whether any complications develop, e.g. lack of oxygen or swelling inside the brain.

Occurrence/Frequency of Injury
The National Institute for Health and Care Excellence (NICE) reports that approximately 700,000 people a year in England and Wales were admitted to A&E with a head injury. Traumatic brain injuries can be incredibly difficult to understand and their effects range from minor and temporary to severe and life changing.

Diagnosis
A TBI can be viewed as a chain of events with three types of injury potentially being sustained..

The first injury is sustained in the first few seconds after an incident. The first injury can be categorised as one of three types:
- Closed: The most common type of TBI, so called because no break in the skin is visible. These often occur as a result of rapid acceleration or deceleration, for example when a car is hit at high speed from behind at traffic lights. The head is rocked back and forth and/or rotated, and the billions of nerve fibres which make up the brain can be twisted, stretched, and even torn in the process.
- Open or Penetrating: A less common injury, which sees the skull opened and the brain exposed and damaged. This type of TBI could be sustained in a collision with a sharp object such as a motorcycle brake lever. If the damage is limited to one specific area, outcomes can be quite good. But in many cases this type of injury is combined with an acceleration type injury, leading to a poorer prognosis.
- Crushing: In this type of injury, the head might be caught between two hard objects, such as the wheel of a car and the road. This is the least common type of injury, and often damages the base of the skull and nerves of the brain stem, rather than the brain itself.

The second injury occurs in the minutes and hours after the first and involves further injury being sustained if the brain is starved of oxygen as a consequence of the first injury. This can happen for several reasons, including choking on vomit after an accident or blood blocking a person's airway.

The third injury can take place at any time in the days and sometimes weeks following the first and second injuries. The third injury occurs when bleeding, bruising or swelling in the brain crushes the soft brain tissue.

Treatment and Recovery Timeframes
Unlike most other cells in the body, brain cells do not regenerate when destroyed. However, this does not mean that no recovery can occur. The brain is somewhat flexible and is able to reorganise itself, to an extent, in order to regain lost function.

In the first month or two after a severe brain injury it is only possible to guess how long recovery will take and what the outcome will be. All that is certain is that recovery is a slow process and will take months or years, rather than weeks.

Historically there has been a suggestion a limited 'window' for recovery exists following brain injury. It was thought, for example, that recovery ceases to take place beyond two years. However, recent research has shown that this is not the case and that people may actually continue improving for a number of years after brain injury. Nevertheless, the greatest visible progress does occur in the first six months post-injury.

NICE website guidance:
Head injury: assessment and early management

Interesting Facts
Anyone can sustain a minor brain injury. Even seemingly trivial knocks can sometimes lead to lasting effects. Very young children, young adult males and the elderly are generally the most at risk of sustaining a minor brain injury, with the most common causes being road traffic collisions, falls, assaults, accidents in the home or workplace and sports injuries.

Concussion is the sudden but short-lived loss of mental function that occurs following a blow (or other injury) to the head. It is the most common, but least serious, type of brain injury. Post-concussion syndrome (PCS) is the term used to describe a collection of symptoms that can last for several weeks or months after an individual has been concussed.

Occurrence/Frequency of Injury
The National Institute for Health and Care Excellence (NICE) reports that approximately 700,000 people a year in England and Wales are admitted to A&E with a head injury. Traumatic brain injuries can be incredibly difficult to understand. Their effects range from minor and temporary to severe and life changing.

Diagnosis
The brain is a soft organ surrounded by spinal fluid. This fluid acts like a cushion during normal movement of the head. But if the head or body sustains a violent impact, the brain can crash into the skull. The resulting injury can damage the delicate neural pathways in the brain, leading to neurological disturbances and abnormal brain activity.

The most common signs and symptoms associated with concussion are:
- Loss of memory
- Brief period of unconsciousness
- Mental confusion

The symptoms of Post-Concussion Syndrome fall into three main categories:
- Physical
- Psychological
- Cognitive (i.e. those affecting a person's thinking ability)

Physical symptoms of PCS can include:
- Headaches – often described as similar to migraines in that they cause a throbbing pain on one side of or to the front of the head
- Dizziness
- Feelings of sickness (nausea)
- Sensitivity to bright lights
- Sensitivity to loud noises
- Ringing in the ears (the medical term for this is tinnitus)
- Double or blurred vision
- Fatigue
- Lost, altered, or reduced sense of smell and/or taste

Psychological symptoms of PCS can include:
- Depression
- Anxiety
- Irritability
- Lack of energy and interest in the outside world
- Problems sleeping
- Changes in appetite
- Sudden and inappropriate outbursts of emotion, such as laughing or crying for no apparent reason

Cognitive symptoms of PCS include:
- Decreased concentration
- Forgetfulness
- Difficulty remembering things or learning new information
- Difficulties with reasoning (working out problems)

Treatment and Recovery Timeframes
Most cases of PCS will resolve themselves within three to six months, and only one in ten affected individuals will still have symptoms after a year.

Interesting Facts
The three main causes of concussion in the UK are:
- Road accidents
- Accidental trips or falls
- Sporting or other recreational activities

Reports from the US show that the number of reported concussions has doubled in the last 10 years. The American Academy of Pediatrics has reported that emergency room visits for concussions in children aged 8 to 13 years old has doubled and concussions have risen 200 percent among teens aged 14 to 19 over the last decade.

Activities known to present a higher than average risk of concussion include: rugby, football, cycling, boxing and martial arts, such as karate or judo.

Skull fractures can be just that: a simple fracture of any of the cranial bones. But, given the important structure the skull protects, they often represent a more significant injury.

The skull consists of 22 bones, divided into two parts: the neurocranium and the facial skeleton. The eight bones of the neuorcranium form the protective cranial cavity that surrounds and houses the brain and brainstem. The facial skeleton consists of the 14 bones to the front of the skull, from the bridge of the nose and cheeks downward, including the jaw.

There are many types of skull fracture, including:
- Linear fracture: where the break in the bone looks like a straight line
- Depressed fracture: where part of the skull is crushed inwards
- Basal fracture: a fracture to the base of the skull
- Simple (closed) fracture: where the skin hasn't broken and the surrounding tissue isn't damaged
- Compound (open) fracture: where the skin and tissue is broken and the brain is exposed
- Diastatic fracture: when a fracture line transverses one or more sutures of the skull (the fibrous bands of tissue that connect the bones of the skull) causing a widening of the suture. This type of fracture is more commonly seen in children.

Occurrence/Frequency of Injury
Skull fractures occur in between 2% and 20% of all cases of head trauma, with an overall incidence of between 35 and 45 per 100,000 people annually. Skull fractures occur most frequently between the ages of 20 and 50 years. Males are overwhelmingly more commonly affected than females. Head injuries in children are more likely to result skull fracture than those involving adults. The most common cause of skull fracture, accounting for up to 35% of cases, is a fall. Simple linear fractures are the most common, found in somewhere between 50% and 80% of all skull fractures

Diagnosis
Skull fractures are diagnosed through diagnostic tests such as X-rays, CT scans and MRIs.

Treatment and Recovery Timeframes
Most skull fractures heal themselves within a couple of months, particularly if they are relatively uncomplicated injuries such as a linear fracture. Open fractures to the skull often require the prescription of antibiotics, as the risk of infection is considerably higher. Severe or depressed fractures often require surgery, especially if the fracture has injured or is compromising the brain. During surgery, metal wire or mesh may be used to help reconnect pieces of the skull.

Interesting Facts
The curious practice of trepanning goes back as far as 6500 BC. This invasive method of treating afflictions of the head involved drilling a ring of small holes in the skull before removing a disc of bone. Trepanning was used to treat a variety of health issues such as fractures, contusions and headaches, but also had a religious significance, with some believing it could be used to excise evil. A version of this technique is still sometimes used in modern medicine, when swelling in the brain requires the removal of part of the skull to relieve the pressure temporarily.

The blood vessels that carry blood to the brain from the heart are called arteries. The brain needs a constant supply of blood to deliver the oxygen and nutrients the brain needs. A Cerebrovascular Accident (or ‘stroke’) occurs when an artery either becomes blocked or bursts, so that a part of the brain does not get the blood it needs and starts to die.

Occurrence/Frequency of Injury
Stroke occurs approximately 152,000 times a year in the UK. That is once every three and a half minutes. Around the world, 17 million people have a stroke for the first time each year. That’s one every two seconds.

Signs of stroke include:
- Sudden numbness or weakness of the face, arm or leg, especially on one side of the body
- Sudden confusion, trouble speaking and/or understanding
- Sudden difficulty seeing in one or both eyes
- Sudden trouble walking, dizziness or loss of balance
- Sudden severe headache with no known cause

Diagnosis
While all strokes happen in the brain, there are different types: ischemic (clot) and haemorrhagic (bleed). Around 85% of all strokes are ischemic and 15% haemorrhagic. Identifying the type of stroke enables quicker and more effective treatment.

Ischemic Stroke
Ischemic stroke is by far the more common type of stroke, occurring when an artery in the brain is blocked. There are two types of ischemic stroke:

Hemorrhagic Stroke
A hemorrhagic stroke occurs when a blood vessel in the brain bursts and spills blood into or around the brain. High blood pressure and aneurysms can make blood vessels weak enough to burst.

Treatment and Recovery Timeframes
All strokes are different. For some people the effects may be relatively minor and may not last long. Others may be left with more serious problems that make them dependent on others for the rest of their lives.

Unfortunately, not everyone survives. Around one in eight people die within 30 days of having a stroke. That’s why it’s so important to recognise the symptoms and get medical assistance as quickly as possible.

The specific medical treatments recommended depend on whether the stroke is caused by a blood clot or by bleeding in or around the brain:
- Ischaemic strokes can often be treated by injecting alteplase ‘clot busting’ medication that dissolves blood clots and restores blood flow to the brain. This is most effective if started as soon as possible after a stroke. A brain scan is required first, however, to confirm the diagnosis of an ischaemic stroke, as clot busting medication would make a haemorrhagic stroke worse.

The sooner an individual receives treatment, the better their chances of a good recovery.

- Haemorrhagic strokes can be treated with medication such as ACE inhibitors that lowers blood pressure. Surgery may also be needed to remove any blood from the brain and to repair blood vessels. This procedure is known as a ‘craniotomy’.

Short-term treatments available to manage problems affecting people after a stroke include:
- Treatment by dieticians and speech and language therapists to address difficulty swallowing (dysphagia)
- Use of a nasogastric tube to provide nutrition and of a nasal oxygen tube or mask to combat low levels of oxygen in the brain.

NICE website guidelines:
Stroke rehabilitation in adults: recommendations

Interesting Facts
- There are over 1.2 million stroke survivors in the UK
- 3 in 10 stroke survivors will go on to have a recurrent stroke or TIA
- Stroke is the fourth largest cause of death in the UK and the second around the world.