Not only does a traumatic brain injury (TBI)  forever change the life of the victim, it also causes serious damage to the health and lives of the victim’s family. The TBI victim is not the same person which causes profound stress to the care giving family. The stress is constant and there is usually no hope for improvement.

The TBI victim has extensive cognitive, emotional and behavioral problems. These problems result in a grim life for the family caregiver. Studies show:

  • A divorce rate of 84% for TBI couples
  • All or most of the family savings gets consumed
  • Compromised immune system for up to three years after caregiving ends
  • An increased risk of developing a chronic illness.
  • Major depression diagnoses for nearly 50% of caregivers.
  • Premature aging, taking as much as 10 years off a caregivers’ life.

When a wrongdoer has caused a TBI, the caregiver victim should also be compensated. While these are the results of scientific studies, how does a caregiver demonstrate her injury to a jury? Some steps to document the impact:

  • Start a diary of events. While the family members may feel disloyal about recording negative behaviors, the diary is necessary to help others understand the depth and breadth of the loss.
  • Seek respite services to relieve the stress of caregiving.
  • Seek emotional support through participating in support groups or counselling with a psychotherapist.

Chronic traumatic encephalopathy (CTE) is a progressive degenerative disease which afflicts the brain of people who have suffered repeated concussions and traumatic brain injuries, such as athletes who take part in contact sports, members of the military and others.

The brain of an individual who suffers from CTE gradually deteriorates and will over time end up losing mass. Certain areas of the brain will atrophy, and other areas are prone to becoming enlarged. Another aspect of CTE is that some areas of the brain experience an accumulation of tau protein, a substance which serves to stabilize the structure of brain cells (neurons). With CTE, neurons become defective and subsequently may cause major interference with the brain’s ability to send messages.

Some of the most common symptoms include loss of memory, difficulty controlling impulsive or erratic behavior, impaired judgment, and behavioral disturbances including aggression and depression, difficulty with balance, and a gradual onset of dementia. An individual with CTE may mistakenly relate the symptoms to the normal process of aging, or might be misdiagnosed to the fact that many of the symptoms are similar to other conditions such as Alzheimer’s or Parkinson’s disease.

Brain imaging technology advances at a rapid pace. A new process, called "high definitiion fiber tracking," reveals areas of brain injury with more exactness than standard scans such as CT & MRI and even the newer DTI method.

Millions of Americans suffer a traumatic brain injury, or TBI, each year. Most TBIs are concussions or other milder injuries that generally heal on their own; some are more severe and may lead to death or disability. Because TBIs also affect more than 200,000 soldiers who served in Iraq and Afghanistan, the U.S. defense department supports TBI research studies including that of Dr. Walter Schneider, professor of psychology and neurosurgery at the University of Pittsburgh Medical Center. Schneider’s study explains the importance of the new technology and how it works.

Why is HDFT Important for Victims of TBI?

With more serious head injuries, standard scans cannot see beyond bleeding or swelling to tell if the brain’s connections are broken in a way it can’t repair on its own. But the researchers say the new technology gives them the ability to see previously invisible wounds. 

How does HDFT work?

Brain cells communicate with each other through a system of nerve fibers that act like a telephone network, making up what’s called the white matter of the brain. White matter runs along cabHigh definition fiber tracking map of a million brain fibers. Credit: Walt Schneider Laboratoryle-like highways called fiber tracts that contain millions of connections. The new scan processes high-powered MRIs through a special computer program to map major fiber tracts, painting them in greens, yellows and purples that designate their functions. Researchers look for breaks in the fibers that could slow or stop those nerve connections from doing their job.

Real Life Example

32-year-old Daniel Stunkard of New Castle, Pa., is one of 50 TBI patients in Schneider’s study. He spent three weeks in a coma after his all-terrain vehicle crashed in late 2010. CT and regular MRI scans showed only some bruising and swelling, unable to predict if he’d wake up and in what shape. DTI was unsuccessful for fiber tracking because it had poor-quality visualizations and some false tracks.

When Stunkard woke up, he couldn’t move his left leg, arm or hand. Doctors started rehabilitation in hopes of stimulating healing, and the HDFT predicted what happened. The scan found partial breaks in nerve fibers that control the leg and arm, and extensive damage to those controlling the hand. In six months, Stunkard was walking. He now has some arm motion. But he still can’t use his hand, his fingers curled tightly into a ball. The doctors say those nerve fibers were too far gone for repair.

This closer look at nerve fibers will provide a valuable diagnostic tool. Dr. Rocco Armonda, a neurosurgeon at Walter Reed National Military Medical Center says: "It’s like comparing your fuzzy screen black-and-white TV with a high-definition TV." 

The wrinkle reducer, Botox is approved by the FDA for very narrow uses only. But Allergan, its manufacturer, has promoted it to doctors all over the country for other uses, including muscle spasms. A doctor’s use of a drug for a purpose not approved by the FDA is often referred to as an “off-label” use. When a doctor used Botox “off-label” to treat Virginian Douglas Ray for hand tremors, it quickly led to brain damage. According to his wife, he now requires round-the-clock care and speaks very few words.

Botox is a purified form of the poison botulinum and is given as an injection. The drug is approved to treat “muscle stiffness” in the fingers and arms, “upper limb” spasticity, and chronic migraine headaches. Botox can migrate outside the injected muscles and cause side effects including botulism and severe autoimmune reactions with resulting brain damage.

Ray claimed Allergan did not properly warn his doctor about the risks of using the drug. A jury agreed, ordering Allergan Inc. to pay to Ray $12 million in compensatory damages and $200 million in punitive damages. This award by the U.S. District Court jury in Richmond, Va., was the largest penalty ever in a Botox injury case.

Botox is Allergan’s top-selling drug, with $1.42 billion in sales last year, or 29 percent of the drug maker’s revenue, according to data collected by Bloomberg.

This is not the first time the Botox manufacturer has had to pay penalties. In September of 2010, the federal government ordered Allergan to pay $600 million to settle civil and criminal allegations against the drug manufacturer for illegally marketing Botox for other uses. Allergan has also been accused of paying kickbacks to doctors and enticing them with all expense paid weekends to learn about off-label usage. 

Decompressive craniectomies are an aggressive surgical strategy increasingly used at trauma centers for victims of diffuse traumatic brain injury. Although surgical methods vary, the decompressive craniectomy involves temporarily removing a portion of the skull to relieve the pressure from the swelling of the injured brain.

As recently reported in the New England Journal of Medicine, results of a randomized trial show that although decompressive craniectomy reduced intracranial pressure and the length of stay in the intensive care unit, it was also associated with a greater risk for unfavorable outcome at 6 months for patients with diffuse traumatic brain injury (TBI) compared with standard care. The standard care involves lowering the patient’s body temperature and administering barbiturates.Rates of death didn’t differ between groups, but scores on the Extended Glasgow Outcomes Scale were lower in the group undergoing bifrontotemporoparietal craniectomy, and there was a significant increase in risk, more than double, for an unfavorable outcome on that same scale, the researchers report. The unfavorable outcomes included vegetative state and conscious but disabled.

Our findings differ from those of most nonrandomized studies and are contrary to our hypothesis," the researchers, with lead study author D. James Cooper, MD, from the Department of Intensive Care at Alfred Hospital, Monash University, in Melbourne, Australia, acknowledge. " Our unexpected findings underscore the critical importance of performing such trials to test common therapies, particularly in patients with complex critical illnesses."

Experts stress that that the procedure should not be abandoned on the basis of these results. Surgeons must think more carefully about the risks and benefits of the decompressive craniectomy before performing the procedure and must work to further define appropriate clinical settings for this procedure.
 

 

Following a recent threat by Air Canada to pull its sponsorship dollars, the NHL announced a revision of the NHL Protocol for Concussion Evaluation and Management. The Protocol now requires:

  1.  Mandatory removal from play if a player reports any listed symptoms or shows any listed signs of a concussion;
  2. Examination by the team physician in a quiet place free from distraction and use of "an acute evaluation tool" by team physicians rather than a quick rinkside assessment.
  3. The NHL board will be asked to elevate the standard for holding a team and its coach accountable if there are a number of "repeat offenders" with regard to supplementary discipline.
  4. A safety engineering firm will evaluate all 30 arenas and determine what changes, if any, can and should be made to enhance player safety.
  5.  A ‘blue-ribbon’ committee of former players including Brendan Shanahan, Rob Blake, Steve Yzerman and Joe Nieuwendyk will look at safety issues.

The Ontario Hockey League has been a proponent of concussion education. Its president David Branch gives a nod to the NHL revisions but emphasizes that it does not go as far as the OHL which penalizes all hits to the head.  Also, the OHL has circulated a DVD to its players. OHL said:

The message to players is: You have to recognize these symptoms and you have an obligation to tell your team . . . We’ve got a problem with head injuries in our game and you are part – part – of the solution. It wasn’t intended to scare them. It wasn’t a threat – that we plan to suspend you. It was intended to educate, to get buy-in from the players, and to support the players.”

Thumbs up to Air Canada and the professional hockey leagues.  As they encourage education about brain injuries education, their fans will also better understand the seriousness of concussions.

Array tomography is a state-of-the-art imaging system invented by Stanford University researchers. It allows researchers to count the myriad connections between nerve cells, as well as to catalog those connections’ surprising variety.

A typical healthy human brain contains about 200 billion nerve cells, or neurons, linked to one another via hundreds of trillions of tiny contacts called synapses. It is at these synapses that an electrical impulse traveling along one neuron is relayed to another, either enhancing or inhibiting the likelihood that the second nerve will fire an impulse of its own. One neuron may make tens of thousands of synaptic contacts with other neurons, said Stephen Smith, PhD, senior author of a paper published Nov. 18 in Neuron.

The new imaging system allows researchers to “travel” through the 3-D mosaic of neurons and observe different colors corresponding to different synaptic types just as a voyager might transit outer space and note the different hues of the stars dotting the infinite blackness. And to make a movie of the whole trip.  

https://youtube.com/watch?v=pNaQ2HAj1rY%3Ffs%3D1%26hl%3Den_US

 

This level of detailed visualization has never been achieved before. “The entire anatomical context of the synapses is preserved. You know right where each one is, and what kind it is. Observed in this manner, the brain’s overall complexity is almost beyond belief", said Smith. “One synapse, by itself, is more like a microprocessor —with both memory-storage and information-processing elements — than a mere on/off switch. In fact, one synapse may contain on the order of 1,000 molecular-scale switches. A single human brain has more switches than all the computers and routers and Internet connections on Earth,” he said.

Researchers plan to use array tomography to tease out more such distinctions within classes of synapses. That should accelerate neuroscientists’ progress in, for example, identifying the synapses that are lost after traumatic brain injury, or in neurodegenerative disorders such as Alzheimer’s.

“Second Impact Syndrome” refers to mild brain injuries suffered repeatedly within a short period (hours, days, or weeks). Although all brain injuries are serious, second impacts can be catastrophic or even fatal. The American Academy of Neurology has developed guidelines  for deciding when it is safe to return to play after a first injury. The Academy recommends that, to reduce the risk of the second impact syndrome, an athlete who suffers a head injury resulting in temporary confusion, amnesia, or other alteration of mental status should not return to play until examined by a health-care provider familiar with these guidelines. Sport oversight committees such as California Interscholastic Federation, have begun to adopt these recommendations.

The guidelines rely in part on self-reporting by student athletes or close observation by coaches and other players. Unfortunately, athletes are often reluctant to admit their injury. To prevent their child athlete from suffering a second impact catastrophe, parents should do the following:

  • Know and recognize the symptoms of a brain injury. As described here.
  • Learn what the coaches know about brain injuries.
  • Find out whether the school has policy for handling brain injuries.
  • Educate your child about the catastrophic risks of a second impact and
  • Emphasize to your child the danger of hiding even the seemingly minor symptoms of brain injury.

Friday night lights. Marching bands. And the smacking of football pads. Yes, it’s football season!

As parents prepare to watch their kids on the football field, discussion returns to topics of injuries and helmet safety. The risk of football-related brain injurieses is undeniable. Each year designers and manufacturers unveil the latest and greatest helmet.  The new helmets can cost between $300 and $400. Does a more expensive high tech helmet make a difference?

Opinions vary.

Some medical experts say there are no conclusive studies that show one brand or style of helmet to be more effective at preventing concussions than another. "We just know that helmets in general don’t protect against concussions," said Dr. Robert Cantu, who has been studying football-related head injuries since 1987. "We do know a newer helmet is better than an older one," he added.
While manufacturers such as Riddell claims that its Revolution helmet reduces the risk of concussion by 31 percent, and Xenith does not call its product a helmet, rather it boasts of an “adaptive head protection system of integrated technologies designed to reduce the sudden movement of the head by adapting to different energy levels."

A study published in the September 2010 issue of Pediatrics reports the number of sports-related concussions is highest in high school-aged athletes, but the number in younger athletes is significant and rising. Visits to emergency departments for minor traumatic brain injuries occurring during organized team sports have increased dramatically over a 10-year period, and appear to be highest in ice hockey and football.

What should schools being doing to protect their students? For one thing, every coach can take the free online concussion training course offered by the Center for Disease Control. The course, which is designed for parents as well as coaches, includes video segments, quizzes and a resource center. It takes approximately 40 minutes to complete, but the time will vary because it’s interactive. The training dispels many of the “myths” about brain injuries that we’ve blogged about previously here and here.