Traumatic Brain Injury (TBI) and Concussion

 

What is TBI?

This term is used when brain is injured from mechanical or physical reasons. This writing provides an outline of traumatic brain injury, but it mostly covers its mild form or concussion. Severe brain injury is a larger topic and is not covered in detail.  

 

What are different types of TBI?

There are different ways to divide TBI into different types:

1. Based upon the type of injury

Closed head injury: When skull is not punctured

Concussion: When there is no visible sign of injury or bleeding on brain scan.

Contusion: When there is a visible brain bruise noted on CT or MRI

Laceration: From a sharp object

Compound: From a blunt object or a fall

2. Based upon the reason

Fall: Most common type, when head hits the ground or a hard object

Blunt object: May vary based upon the object or location

Gunshot: Different weapons may lead to different types of injury

Piercing object: Varies based upon the nature of object

Explosion: May lead to both coup and countercoup injury

3. Based upon the mechanism

Coup: Direct injury to brain

Countercoup: Injury to the opposite side of the impact

Rotational: From severe rotational force

Explosion: From explosions like a bomb

4. Based upon severity

Mild

Moderate

Severe

 

What is a concussion?

It is a type of mild injury to brain without evidence of intracranial injury (e.g., bleeding or contusion) on head CT or MR.

 

Are there different levels of concussion?

There have been some efforts to divide concussion in different levels, but the criterion is not precise and should be used with caution. Following is how I divide concussion in 3 types. It is based upon symptoms without evidence of intracranial injury (e.g., bleeding, contusion) on head CT or MR:

Level I Concussion

Headache, nausea, dizziness or “seeing stars”, ringing in ears, confusion, forgetfulness, photophobia, blurred vision, difficulty with concentration, with or without momentary loss of consciousness (LOC).

Level II Concussion

More severe and/or prolonged above symptoms, double vision, amnesia of the event, vomiting, mood changes, insomnia, brief LOC (up to 5 minutes),

Level III Concussion

More severe and/or prolonged above symptoms, seizure, stroke like weakness, longer LOC (more than 5 minutes).

 

Why do I have symptoms of concussion if my brain scan is normal?

This is an excellent question. Having a normal brain scan does not necessarily mean there is no injury to the brain, or other structures. Injuries could be microscopic and not visible with conventional CT or MRI scan. Scans are not done to detect microscopic injury; they are done to rule out causes that may need an acute intervention.

 

How is concussion diagnosed?

It is diagnosed based upon history and examination. Based upon the type of concussion, a head scan may also be required.

 

What should be done if someone has a suspected concussion?

First thing is to help the person move to a safe place away from any further risk. The person should be quickly reassured and evaluated, even by a non-medical person, to assess the severity. Not everyone needs to go to ER or consult a doctor. With a mild injury and mild or transient symptoms, especially without LOC, many patients only require some rest. Someone should stay with the patient for a few hours to a day, to detect any change in symptoms, and behavior or physical features. Symptoms usually clear up in a few hours to a few days. If concerned, consider calling the primary care’s office, or going to an urgent care center. But then, in my experience, they almost always tell the patient to go to ER. Anyone with symptoms of Level II or III concussion should go to emergency room for evaluation and should at least have a head CT. The purpose of head CT is not to confirm concussion. It is done to rule out some injuries that may require closer observation or a medical or surgical intervention. In those cases, as a routine, cervical spine CT is also obtained to rule out an injury to the cervical part of spine.

 

Which test is needed to diagnose concussion?

Presently, no specific test is available to diagnose concussion, especially in mild cases. This situation is like a patient having a mild heart attack, in which case, a blood test is available to detect evidence of heart muscle injury. But this kind of test is not yet available for brain injury. With that said, a lot of people end up in emergency rooms after a mild head injury and usually have CT scan done.  Most of those scans do not reveal any sign of brain injury. The decision to obtain a scan should be made in case-by-case basis. For example, patients with symptoms only of Level 1 concussion, without any LOC, do not necessarily need any brain scan.

 

How is concussion treated?

No specific treatment is available for concussion. It is treated with patient education, reassurance, guidance for future activities, and treatment of some of the symptoms with medicines. Headache, neck pain, nausea, anxiety, depression, and insomnia type of symptoms can be treated with medicines. Specialized physical therapy also has a role. No specific medicine is available for some other symptoms like forgetfulness or cognitive dysfunction.  

 

Does exercise or physical therapy help with concussion?

Brain requires some resting to recover. Based upon severity of symptoms, strong physical or cognitive activities should be avoided for a few hours to a day or two. After that, it is better to slowly and gradually proceed with activities while still avoiding severe activities. Physical therapy may help with neck or spine pain, headaches, dizziness, and visual, or imbalance type of symptoms. Activities may be resumed couple of days after resolution of symptoms. Rules for exceptionally strenuous activities including professional sports may vary and are more conservative. Clinical decision is made on case-by-case basis with an aim of preventing any long-term consequences for the patient, or the player.

 

Can sexual activity harm a patient with concussion?

As suggested above, common sense measures should be taken. Sexual activity increases brain pressure and muscle tension, especially in the back of neck muscles. This may cause muscle strain, further worsening the headache, neck pain, and many other symptoms. It is best to avoid it during recovery period. It may be safe after symptoms are somewhat better. Until fully recovered, it is prudent to avoid positions and maneuvers that may strain the neck or back muscles.

How about alcohol or marijuana, does it help with concussion? 

Neither of them is helpful. Both are shown to be toxic to brain cells, which are already at risk of dying. It is best to avoid all chemicals potentially toxic to brain. 

 

How about coffee or caffeine? 

There is no evidence that coffee or caffeine are harmful, if taken in moderation, or as the routine was before the injury. Caffeine has a mild pain and headache relieving effect. 

 

I go to a gym every day, should I continue that routine after I have a concussion? 

The answer is same as above for physical therapy or exercise. Take a day or two off and, if feeling alright, gradually resume gym activity. At the same time, avoid activities or exercises that may strain back or neck muscles. 

 

Can I travel if I have a concussion? 

It depends. Ideally, avoid traveling same day even after a mild concussion. Travel is a stressful activity, which may exacerbate symptoms of concussion. Use common sense. In terms of mode of travel, there is no specific problem but be aware that air travel is prone to make headache worse. Keep a medicine handy. Traveling on a boat or a ship, until symptoms are resolved, may not be a good idea. 

 

Any foods to avoid, or any food helpful in concussion? 

Anything with risk of dizziness or drowsiness, like alcohol, should be avoided. Otherwise, there is no dietary restrictions or benefit from a particular diet. Hydrate yourself well, eat healthy meal, and avoid constipation. 

 

Does stress make concussion worse? 

There is a significant psychological component making physical symptoms of concussion worse. This is likely triggered by a fear of serious injury, which in most cases is not the case. Patients with underlying anxiety or panic disorder are particularly at risk of worsening psychological and physical symptoms. For a treating physician, medico-legal issues, if involved, create a complex socio-medical situation, which usually improves only after the case is settled. 

 

Is there an underlying condition that makes concussion worse? 

There are many conditions, both psychological and physical, which may result in more severe or prolonged symptoms of concussion. Examples are anxiety, depression, panic disorder, personality disorder, insomnia, low socio-economic status, PTSD, household or social stresses, migraine, neck arthritis, or any other chronic pain syndrome. 

 

 

Does concussion lead to dementia?

It depends. Multiple minor concussions or a severe one may increase the risk of dementia in later life. This is the reason I advise young people who get into a concussion or two to avoid any further contact sports or activities.

 

What is chronic traumatic encephalopathy (CTE)?

This is a rare condition affecting people with multiple or repeated concussions or mild head injuries. In USA, it is mostly related to contact sports (e.g., football, boxing) or wartime explosions. In biochemical terms, it leads to degeneration of brain cells, but it is not clear why it happens or what exactly triggers it. There might be genetic propensity, like other degenerative brain disorders, worsened by head injuries. Symptoms may appear years after the injury. Most troubling symptoms are cognitive and behavioral, sometimes leading to suicide. During life, no test is available for diagnosis. Its diagnosis is made with brain autopsy. There is no known treatment, and prevention should be the paramount strategy.

 

What is vision therapy for concussion?

Many patients with concussion have imbalance, blurred vision, double vision, and vertigo type of dizziness. They can benefit from a specialized form of therapy called vision therapy. It is offered through physical therapy or specialized brain trauma centers. There are also some specialized tools that may help with this type of therapy and expedite recovery. One such example is found at www.neurosync.health. Its availability is limited and may be useful for sports and military related head injuries.

 

Where may I find more information about concussion or traumatic brain injury?

American Academy of Neurology

American Association of Neurological Surgeons