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News Gram™ October 2004

October 2004 ~ Volume 11, No. 3

Head injuries are some of the most serious medical-surgical problems encountered in medicine. They also present serious problems for the psychiatrist. Figuring out whether a person's clinical appearance is due predominantly to a blow to his head, medication he's been taking, alcohol he's been consuming or his underlying personality is often a difficult task. Nevertheless, it is a question that arises all too often. For those involved in paying for the treatment of individuals who present with a panoply of complaints and a history of some kind of blow to the head, determining who is financially responsible for the evaluation and treatment of such people can be daunting. A look at the facts surrounding such cases can be helpful.

For people under the age of 45, head injury is a leading cause of death. There are about 5 million Americans contending with the disabling results of traumatic brain damage. Automobile, accidents, falls and sports injuries are the major causes of injuries to the brain. Unfortunately, while the brain is amazing and complex, it is soft and readily damaged by objects that strike the head.

Perhaps the most common class of brain injuries is a concussion. This condition occurs when the head (cranium) is dealt a sudden blow (trauma) of sufficient force. A baseball or golf ball at sufficient speed can induce a concussion. Clinically, the person may find it hard to concentrate, feel confused or lose consciousness. In cases of multiple blows to the head over a period of years, neurologists have found permanent brain damage.

One way injury to the brain occurs is that the inside of the cranium is driven up against the brain. Since this gelatinous mass has nowhere to go, it must absorb all of the energy imparted to it by its bony protector. Sometimes, the brain will be slammed against the opposite side of the cranium causing a so-called contrecoup injury far from the original site of impact.

Athletes who strike their heads against each other, as in the case of football, occasionally sustain injury to their brains. Aside from the musculoskeletal derangements that can occur, in such incidents, the brain can be damaged because of the rapid deceleration that occurs when the player's head strikes another player's abdomen or chest. Helmets protect the head because the cushioning effect of headgear decreases the deceleration, i.e., increases the time required for the head to slow down, thereby diminishing the force that is ultimately transferred to intracranial tissue.

The main kinds of brain injury are the contusion, i.e. traumatic damage caused by the brain hitting something or vice versa and diffuse axonal injury caused by torque being applied to the head that results in stretching of the white matter - the nerve fibers of the brain. Interestingly, if someone, usually an infant, is shaken aggressively, the result can be a Shaken Baby Syndrome. The damage done to very delicate nerve fibers can be deadly. The adult counterpart of this syndrome is whiplash, often spoken of in relation to automobile accidents.

Diffuse axonal injury presents a substantial challenge to a physician who is trying to correlate clinical findings with various imaging data. The damage is often microscopic and, therefore, will not be visualized by a CT or MRI scan.

Toxins and a loss of oxygen to the brain are two other broad causes of serious brain injury. Carbon monoxide poisoning brings about decreased oxygen tension in the blood the result of which is that less oxygen gets to nerve cells. One region of the brain particularly sensitive to oxygen, the hippocampus, is the area responsible for making new memories. Hippocampal damage may prevent a person from recalling even simple events happening seconds before.

Other forms of brain damage can occur because of medical conditions. The brain may swell, a condition known as edema, and the resulting increased intracranial pressure can prevent adequate blood flow to brain tissue. Similarly, a hematoma, a pool of blood inside the head, can push down against the brain with considerable pressure. Strokes are often the cause of such a condition.

The clinical features accompanying a traumatic brain syndrome are important to know. Loss of consciousness is one of the most important findings. A person may also have just a clouding of consciousness, a dazed appearance, and little more. The Glasgow Coma Scale is helpful in assessing the degree of coma and is important to look for in any neurological assessment of a comatose patient. Loss of memory, dizziness, nausea, vomiting, headache, irritability, insomnia, decreased sex drive, disorientation, mood swings and other findings characterize post-concussion syndrome. Finally, a seizure may indicate the occurrence of a head injury several months before.

Head injury has widespread effects on the individual. It takes hard clinical experience to recognize and understand the meaning of the numerous signs and symptoms that appear in its wake.

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