Chapter 34 - Traumatic and nontraumatic brain injury
Section snippets
Acquired brain injury
Acquired brain injury (ABI) is damage that occurs after birth caused either by a traumatic or by a nontraumatic injury (Table 34.1). There are now many possibilities for treating the resulting disability and limitations of participation in these people in order to allow them the best individual level of autonomy. There is much new research showing, for example, the usefulness of synergy between the intensive care unit and the rehabilitation team, and the necessity for long-term care based on
Epidemiology
In the USA, monitoring by the Centers for Disease Control and Prevention shows the annual incidence of emergency department visits and hospital admissions for TBI to be 403 per 100 000 and 85 per 100 000, respectively. Epidemiological data on TBI from the European Union are scarce, but do indicate an annual aggregate incidence of hospitalized and fatal TBI of approximately 235 per 100 000, although substantial variation exists between European countries (Tagliaferri et al., 2006, Jennett, 1996).
Pathophysiology
In the literature it was concluded that traumatic and nontraumatic brain injury may be associated with three main patterns of brain damage: (1) widespread destruction of the cortical ribbon; (2) widespread damage of the white matter tracts; and (3) damage of deep brain structures such as the thalamus and basal ganglia. Examples of each of these patterns were found in many cases of severe brain injury, such as VS and MCS (Kinney and Samuels, 1994).
In some cases, extensive damage to the
Rehabilitation
Moderately to severely injured patients may receive specialized rehabilitation treatment, involving programs in the areas of physical therapy, occupational therapy, speech/language therapy, physiatry (medical specialist in physical medicine and rehabilitation), neurology, psychology, psychiatry, and social work, among others. The services and efforts of this team of healthcare professionals are generally applied to optimizing patient function and independence through the coordinated application
Evaluation scale in brain injury
Evaluation with a standardized scale is a useful tool for monitoring patients’ clinical improvement. The Disability Rating Scale (DRS) (Rappaport et al., 1982), the Rancho Los Amigos Scale, also known as Levels of Cognitive Functioning (LCF) (Hagen et al., 1972), the Coma Recovery Scale (CRS) (Giacino et al., 1991), original and modified (Giacino et al., 2004), and the Wessex Head Injury Matrix (Shiel et al., 2000) are some of the most useful scales used in brain injury patients.
The LCF is a
Complications
Health complications may occur in the period immediately following a brain injury, both traumatic and nontraumatic. These complications are not types of ABI, but are distinct medical problems that arise as a result of the injury. Although complications are rare, the risk increases with the severity of the trauma (Jennett et al., 1979). Complications of ABI include immediate seizures, hydrocephalus or posttraumatic ventricular enlargement, spinal fluid leaks, infections, vascular injuries,
Prognostic criteria
Outcome is generally assessed at 6 months after injury, representing a compromise between true final outcome and logistic limitations. Experience shows that about 85% of recovery occurs within this time period, but further recovery can occur later. Accurate and consistent outcome determination at a fixed timing is a prerequisite for any ABI study.
The prognostic factors that affect the outcome after head injury have been studied extensively. Most studies are in agreement that age, motor
Future research perspectives
Great advancements have been achieved over the past 10–15 years, but advances in basic science have not yet led to new treatments of clinically proven benefit. Clinical trials have had methodological problems posed by the inherent heterogeneity of the population. From the perspective of clinicians, we would suggest that the following topics are prioritized. First, standardized epidemiological monitoring should be implemented to offer a sound basis for appropriate targeting of prevention.
Conclusions
There is currently inadequate support for creating a network of rehabilitation services for brain-injured patients and their families who are actively involved in the recovery process. There is an increasingly urgent need for a supportive network that guarantees continuity of care, assistance, and emotional support until such a time as the patient reintegrates successfully into the community.
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