TRAUMATIC BRAIN INJURY 1995

Mild Traumatic Brain Injury (MTBI) and Post Traumatic Stress Disorder (Medical Litigation News Volume 1, Issue 4) are mutually exclusive, according to the neurosurgical authors[1] of a study of 70 patients with either diagnosis. MTBI requires at least brief loss of consciousness, precluding experience or memory of the events which might cause the emotional trauma.

PRACTICE POINT

Question concurrent diagnoses of Mild Traumatic Brain Injury and Post Traumatic Stress Disorder

A team of pediatric emergentologists propose[2] clinical criteria for the rational use of Computerised Tomography in the acute assessment of childhood TBI. The imaging should be routinely used in the assessment of patients with suspected abuse, focal motor deficits or abnormalities of the pupils.

Global deficits are common after Moderate or Severe TBI. The characteristic profile is that cognitive functions are differentially damaged, from least to most: intelligence, attention, memory, speed of processing, and cognitive flexibility[3].

After severe injury, children's deficits will be underestimated[4] if their test results are compared with population norms rather than with controls matched for age, sex and academic functioning.

PRACTICE POINT

Estimation of deficits in children should take into account age, gender and premorbid academic functioning.

A study[5] of 20 patients contradicted the widely held belief that recovery plateaus after a couple of years. Gains were seen up to at least 10 years.

PRACTICE POINT

Recovery may continue up to at least 10 years, especially with multidisciplinary rehabilitation

Is Rehabilitation effective? Randomised, controlled trials still have to be undertaken, but a wide range of studies strongly supports the efficacy and cost-effectiveness of multidisciplinary rehabilitation programmes[6]. Improvements in functioning, sometimes considerable, can be demonstrated in up to three-quarters of even the most severely brain-damaged[7].

Depression and anxiety reduce functioning and distort self-perception of the severity of injury and cognitive impairment[8]. Patients with depression report more postconcussion symptoms, which increase in severity with the passage of time. These common psychiatric sequelae must be recognised and adequately treated.

Following moderate to severe injury, balancing may be impaired by slow reaction to unexpected imbalance and by asymmetrical posturing[9].

PRACTICE POINT

Neuropsychological testing and PET or SPECT scanning remain the most sensitive methods for detecting subtle Traumatic Brain Injury

After a child suffered Mild Traumatic Brain Injury of Whiplash type, neurobehavioural changes such as staring increased over 2 years. At 4 years, neuropsychological testing and ambulatory (but not resting) Electro-EncephaloGraphy were abnormal, as was Positron Emission Tomography. Antidepressant medication caused considerable improvement[10].