Diagnosis and Treatment
Diagnosing moderate and severe traumatic brain injuries (TBI) is relatively simple. The patient will have specific symptoms and/or signs associated with this type of injury (abnormal CT/MRI findings, loss of consciousness for more than 30 minutes, symptoms that do not go away), as well as physical evidence of the injury (open wounds, epilepsy, etc).
Diagnosing a mild traumatic brain injury (mTBI), on the other hand, presents a greater challenge because many patients may not have any visible physical signs, or the signs they do have will not be as notorious as moderate or severe brain injuries. Rather, many patients will present disabling cognitive, psychological, behavioral impairments, and/or employment disabilities that may go unnoticed for several days, weeks, months, or, in some cases, even longer. In other words, a mild traumatic brain injury may not be diagnosed until the individual begins to have problems in what were once easy tasks or social situations. For this reason, a mild traumatic brain injury is referred to as the “silent epidemic” or the “invisible injury.”
Persons seeking medical attention as a result of a mild traumatic brain injury will generally receive only a standard history and a physical exam based on subjective complains. In those cases, further imaging such as head Computerized Tomography (CT) or possibly Magnetic Resonance Imaging (MRI) will be obtained only if the patient has loss of consciousness, posttraumatic amnesia, focal neurological deficits, or physical signs of a skull fracture if the cause of the injury is an indicator as to the severity of the injury, or the particular circumstances require further medical examination.
However, this method may not be specific enough to identify individuals who have suffered a mild traumatic brain injury because:
- Neurological tests as well as the subjective complaints or symptoms can be influenced or “tainted” by numerous demographic, situational, preexisting, co-occurring and injury related factors;1
- The subjective nature of the complaints and the significant overlap with other conditions (e.g. Post-traumatic stress disorder);2 and
- Due to the diffuse and subtle nature of mild brain injury, it is common for typical neuroimaging (CT scan or MRIs) to show no evidence of the injury. The limitation of these brain imaging technologies is that they often cannot detect mild brain injury. The reason for that is because a mild brain injury can often damage the white matter of the brain, and white matter consists of the axons of neurons (connections) in the brain which is much harder to capture or visualize using common types of brain imaging.3
In addition, this subjective symptom-based approach has led to several patients with mild traumatic brain injuries to be underdiagnosed. A University of Washington study demonstrated a 56% diagnosis rate of traumatic brain injuries in the emergency room setting.4
The numbers speak for themselves. Diagnosing mild traumatic brain injuries relying solely on subjective evaluations and typical neuroimaging (CT scans or MRIs) can lead to traumatic brain injury misdiagnosis. Therefore, it is highly advisable to consider both the subjective complains of the patient as well as objective findings, including new technology capable of bringing out evidence of mild traumatic brain injury, so that it can be properly diagnosed and treated, thus, increasing the probability of recovery.
Currently, the most common systems that medical practitioners initially use to bring out evidence of traumatic brain injury are the Glasgow Coma Scale and the Ranchos Los Amigos Scale.
The Glasgow Coma Scale is based on a 15-point scale for estimating and categorizing the outcomes of brain injury on the basis of overall social capability or dependence on others. The test measures the motor response, verbal response, and eye opening response with the following values:
I. Motor Response
6 – Obeys commands fully
5 – Localizes to noxious stimuli
4 – Withdraws from noxious stimuli
3 – Abnormal flexion, i.e. decorticate posturing
2 – Extensor response, i.e. decerebrate posturing
1 – No response
II. Verbal Response
5 – Alert and Oriented
4 – Confused, yet coherent, speech
3 – Inappropriate words and jumbled phrases consisting of words
2 – Incomprehensible sounds
1 – No sounds
III. Eye Opening
4 – Spontaneous eye opening
3 – Eyes open to speech
2 – Eyes open to pain
1 – No eye opening
The final score is determined by adding the values of I+II+III. This number helps doctors and medical practitioners categorize severity of the brain injury as Mild (13-15), Moderate (9-12), and Severe (8-3).
Ranchos Los Amigos Scale
Measures the levels of awareness, cognition, behavior and interaction with the environment.
Level I: No Response
Level II: Generalized Response
Level III: Localized Response
Level IV: Confused-agitated
Level V: Confused-inappropriate
Level VI: Confused-appropriate
Level VII: Automatic-appropriate
Level VIII: Purposeful-appropriate
Over the years, modern medicine has developed several tests to determine with reasonable medical certainty whether a person has suffered a traumatic brain injury, such as CAT and MRI scans, SWI (Susceptibility Weighted Imaging), Diffusion Tensor Imaging (DTI), Magnetic Resonance Angiography (MRA), Electroencephalogram (EEG), Quantitative EEG, Position Emission Tomography (PET) scan, Single Photon Emission Computed Tomography (SPECT), lumbar puncture, and Magnetic Resonance Spectroscopy (MRS).
There is also new technology for diagnosing traumatic brain injury in the form of tests which measure the extent of the physical trauma that the brain suffered by looking at the body response to such injury, such as bleeding in the brain or markers in the bloodstream.
The FDA has approved a battery-powered device called the InfraScanner, developed by the Office of Naval Research (ONR).5 When there is bleeding in the brain as a result of an injury, there will be pools of blood in the brain which absorb and reflect light differently than normal brain tissue. By shinning a particular wavelength of light onto different parts of the head, the device can spot life-threatening bleeds or hematomas.6
In addition, scientists are also trying to find ways to spot changes in blood chemistry which are specific to brain injuries. This is done through biomarkers tests which indicate the presence of some disease or injury. Biomarkers, reflecting a biological response to injury or disease, have proven useful for the diagnosis of many pathological conditions including cancer, heart failure, infection, and genetic disorders.7
In the traumatic brain injury context, there are specific biomarkers in the cerebrospinal fluid and serum, such as BB isozyme of creatine kinase (CK-BB, predominant in brain), glial fibrillary acidic protein (GFAP), myelin basic protein (MBP), neuron-specific enolase (NSE), and S100B.8 The presence of these biomarkers may be helpful to diagnose persons with mild TBI where other tests and procedure are not successful in that regard.
There are several methods, procedures and tests to determine whether a person has sustained a traumatic brain injury. However, even though most of these test have proven to be extremely effective regarding moderate to severe traumatic brain injury, they are not as effective when the injury is mild, which can lead to misdiagnosis issues.
1 Recommendations for Diagnosis a Mild Traumatic Brain Injury: A National Academy of Neuropsychology Education Paper.
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