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National Institute of Neurological
Disorders and Stroke's brochure, Head Injury: Hope Through Research, NIH
Publication No. 84-2478, August 1984.
Types Of Head Injury & PreventionDriving home late at night from a high school graduation party, Frank lost control of his car. The car went off the road and struck a tree. Frank, only 18 years old, survived severe injuries—a fractured skull and a blood clot on the brain—but his life has never returned to normal. Despite immediate surgery in the local hospital, Frank was comatose for 3 weeks. He then required hospital care for another 3 months. Now at home for more than 2 years, the left side of his body remains weak and he has such serious memory problems that he cannot hold a job or continue his schooling. He is quiet but occasionally he gets angry and breaks things or threatens his family. His parents are having trouble coping with the heavy emotional and financial burden that has resulted from the accident. They do not know where to get help for him nor are they aware of support systems for the family. Frank's story is a common one. According to one estimate, each year between 400,000 and 500,000 Americans suffer head injuries severe enough to cause death or admission to a hospital. Of course, many of these people do not experience head injuries as severe as Frank's. And not all are involved in car accidents. Some people receive head injuries while playing sports; others are hurt in falls; still others are victims of crime. But the most common cause of severe head injuries is motor vehicle accidents. The more serious the injury, the more likely it is to have been caused by a motor vehicle. Victims of car accidents and other causes
of serious head injury face years of disability and lost productivity. Like
Frank, many of these patients struggle to regain memory and the ability to
concentrate. National Brain Research InstituteFinding ways to restore Frank's
capabilities, and to help the thousands of head-injured people like him, is a
major goal of the National Institute of Neurological Disorders and Stroke (NINDS),
the leading Federal agency responsible for research on head trauma. The NINDS is
the focal point for brain research in the United States. As a unit of the
National Institutes of Health in Bethesda, Maryland. NINDS supports and conducts
studies to find more effective ways to repair brain damage, to improve
rehabilitation techniques, and to prevent the devastating consequences of head
injury. A Major Health ProblemMuch of what we know about head injuries in this Nation comes from a survey supported by the National Institute of Neurological Disorders & Stroke:
The survey found that head injuries occur most often among people aged 15 to 24 years. Young men are more than twice as likely as women to suffer a head injury. Two other age groups are at high risk of head injury: the elderly and infants. The elderly are likely to injure themselves in falls; infants and children may be dropped from an adult's arms, stumble down stairs, or fall from highchairs or changing tables. Abused children may also suffer from head injuries. Too often, children are injured in automobile accidents because they were not protected with safety seats or seat belts. Children struck by moving vehicles can also receive head injuries. According to another study supported by NINDS, children are more likely than adults to be hit by cars and thus risk head injury. That same study revealed that children are more apt than adults to survive severe head trauma. Nevertheless, there is still a substantial death rate among head-injured children. Because the victim of head trauma are usually young people, the cost to society is high—almost $4 billion annually. This figure includes the direct expense of medical treatment, indirect costs of rehabilitation and support services, and the patient's lost income. A middle-aged woman expresses the human
side of these statistics: "My husband had a head injury 10 years ago. Now he's
in a nursing home. He's only 45 years old, and he'll probably have to stay there
the rest of his life. My children miss his guidance and compassion." No Two Head Injuries Are AlikeThe injuries that prevent head-trauma victims from participating fully in society are as varied as the functions of the brain. Lying within the bony protection of the skull, and encased in a watery fluid, the brain works by means of signals that are passed from nerve cell to nerve cell through a network with billions of connections. Different regions of the brain are responsible for specific functions. One part of the brain controls speech; another regulates movement. The brain stem, at the base of the brain, controls heart rate, breathing, and blood pressure and regulates temperature. Depending upon what areas of the brain are damaged, a head injury can produce losses in movement, sensation, intellect, and memory. There is no such thing as a typical brain injury. The effect of brain damage varies according to the location and the severity of the injury. The outcome of a head injury is equally
variable. Some victims die. Other people with serious head injuries become
totally unresponsive for an indefinite time—a condition known as coma.
Head-injured people may also suffer physical, emotional, intellectual, or
psychological handicaps. Preventing Head Injuries"As long as we're in a motorized, highly mechanized society, we'll always have traumatic brain damage," says one head-injury expert. "We're never going to eliminate it, but we can prevent some of it." Many of the head injuries that occur in this country each year can be prevented. Use of seat belts for every trip in an automobile—no matter how short—can lower the chance of serious head injury in accidents. Cars can be designed so that the head of the drivers and passengers are unlikely to hit protection or hard surfaces. Decreased alcohol consumption by drivers and pedestrians can also reduce the number of accidents causing severe head injuries. "Both my husband and daughter are living with the effects of head injuries caused by a 20-year-old drunk driver," says one woman. "This guy drove down the street drunk after a football game and hit my family and six other people." Motorcyclists can protect themselves from head injuries by wearing safety helmets. Studies show that riders without helmets are two to four times more likely to incur a head injury than are helmet wearers. Unhelmeted riders are three to nine times more likely to suffer fatal head injuries. Helmets are a wise protective measure for many other activities that can lead to head injuries—construction work, for example, and such sports as bicycling, boxing, football, and rock climbing. Parents can protect children from head
injury by using approved infant and child restraint seats in automobiles.
Infants and young children should be kept away from open, unguarded windows.
Toddlers should not be left unattended in highchairs, buggies, or strollers, nor
should they be allowed to climb out of their cribs. Two Major Types Of Head InjuriesHead injuries can be placed in two categories: Penetrating injuries and closed head injuries.
Much of what we know about how penetrating injuries damage the brain and how the damage is best treated comes from studying the many thousands of soldiers who received head injuries during World War II, Korea, and Vietnam. Almost 1,000 men who were head injured during World War II participated in a Veterans Administration study designed to determine the long-term effects of head injuries. The study found that few men considered themselves "perfectly normal" years after the injury even though the results of their neurological examinations showed that they were normal. About 80 percent of these men still had injury-related headaches 7 years after the trauma. In a similar collaborative study by the NINDS, the Veterans Administration, and the Department of Defense, scientists are now evaluating the condition of head-injured Vietnam veterans 10 years after injury. Penetrating injuries, however, are not limited to war. In any major hospital, surgeons are called upon to treat penetrating head injuries caused by objects such as a steak knife or an ice pick. Even do-it-yourself home repair may cause penetrating injuries. Great care must be taken when using stud guns and power staplers. The force of the gun can easily drive a nail or screw through a thin wall or board, and the object may then become a dangerous flying missile that could pierce the head and cause a serious head injury.
A person's head hitting a car windshield is an example of closed head injury. When a person without a seat belt is thrown forward in a car that stops suddenly, the brain can be hurled against the inside of the skull. The soft brain collides with bone that is not only hard but has rough protrusions. This same kind of force can also squeeze and twist the brain in ways that are damaging. In closed head injury, the blow may also
injure the scalp and fracture the skull. Where Is The Damage?Regardless of the source of the head
injury, the area of the brain damaged partly determines the resulting symptoms.
Focal LesionsFocal lesions, injuries that affect a single, specific part of the brain, are of two types:
A contusion is a frequent result of severe head injury, occurring in almost 90 percent of cases. A contusion can occur at the point where an object strikes the head, or at a distant point where the jostled brain hits the hard surface of the skull. The symptoms of a brain contusion vary according to the severity and location of the bruise. Some patients may be confused, restless, delirious, or even unconscious; others may develop severe headache, paralysis, or seizures which may lead to epilepsy. A hematoma, which is generally considered a severe symptom of head injury, may accompany a contusion. Hematomas occur when a blood vessel is torn at the time of impact and blood leaks into the brain or its covering membrane (the dura). Intracerebral hematomas are formed within the brain tissue. Extracerebral hematomas occur between the brain and the skull—either below or above the dura. A hematoma may be as small as a typed letter on this page or it may involve a large part of the brain. Hematomas can result in increased pressure
on the brain, causing further brain injury. Diffuse LesionsFocal lesions are confined to one brain site, but diffuse lesions are spread out and involve several areas of the brain. Billions of brain cells in these areas are distorted by the twisting, stretching, and compressing force unleashed during the injury. This distortion can be temporary or can damage the nerve cells so severely that they die. A physician describing the type of diffuse lesion suffered by a patient may use such terms as mild concussion, concussion, or diffuse axonal injury. The least harmful form of diffuse lesion is the mild concussion, which occurs, for example, when a tall person bumps his or her head on the top of a low staircase and "sees stars." This sort of injury is reversible and probably leaves no ill effects. In the mild concussion, a person experiences temporary neurological problems but does not lose consciousness. Mild concussions frequently occur in sports-related injuries. A blow to the head in a football game may cause confusion for a few seconds, and 5 to 10 minutes later the player may not remember the injury or events just before it. With more powerful blows, the player has longer periods of confusion and forgets events just after as well as just before the injury. A person who has a full concussion loses consciousness for a period of time and also the memory of events just before and after the impact. Many people have no lasting ill effects from a concussion; however, some may show permanent subtle changes in personality or more prolonged memory loss. In both the mild and severe concussions,
the regions in the base of the brain involved in breathing and heart rate—called
the brain stem—are temporarily disturbed. The parts of the brain that control
memory are also affected. Diffuse Axonal InjuriesThe third type of diffuse lesion, involves a damaged brain stem as well as torn brain axons, the fiber-like projections from nerve cells that help transmit chemical "messages" from the brain to the body. Diffuse axonal injuries range from mild to severe. All forms involve coma, a loss of consciousness triggered by brain stem damage. Recovery of consciousness is followed by confusion and memory lapses. Some patients recover to resume all normal activities, but others suffer intellectual, memory, and personality losses. A severe diffuse axonal injury involves
the tearing of many nerve fibers throughout the brain and brain stem. Patients
with this type of injury remain deeply unconscious for a long time. They often
have extensive loss of intellect, sensation, and movement. Some of them will
die. ComaBrain damage caused by a head injury may cause a patient to lose consciousness for a prolonged period of time. Such a person is considered to be in a state of coma. Someone in a coma does not respond normally to stimulation. A comatose patient's eyes are closed, and he or she does not speak or move voluntarily. As one young man wrote about his brother who was in a coma after a car accident: "His body is whole, his brain is physically all there, but his mind, at least for now, is gone." Coma can last from 6 to 24 hours or longer, depending on the severity of brain damage. Occasionally, a person remains unconscious for months or even years. While in a coma, a patient must be given special care to survive. In an extended coma without intensive care, muscles will shrink and the body will become vulnerable to infection. When patients first come out of a coma, they may follow people around the room with their eyes or blink in response to simple questions. "My daughter was in a coma for 3 weeks," says one woman. "She woke up slowly. Physically, she was in good shape, but most of her mental processes were impaired. She didn't recognize us, and I don't think she knew who she was." People often emerge from a coma with a combination of physical, intellectual, and psychological difficulties that need specialized attention. Recovery usually occurs gradually, with patients acquiring more and more ability to respond. Some patients never progress beyond very basic responses, but many recover full awareness. Bill, for example, was in a coma for 4
months. He was left with few physical problems but many intellectual and
emotional difficulties that prevent him, 8 years later, from taking care of
himself. Susan, who was 8 years old when she received a head injury, was in a
coma for 2 weeks. The only remaining effect of her injury is occasional
headaches. A Threat To SurvivalIn addition to causing direct damage to the brain, a head injury may be complicated by pressure on the brain resulting from brain swelling or edema. These consequences of head injury can be life threatening. Although poorly understood, brain swelling is thought to be partly the result of dangerously increased blood flow to the brain. The head injury disrupts the normal action of the brain's blood vessels, causing them to expand with blood and take up more space within the skull. Because the skull is a rigid container, this swelling may cause increased pressure on the brain. The brain is compressed and receives insufficient oxygen. Swelling may occur immediately after injury, or be delayed by minutes or hours. The most common visible sign of brain swelling is a decrease in the patient's alertness. Some patients may lapse into unconsciousness. If the swelling can be controlled, it may not cause permanent damage. Uncontrolled, it may lead to the patient's death. Treatment for severe prolonged brain swelling is difficult, so the symptom is best taken care of at the earliest stages. The increased pressure in the brain caused by swelling may be monitored by any of several measuring devices developed through biomedical research. One such device is placed in the brain during a minor surgical procedure called ventriculostomy. The device is attached to fluid-filled spaces of the brain called ventricles and then hooked up to a wall monitor. Because currently used pressure-monitoring instruments require opening the skull, infection is a potential problem. Scientists and engineers at Case Western Reserve University are developing a totally implantable miniature electronic sensor (not physically connected to a monitor) that could record pressure on the brain for long periods of time without the risk of infection. The development of this device is supported by the National Center for Research Resources of the National Institutes of Health. Brain edema, the excessive accumulation of water and other fluids within the brain, also causes increased pressure within the skull. Edema often occurs where the brain has been bruised—around a contusion, for example. The same devices used to monitor brain
swelling are also used to check for edema.
Head Injury Treatment, Care & RehabilitationImmediate Care Saves LivesTwo decades ago, 90 percent of patients with severe head injury died. Scientific research haslowered this percentage. As a result of modern emergency-room, surgical, and intensive-care treatment, at least 50 percent now survive. Emergency treatment before the patient reaches the hospital is a critical aspect of head-injurycare. Proper immediate care may prevent additional damage to brain tissue from inadequate blood flow or insufficient oxygen supply. The rescue team that cares for a head-injured victim at the scene of an accident usually consists of a paramedic and an emergency medical technician. They will first determine the location and severity of the victim's injuries. The team will then test the injured person's neurological condition—level of consciousness and the eye's pupil response, for example—and such vital signs as heart rate and blood pressure. They will also examine the patient for broken bones—particularly a broken neck. A head-injured patient will probably be splinted onto a rigid support to keep the neck immobile and prevent spinal cord injury. The medical team will quickly transport the patient to a hospital with a staff qualified to care for head injuries or to a special facility called a shock trauma center. While in transit, the patient will be given needed care and the rescue team will establish radio communication with a physician in the hospital or trauma center. If the patient is deeply unconscious, the emergency medical team may insert a mouth tube to help breathing. This procedure is sometimes performed in the hospital emergency room. When the patient arrives at the hospital, accurate and immediate evaluation and treatment of the injury is essential for survival. One patient who benefited from speedy treatment in the hospital and the latest research in emergency-room and surgical care was James Brady. The 40-year-old presidential press secretary was shot in the head during the attempted assassination of President Reagan on March 31, 1981. Thanks to fast action by the Secret Service, Brady was taken immediately to a nearby hospital that has a skilled neurosurgical team. A bullet had tunneled through Brady's brain, leaving a trail of bone fragments, metal, and air. The bullet, which had enter Brady's forehead above the left eye, was surgically removed from his head near the right ear. Brady was in the hospital for 8 months. He
underwent several operations in addition to the 6 1/2-hour emergency surgery the
first day. Intensive physical therapy has helped him regain a degree of
coordination and balance, although he is still partially paralyzed. He also has
some speech impairment. Throughout the long ordeal, Brady maintained his sense
of humor and interest in his work. His progress in rehabilitation is attributed
to personal courage, to the outstanding care he received, and to the advances
made possible in recent years through medical research. Scans, Surgery, and DrugsOnce initial care has been provided and the patient is not in immediate danger of death, the physician will turn to an array of tests and procedures to determine the extent of damage and restore function. Because the skull completely surrounds the brain, it is difficult to tell whether the brain has been injured and, if so, the type and extent of damage. A technique called computerized tomography (CT) scanning has helped improve diagnosis and treatment of head-injury patients. The technique, perfected after years of research, creates a series of computerized X-ray images of the brain. After special X-rays are taken of the patient's head, a computer is used to reconstruct a cross-sectional view of the brain. With the CT scan, a neurosurgeon—a physician who specializes in surgery of the brain—can detect skull fractures and damage to the brain. Surgical repair of injuries and bleeding is a common form of treatment for severe head injuries. Most hematomas require prompt surgical removal. In a study funded by National Institute of Neurological Disorders and Stroke (NINDS), patients with hematomas who were operated on up to 2 hours after injury had a death rate of less than 30 percent, compared to 95 percent in patients operated on more than 6 hours after injury. Head-injury patients are monitored to ensure that they have no problems breathing and that brain swelling is under control. Some patients may need a breathing tube inserted into the nose or mouth. This tube is attached to a respirator. Drugs can also help to control brain
swelling and edema. Diuretics, which help the body eliminate water, and
steroids, which decrease water in the brain, are drugs commonly used for this
purpose. Barbiturates, a class of drugs that reduces the activity of nerves in
the brain and spinal cord, are also administered on occasion. Treatment of
increased intracranial pressure with barbiturates was the result of
NINDS-sponsored research. Although scientists are not certain how barbiturates
control brain swelling, they suspect that the drugs' ability to slow body
functions may also reduce blood flow to the brain. Treatment for brain swelling
is begun before the pressure within the skull becomes too high to respond to
therapy. Head Injury RehabilitationAfter receiving treatment in the hospital, the head-injury patients may be allowed to go home to complete the recovery process. Outpatient therapy may be provided at a rehabilitation center or in a hospital with a rehabilitation program. People with more severe injuries, however, will live at a rehabilitation center for some time in order to participate in a more intensive program of physical and psychological therapy. These patients may make periodic visits home. "I remember when Jack came home from the rehabilitation center," says a young woman. "He was visiting us for a weekend on a trial basis. On the first night, he stayed upstairs a very long time—so I went to see if he was okay. I found him crying there. 'What's the matter?' I asked. He said, 'I'm so afraid the children won't love me because I'm different now.'" Like Jack, many people who have had a head injury are sad or depressed. Helping the patient cope with these and other effects of head injury is one goal of long-term therapy. A number of specialists may be called upon to help rehabilitate the head-injury patient. Psychologists can help patients like Jack to understand the consequences of their injury, cope with marital and sexual difficulties, and ask for assistance when they need it. Other experts involved in the rehabilitation process include psychiatrists and speech, physical, and occupational therapists. Services offered to the patient include instruction in basic living skills such as bathing, dressing, cooking, and reading. Some patients benefit from memory retraining therapy which helps them remember words by forming visual images. For example, they might picture Uncle Sam to remember "United States." Another type of rehabilitation called cognitive therapy "opens the doors to understanding thinking processes," says a head-injury expert. Cognitive therapy may help people whose mental processes no longer interact in the normal, effective way. The training teaches patients to respond appropriately in a wide variety of situations, and improves attention span, self-awareness, and flexibility of thought. Techniques may include computer games, videotapes, and group role-playing sessions. Rehabilitation may play a role even after mild head injuries, which can reduce a person's ability to process information. A patient who returns to work too soon after such an injury may not be able to succeed at ordinary tasks, especially at jobs requiring attention to several factors at once. A lawyer may not be able to follow court arguments; an insurance agent may find it hard to perform necessary calculations. Such difficulties can lead to tension, fatigue, irritability, anxiety, and depression—conditions that can only aggravate the cognitive or thought process. Experimental occupational therapy tries to increase tolerance to fatigue and noise, thus improving work efficiency and ability to concentrate. The therapy program gives the patient increasingly abstract and complex activities to deal with—activities that are selected according to the patient's progress. The therapist also provides the patient with emotional support, while periodic tests measure patient improvement. Occupational training and most other types
of therapy are begun as soon as possible after the injury. Research has shown
that this is the most effective way to approach the rehabilitation process.
Exercise therapy, for example, is sometimes begun while the patient is still
unconscious. Physical Troubles InterfereThe patient's physical troubles often complicate the early stages of rehabilitation. The more severe the injury, the more lasting and serious will be the resulting physical problems. Loss of muscle control and muscle weakness on one side of the body, interfering with leg and arm movement, can occur after head injury. Recurrent epileptic seizures may also be a problem. In fact, head injury is a leading cause of epilepsy. Fortunately, most seizures can be controlled with medicines. Hematomas and skull fractures that press on the brain can cause facial paralysis, deafness, disorders in muscles controlling eye movement, and loss of the sense of smell. Therapy for physical problems may restore old skills to damaged parts of the brain and teach new skills to brain areas that were spared by the injury. Some physical problems, however, may be
difficult to control, including relatively minor ones. "It's very embarrassing
to be talking to someone, especially someone you don't know, when a rush of
saliva spills from your lower lip," says one patient. "This can be
controlled—but only if your every thought is to swallow. Just tell me one person
whose every thought is to swallow." Coping With Personality ChangesJust as important as the consequences of physical disabilities are the psychological and mental problems that are the most common result of head injury. Psychological difficulties include depression, anger, and behavior inappropriate to the situation. Immediately following severe injury, most patients have impaired mental functions that can last for a long time. Some impairment may be permanent. Patients may have problems with abstract thinking, being unable to consider an idea in general terms without having a specific example in real life. Patients may also have difficulty concentrating and they may find it hard to remember or to learn. Scientists have found that even a mild head injury such as a concussion impairs the brain's ability to handle new information for varying periods of time. "It takes him 10 minutes to read a sentence," says a woman about her head-injured husband, "and a few minutes later he may not remember what he read. My husband has no long-term memory and he can't follow directions. You tell him to turn off the light, he'll shut the door." Children, like adults, may have persistent memory problems after head injuries. The ability to learn new things may be impaired, interfering with school progress. In NINDS-funded research at the University of Texas Medical Branch in Galveston, investigators found similar patterns of memory problems in head-injured children, adolescents, and young adults. Among head-injured children, they found that nearly half later had trouble with the storage and retrieval functions of long-term memory. Those with the most severe head injuries suffered the greatest memory impairment. Changes in personality, although harder to measure, seem to be more frequent than mental changes in head-injured patients, and are at least as disabling. One common personality change involves apathy—a reduced interest in life's activities and challenges. An example is Cheryl, who at age 21 was knocked off her bicycle by a car, causing her to hit her forehead. Her family was overjoyed when she seemed to recover. However, when Cheryl was discharged from the hospital months later, she had a tendency to sit idly. Cheryl had no interest in doing anything, her parents complained. Doctors examined Cheryl 14 years later. Although her thinking was slow, her intellectual functions appeared normal and she'd held a job requiring above-average intelligence. But she said she was uninterested in doing anything except mundane household chores, and that she felt surprisingly little affection for her husband and children. Other patients may become overly optimistic—believing that things are better than they are. Or they may underestimate their disabilities. A third common personality change is loss of social restraint and judgment. A person becomes tactless, talkative, and hurtful, and may have outbursts of rage in response to trivial frustrations. These rages occasionally become so violent that the patient may require hospitalization. The embarrassment that some head-injury patients unintentionally cause their relatives can be a problem. "One night we took Phillip to the movies," says his wife. "He had to go to the bathroom. Normally, I would take him, but I was really involved in the film. So he went by himself. But when he came back, he couldn't find us. He started yelling, 'Janet, where are you?' It was so embarrassing. I didn't want to claim him. But of course I went and got him." Patients may also react with psychiatric
symptoms to the stress of mental disabilities and lifestyle readjustment. A law
student might become depressed at having to change to a community college or a
former accountant at having to take a menial job. Regaining The Quality Of Life After A Head Injury"Up until now," says one expert, "we've attended to the acute needs of the patients. But it is becoming apparent, as more and more head-injury patients are surviving, that we need to look at the quality of their lives. Many survive at least 40 years." Generally, the greatest recovery occurs in most patents in the first year. Some people continue to improve for years. Therapists believe that patients who receive concentrated therapy soon after their injuries will continue to improve for a longer time. Long-term therapy can lead to a patient's continued improvement over a lifetime. One patient who had been a photographer devised her own form of therapy—creating photographic collages—which helped to express the sense of loss and change experienced after a head injury. The patient illustrates her post injury verbal problems by photographic documents written in the unfamiliar language of Arabic. "Though I recognized alphabet, words, sentences on the page, for a period of time not a scrap of sense could I make of them," she says. The progress made by a brain-damaged patient may be described according to one of four categories which make up Glasgow Outcome Scale. These categories range from good recovery to the vegetative state where there is no evidence of a functioning brain. In an National Institute of Neurological Disorders & Stroke sponsored study of survivors of severe head injury, 50 percent showed good recovery after 3 months or more, 35 percent had moderate disability, 10 percent remained severely disabled, and 5 percent were in the vegetative state. The extent of an injury affects a person's ability to return to work—although not always to the degree expected. A recent study sponsored by the National Institute of Neurological Disorders and Stroke (NINDS) at the University of Virginia Medical Center showed that a surprising number of patients with very minor head injuries found themselves unable to work for several months. Certain jobs can be handled by someone with a serious disability, while other jobs cannot be performed with even minimal disability. In some patients, thought-process or memory problems are not apparent until they attempt to return to their occupations. For this reason, it is important for even the minimally injured patient to be tested. The length of a person's life as well as
its quality may be affected by a nonfatal head injury. NINDS scientists have
shown that World War I veterans whose head injuries led to later epileptic
seizures had a decreased life span. Head Injuries and the Impact on the FamilyWhen 16-year-old Lily found out that her younger sister, Fran, had been in a car accident and suffered a head injury, she felt "as if I had just been thrown into a make-believe world, one that I would just as soon not have known. I remember the endless trips to the hospital. I hated each and every one of them. My mother was there every day—all day. There was nothing else on her mind. I hated that too. In fact, I hated everything then. Fran was not the little sister I grew up with. She was a lifeless body—a part of machines and wires." Whether it is a sister, brother, mother, or father who has been injured, the effect on the family can be dramatic. Relatives undergo tremendous emotional turmoil—from worrying whether the injured victim will survive to dealing with a mentally or physically handicapped person. When a family member is injured, relatives need information about the condition of the patient and about the prospects for recovery. Later, they need to be taught to participate in rehabilitation and to plan for the patient's long-term care. It is particularly difficult for a family to deal with a member who has trouble thinking, withdraws emotionally, and lacks initiative. Families need to be forewarned of ways in which the head-injury patient is likely to seem different, to experience difficulty, and to pose extra burdens. It is also important for the family to understand the reason for a patient's behavior. A person who recently awoke from a coma, for example, will probably experience confusion. "My daughter was so confused, she couldn't find her own room," says one mother. "Things didn't look right because her visual perception was off. She'd go into the bathroom and sit 6 feet away from the toilet—all the while thinking she was on the toilet." If a patient is disoriented and has visual, perceptual, and verbal problems, he or she can experience an overwhelming feeling of confusion and frustration. Not only does everything "look wrong," but the patient may be unable to talk about the unsettling after-effects of the injury. For that matter, the patient may have difficulty talking about anything if the part of the brain that controls speech and language is impaired. The patient's confusion and frustration can lead to a temporary state of agitation where he or she becomes verbally and physically abusive. "I remember when Judy was in the hospital," says her mother," and she asked for milk. I got a glass of milk for her and then had to leave her room. When I came back, she was screaming and throwing the milk at the nurse. Everyone was very upset with her. Later I realized she wanted a milk shake but was unable to say what she wanted." Although some patients remain combative, most people progress to a condition of greater control. Whatever the patient's disability, any denial of the problem by the family can subject the patient to more frustration and put pressure on the person to reassume responsibilities prematurely. Even when a patient recovers, the rehabilitation process can be terrifying to relatives. Distressing effects of personality change and impaired intellectual function—no mater how temporary—can be overwhelming. One research study in Scotland found that an injured person's mental handicap tends to break up a family far more than does a physical handicap. But many families learn to cope. "It's
been 6 years since Fran's accident," writes her sister, Lily. "The waiting was
worth it. Fran continues to improve; but mentally and physically she would never
be the same. My sister is becoming a new person, a strong young woman whom I am
growing to respect. It does no good to look for the Fran of yesterday—she is no
more. There is only the Fran of today. I've learned to understand that the
brain-damaged victims of head injury are new people with their own unique needs
and desires. It is our responsibility to understand and accept." Do's & Don'ts Of Head Injury Patient CareRehabilitation experts consider family
support an important factor in patient recovery. As family< members struggle to
assist an injured person, they may be helped by the following guidelines
advocated by a rehabilitation expert with the Maryland Head Injury Foundation:
Head Injury ResearchResearch Fights BackThe increased success of rehabilitation techniques in improving quality of life and survival rates for head-injured patients is largely due to better knowledge of the brain itself. Brain research, much of which is supported by the National Institute of Neurological Disorders & Stroke (NINDS), continues to provide more answers. But the neuroscientist's task is made difficult by the nature of the brain: it is the most complex organ in the body. Much remains to be learned about how the brain functions normally and after injury. NINDS-supported scientists pursue a variety of approaches to the study of head injuries. Some research teams look at what happens to brain cells when they are injured and explore ways to stimulate recovery and regrowth. Other investigators follow the history of head-injury patients to make better predictions of survival and extent of recovery. Scientists will be better able to predict the outcome of head injuries as a result of information obtained through the NINDS-sponsored Traumatic Coma Data Bank. At four U.S. medical centers, physicians feed into a national computer network information about the types of head-injured patients they see and the treatment they provide. These data will help research scientists determine which factors influence the survival of head-injury victims, and what kind of life survivors can expect. Scientists will also be able to compare
the results of treatments used at different neurosurgical centers, and to
evaluate the effectiveness of various therapies. Consequences Of Head InjuryAn NINDS-funded study at the Medical College of Virginia addressed the important question of what happens to patients who survive a severe head injury. Medical advances have decreased the number of deaths, but have they increased the number of severely disabled survivors? The study concluded that aggressive surgical and medical therapy enables some patients who would have died to make a good recovery without increasing the proportion of severely disabled patients. Other studies looking at patients with minor head injuries such as concussions indicate that subtle consequences may be more frequent and more lasting than previously believed. Scientists hope to identify the structural
and functional changes in the brain produced by a head injury. These changes
could then be related to the condition of the patient after the injury and
possible methods of treatment. Looking at the Brain after a Head InjuryThe development of computerized tomography (CT) has enabled neurologists to detect and identify different types of head injuries. Scientists continue to investigate new ways to use the CT scan. One study sponsored by NINDS at the Medical College of Virginia, Richmond, is evaluating the CT scan as a tool for deciding when brain-pressure monitoring devices should be used. Other measures of brain changes should provide valuable information for the care and treatment of the head injured. At the University of Texas, Houston, the Medical College of Virginia, and the University of California, San Diego, scientists are examining electrical activity in the brain which results from stimulating the senses of touch, hearing, and sight. A new brain-imaging technique called positron emission tomography (PET) is helping scientists learn more about changes in brain function after injury. This research technique, whose development has been funded by NINDS, is already used to identify areas of specific brain function in normal subjects, to locate the origins of epileptic seizures, and to evaluate brain tumors. Unlike conventional X-rays which show how the brain looks, PET shows how the brain works by depicting its chemical activity or metabolism. Chemical activity in the brain is fueled by glucose—a form of sugar. In order to "see" the brain at work, scientists attach a harmless radioactive tag to glucose which is then given to the patient. The PET scanner "reads" the tag, showing where the glucose goes in the brain. The more active the brain cells, the greater the use of glucose. To explore this new research technique fully, NINDS established a national PET research program involving medical centers around the country and the NIH research facility in Bethesda, Maryland. One study at the University of Pennsylvania is using PET and CT scans to determine the cause of edema and brain swelling after head injury. A technique similar to PET, called 2-deoxyglucose autoradiography, was used to conduct the first study of how specific brain regions function after head injury. Investigators carrying out animal experiments at the Medical College of Virginia found decreased brain activity in most areas. But a surprising finding was increased activity in one small region. This area of increased activity may somehow trigger coma-like states in animals; similar increase in activity in a certain part of the human brain may also be connected to human coma. Perhaps certain areas in animal and human brains can suppress activity in other parts of the brain—resulting in coma. Scientists are using another imaging technique, nuclear magnetic resonance (NMR), to study the brain. NMR scanners use the magnetic properties of atoms in living tissue to produce computer-reconstructed images of the brain or other organs. These images can detect changes in cells and the structures surrounding cells. NMR scans have shown hematomas and small brain lesions not visible on a CT scan. A new experimental technique, called the
133Xenon Cerebral Blood Flow System, does not produce an image of the
brain, but allows scientists to create a map or chart of the brain's blood flow.
The patient inhales a small amount of radioactive xenon gas. The amount of xenon
circulating in the blood is then measured by detectors attached to the patient's
head. By determining the concentration of xenon carried though blood vessels to
brain tissue, scientists can produce a map of blood flow within the brain.
NINDS-supported scientists using this method at the University of Pennsylvania,
the Medical College of Virginia, and the University of Texas, Galveston, found
that there are marked changes in brain blood flow during the early phase of head
injury. Certain areas of the brain have normal blood flow while other areas show
reduced flow. These changes in blood flow can help predict a patient's recovery,
according to one of the investigators. Drugs Help Reduce DamageDrug therapy can also be useful in treating head injury. Research studies suggest that barbiturates may reduce the damage caused by insufficient oxygen in the injured brain. Several groups of investigators have reported that these drugs lower the brain's energy requirements. Other scientists are examining the role of diuretics—drugs that increase the body's excretion of fluid—in decreasing brain swelling. In laboratory studies at the Medical College of Virginia, NINDS-supported scientists found that apnea, a temporary breathing halt that can occur during a concussion, is caused by the release of certain body chemicals. Experimental drugs designed to block the effects of these chemicals appear to control apnea. Other research supported by NINDS at Albany Medical College showed that one type of serious brain swelling involves a type of support cells called astrocytes. The investigators then discovered that diuretic drugs inhibiting astrocyte swelling also reduced the death rate among head-injured animals. This work led to the synthesis of new chemicals that may have advantages in treating human head injuries. Some scientists are examining the
biochemical events that lead to brain cell death and are looking for drugs to
intervene in the process. There is hope that a combination of drugs may someday
control these events that inhibit the healing process. Reestablishing ConnectionsSkin and muscle nerves grow back and regain function after they are cut or crushed. Traditionally, however, scientists believed that damaged nerve cells in the brain and spinal cord—the central nervous system—were incapable of regeneration. But recent work shows that under special laboratory conditions these damaged nerve cells may be able to function again. In NINDS-supported experiments, nerve cells from the mammalian central nervous system sprout new branches when they are in contact with the supporting (glial) cells associated with skin and muscle nerves. This research shows that adult brain cells have the capacity for growth. But whether this property can be used to repair the injured brain—with its billions of nerve cell connections—remains to be seen. Other studies of implanted cells offer hope for people with head injuries. Recent animal studies have shown that in some cases implanted embryonic nerve cells appear to connect with other nerve cells and restore disrupted functions. The brain has also shown a remarkable
ability to compensate for loss on its own. When the left half of a child's brain
is damaged, for example, the language processing function normally carried out
there shifts to the right half. Behavior that is suddenly controlled by a
different area of the brain, however, may be somewhat altered. Examining RehabilitationRehabilitation is crucial if the ever-growing number of severely head-injured patients are to attain a satisfactory lifestyle. Efforts expended on intensive care immediately after the injury may be wasted if subsequent therapy is inadequate. Recently, methods of therapy have been specifically designed for patients with head injuries. In rehabilitation studies, a patient's
family stability, higher intelligence, and occupational status before an injury
were associated with better recovery and a more likely return to work. Lengthy
periods of coma, persistent motor impairment, and seizures reduced the chances
of good recovery. In addition, realistic self-appraisal, high motivation, and
family support appeared important for successful rehabilitation. Hope For The FutureRehabilitation helps many head-injured
patients return to the community, even if they are different in some ways. And
more patients are reaching the rehabilitation stage. Scientific research has
produced improvements in emergency-room practice, diagnosis, and surgery which
allow more head-injured patients to survive. With continued research, there is
hope that these head-injury victims will be able to resume their former jobs and
lifestyles. Where to Get Help and InformationThe National Brain Injury Foundation was formed by families of head-injured patients and health professionals. The organization provides information, including a newsletter, and brings together families for mutual support. National Brain Injury Foundation
Some local chapters of the National Easter Seal Society also have programs for the head injured. The National Easter Seal Society, Inc.
The American Speech-Language-Hearing Association can help head-injury patients locate clinical services. American Speech-Language-Hearing
Association The American Paralysis Association supports research on paralysis resulting from brain and spinal cord injury. The organization also publishes a free quarterly newsletter, "Progress in Research." American Paralysis Association For additional information concerning NINDS research on head injuries, contact: Office of Scientific and Health Reports
This publication is not copyrighted. Readers are encouraged to duplicate and distribute as many copies as needed.
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