The 3 Levels of Brain Injuries

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TBI - Traumatic Brain Injury (Three Levels of Brain Injuries)

Historically, words such as "mild", "moderate", and "severe" were utilized to define brain injury. For many years, these terms were utilized based on duration of loss of consciousness.

Today, it is universally accepted that brain injury can occur without loss of consciousness, without direct external trauma to the head, and without positive findings on CT, MRI, or other sophisticated diagnostic testing.

I. MILD TRAUMATIC BRAIN INJURY

Glascow Coma Scale (GCS) Score 15-13

A patient with mild Traumatic Brain Injury is a person who has had a traumatically induced physiological disruption of brain function, as manifest by at least one of the following:

• Any period of loss of consciousness;
• Any loss of memory for events immediately before or after the accident;
• Any alteration in mental state at the time of the accident (i.e., feeling dazed, disoriented, or confused); and
• Focal neurological deficits that may or may not be transient; but where the severity of the injury does not exceed the following: 

* Post-traumatic amnesia (PTA) not greater than 24 hours;
* Loss of consciousness of approximately thirty minutes or less;

This definition includes: The head being struck; the head striking an object; 3. the brain undergoing an acceleration/ deceleration movement (whiplash) without direct external trauma to the head.  With a Mild TBI, computed tomography magnetic resonance imaging MRI, electroencephalogram or routine neurological evaluations may be normal. Due to the lack of medical emergency, or the realities of certain medical systems, some patients may not have the above factors medically documented in the acute stage. In such cases, it is appropriate to consider symptomology that, when linked to a traumatic head injury, can suggest the existence of a mild traumatic brain injury.

Symptoms

The above criteria define the event of mild traumatic brain injury. Symptoms of brain injury may or may not persist, for varying lengths of time, after such a neurological event. It should be recognized that patients with mild traumatic brain injury can exhibit persistent emotional, cognitive, behavioral and physical symptoms, alone or in combination, which may produce a functional disability. These symptoms generally fall into one of the following categories, and are additional evidence that a mild traumatic brain injury has occurred.

• Physical symptoms of brain injury (nausea, vomiting, dizziness, headache, blurred vision, sleep disturbance, quickness to fatigue, lethargy, or other sensory loss) that cannot be accounted for by peripheral injury or other causes;
• Cognitive deficits (attention, concentration, perception, memory, speech/language or executive functions) that cannot be completely accounted for by emotional state or other causes; and
• Behavioral changes and/or alterations and degree of emotional response (irritability, quickness to anger, a lack of inhibition, or emotional lability) that cannot be accounted for by a psychological reaction to physical or emotional stress or other causes.

Some patients may not become aware of, or admit, the extent of their symptoms until they attempt to return to normal functioning. In such cases, the evidence for mild traumatic brain injury must be reconstructed. Mild traumatic brain injury may also be overlooked in the face of more dramatic physical injury (orthopedic or spinal cord injury). The constellation of symptoms has previously been referred to as minor head injury, post-concussion syndrome, traumatic head syndrome, traumatic dephalgia, post-brain injury syndrome and post-traumatic syndrome.

II.  MODERATE TRAUMATIC BRAIN INJURY

Glascow Coma Scale Score 9-12

A moderate traumatic brain injury occurs when:

• Loss of consciousness lasts from a few minutes to a few hours.
• Confusion lasts from days to weeks.
• Physical, cognitive and/or behavioral impairments last for months or are permanent.

Persons with moderate traumatic brain injury can generally make a good recovery with treatment or successfully learn to compensate for their deficits.
Statistically, between 8% - 10% of all traumatic brain injuries are Moderate Traumatic Brain Injuries. Certain literature suggests that this percentage may be low, and that moderate traumatic brain injury may be as high as 28% of all traumatic brain injuries occurring.

Various tests can be utilized in order to determine and rate traumatic brain injury severity. As indicated earlier when discussing mild traumatic brain injury, estimates of severity of injury based on posttraumatic amnesia duration (PTA), can be utilized. Where the posttraumatic amnesia lasts between 1 hour and 24 hours, the injury rating is generally listed as being moderate.

Neuro-imaging, including CT scan, MRI (functional as well as T-3 and other strength ratings, gradient echo and other software applications), SPECT scan and PET scans are often used as diagnostic tools for the purpose of rating moderate traumatic brain injury.

The length of a coma or unconsciousness is yet another indicator of injury severity. Length of unconsciousness greater than 20 minutes, though no longer than six hours indicates a moderate traumatic brain injury. (Less than 20 minutes coma duration would therefore indicate a mild traumatic brain injury, while greater than six hours of coma duration would generally indicate a severe traumatic brain injury.)

Statistics vary on the outcome of individuals sustaining moderate traumatic brain injury. At least one study indicated that as many as 28% of those individuals seen in an emergency room and in an intensive care unit diagnosed with a moderate traumatic brain injury made a "good recovery" on the Glasgow Outcome Scale. Changes in sleep patterns, fatigue, judgment, headache, multitasking, memory, concentration, word selection, attention deficits, processing speed problems, and problems with independent living were nonetheless found to persist. Most individuals sustaining moderate traumatic brain injury will find it extremely difficult to return to their pre-morbid (pre-injury) vocation (job).

The specific area of the brain where damage occurs can likewise have an extreme impact on outcome. For example, where the injury is localized in the temporal lobes, seizure or temporal lobe epilepsy (TLE) can develop. Where the injury is primarily localized in the frontal lobes, frontal lobe syndrome can develop. Depending on whether the injury is focal or diffuse, and further depending on the area of the brain affected, the outcome of individuals sustaining moderate traumatic brain injury is difficult to predict, as are the clusters of symptoms likely to remain.

III. SEVERE TRAUMATIC BRAIN INJURY

Glascow Coma Scale Score 8 or less

Severe brain injury occurs when a prolonged unconscious state or coma lasts days, weeks or months. There are six (6) states that a person can undergo when they have sustained a severe brain injury:

1) Coma
Coma is defined as a state of unconsciousness from which the individual cannot be awakened, in which the individual responds minimally or not at all to stimuli, and initiates no voluntary activities.

• Persons in a coma appear to be asleep, but cannot be awakened.
• There is no meaningful response to stimulation.

Persons who sustain a severe brain injury can make significant improvements but are often left with permanent physical, cognitive or behavioral deficits.

2) Vegetative State (VS)

Vegetative State describes a severe brain injury in which:

• Arousal is present, but the ability to interact with the environment is not.
• Eye-opening can be spontaneous or in response to stimulation.
• General responses to pain exist, such as increased heart rate, increased respiration, posturing, or sweating.
• Sleep-wake cycles, respiratory functions and digestive functions return.

There is no test to specifically diagnose vegetative state. The diagnosis is made only by repetitive neurobehavioral assessments.

3) Persistent Vegetative State (PVS)

Persistent Vegetative State (PVS) is a term used for a vegetative state that has lasted for more than a month.

• The criteria is the same as for vegetative state

The use of this term is considered controversial because it implies a prognosis.

4) Minimally Responsive State (MR)

Minimally Responsive State is the term used for a severe traumatic brain injury in which a person is no longer in a coma or a Vegetative State. Persons in a minimally responsive state demonstrate:

• Primitive reflexes
• Inconsistent ability to follow simple commands
• An awareness of environmental stimulation

The frequency and the conditions in which a response was made are considered when assessing the meaningfulness or purposefulness of a behavior.

5) Akinetic Mutism

A condition of silent, alert-appearing, immobility that characterizes certain subacute or chronic states of altered consciousness. Sleep-wake cycles have been retained, but no observable evidence for mental activity is evident; spontaneous motor activity is lacking; person appears to be aware but inactive. Exhibited by persons with high brain stem lesions

6) Brain Death

With the development over the last half-century of medical equipment that can artificially maintain blood flow and breathing, the term “brain death” has come into use. Brain death is the absence of brain function. Before life support equipment was invented, the body would die as soon as the brain died because the brain is necessary to control vital bodily functions such as breathing and the beating of the heart. Brain function may stop after widespread damage to the brain leads to loss of the brain's ability to coordinate activity among distinct areas of the brain. Brain death is irreversible. In 1981 the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research developed specific criteria to determine when brain death has occurred. Immediately after a brain dead patient is removed from life support equipment, the heart quits beating and breathing stops.

Severe TBI - A Life Long Problem

Statistically, severe traumatic brain injury victims comprise approximately 10% of all traumatic brain injuries. However, because individuals sustaining severe traumatic brain injury are unlikely to ever return to work or independent living, and because their rehabilitative needs are so great and expensive, and because almost all are unable to return to independent living, this group represents a growing problem for society and for the health care profession. Families of individuals sustaining severe traumatic brain injury are subjected to severe financial and emotional burdens.

Severe traumatic brain injury continues to have significant effects on emotional, cognitive, vocational, psychosocial, independent living, and family function decades after the injury. There is a distinct interplay between emotional components and organic injury that interplays and interacts cumulatively in effect.

Generally speaking, individuals sustaining severe traumatic brain injury display dysfunction in virtually all areas of cognition, and indeed display motor defects affecting physical response. While there may be some unique characteristics demonstrated, patient by patient, it is not uncommon for the following deficits to persist in varying levels of severity over the course of the patient's life:

• Motor Function Problems
• Frontal Lobe Syndrome/Executive Dysfunction
• Attention and Memory Deficits
• Speech/Language Difficulties
• Smell/Taste Difficulties
• Seizure Disorder
• Emotional/Psychiatric Overlay
• Other Physical Injury