Head Trauma: Traumatic Brain Injury

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Head Trauma: Traumatic Brain Injury




Guest:  Dr. Angela Hays - Neurosciences

Host:  Dr. Linda Austin – Psychiatry


Dr. Linda Austin:  I’m Dr. Linda Austin.  I’m interviewing Dr. Angela Hays who is Assistant Professor of Neuroscience here at the Medical University of South Carolina.  Dr. Hays, let’s talk, today, about an area that’s an interest of yours.  I know that you are a neurological intensivist and, as such, you take care of a lot of patients who have had bumps on the head, who have what we call traumatic brain injury or TBI.  Let’s talk about that.  What would make you suspect, first, that a person might have had an injury to their brain?


Dr. Angela Hays:  Well, usually the best clue is the history that get from the patient or from the people who’ve brought them to the emergency department.   The most common causes of traumatic brain injury are motor vehicle accidents, falls, people getting hit by various objects, for instance, a falling brick, or something like that, and, lastly, assaults, which are responsible for about 10 or 11 percent of traumatic brain injury.  The symptoms that people most commonly present with are loss of consciousness, headache, confusion, dizziness, blurry vision and sometimes nausea and vomiting.


Dr. Linda Austin:  Now, is loss of consciousness an essential component of this?  For example, can one have sustained injury, actually, without losing consciousness?


Dr. Angela Hays:  Absolutely.  People classify head injury according to a variety of different criteria but, generally speaking, a mild head injury can occur without loss of consciousness.  Those are the patients that might present with a story of having been hit on the head and then find that they are a little bit confused, maybe have some short-term memory loss.  Nausea and vomiting are very common.  They may complain of ringing of the ears or a sense of imbalance.  But, that would qualify as a mild symptomatic traumatic brain injury and that’s probably the most common type that people see in the community. 


A moderate or severe head injury would be characterized, typically, by loss of consciousness.  If it’s less than 30 minutes, that might fall into the moderate category.  People that remain comatose or unconscious for a longer period of time are usually characterized as having severe brain injury, just generally speaking.


Dr. Linda Austin:  So, even, say, a couple of hours would qualify, then, as a severe case?  Is that right?


Dr. Angela Hays:  Yes.  That’s one of the criteria.  Usually you have to have one of several in order to qualify as severe brain injury.  Other things that we would look for, aside from loss of consciousness lasting more than 30 minutes, would be amnesia, which is a common consequence of traumatic brain injury.  And the amnesia that we talk about, almost always, people will forget the actual accident if the head injury has been severe enough, but what we’re really interested in is what’s called anterograde amnesia, meaning, can’t lay down new memory.  So, frequently what we’ll see when we’re assessing somebody who’s had a significant bump on the head, as you put it, is that we’ll introduce ourselves, leave the room, come back in and they don’t remember having seen us before.  Or, for instance, we’ll tell them, you had a car accident, leave the room, come back in and they say, how did I get here?  If that lasts for more than 24 hours after the event then that’s another criteria, even if they didn’t have prolonged loss of consciousness, that would qualify them for a severe traumatic brain injury.


Dr. Linda Austin:  So, you get worried if that really persists?


Dr. Angela Hays:  Yeah. 


Dr. Linda Austin:  Dr. Hays, given, then, that sometimes even without loss of consciousness; a person may have sustained an injury, what are some of the symptoms to watch for that would make someone think that they really ought to get to the emergency room?


Dr. Angela Hays:  I would say that if a person has persistent trouble with memory, lasting more than several minutes, I would certainly consider being seen.  Another thing that you need to watch out for is a worsening level of arousal.  For instance, if somebody seems sleepy, that might be normal, but if they continue to get sleepier then that person, absolutely, needs to be assessed.  Any weakness or numbness on one side or the other needs to be evaluated.  If the person has any nausea of vomiting ought to signal somebody to be seen by a physician.  And the main reason for that is because nausea and vomiting can be early symptoms of what we call intracranial pressures.  That can be a symptom of, for instance, bleeding inside the skull, which can be dangerous and sometimes even life threatening.  That’s the main thing that we want to rule out whenever somebody has had a head injury.


Dr. Linda Austin:  So, that’s what you’re really worried about, that they have a bleed?


Dr. Angela Hays:  Absolutely.


Dr. Linda Austin:  Now, if there is a bleed, what part of the brain is that bleed occurring in?


Dr. Angela Hays:  There are several different types of intracranial hemorrhages that you might run into after traumatic brain injury.  Probably the most concerning is what’s called an epidural hemorrhage.  And that occurs, usually, in association with a skull fracture.  It most commonly results from a tear in one of the arteries running along the surface of the brain.  And that’s what makes it so dangerous, because, obviously, if you tear an artery, the bleeding is under much higher pressure than hemorrhages that result from tearing of a vein.


An epidural hemorrhage usually presents with what’s called a lucid period, meaning that the person may look just fine for the first several minutes to hours after the injury and then they become sleepy after that.  And that’s why I commented that a worsening level of arousal is something is a very concerning sign.  And that’s a type of hemorrhage that can be picked up very easily on a CAT scan.  And, if it is found, sometimes it requires surgical drainage, but sometimes it be just watched, depending on how big it is and how severe the symptoms are.


The second most serious type of hemorrhage we worry about is what’s called a 

subdural hemorrhage, and that results from tearing of the veins that cross from the skull to the surface of the brain.  So, because it’s the veins that are bleeding, in this case, those hemorrhages grow much more slowly and result in a blood clot that lays over the surface of the brain.  As the hemorrhage grows, people can develop headaches.  They can develop nausea.  They can develop vomiting.  And sometimes, they get sleepy as well.  They may also have symptoms such as tingling or weakness on one side of the body or the other.  And, again, these are the kind of hemorrhages that can be very easily picked up on a CAT scan and sometimes might require surgery, depending on severe they are.


The last thing that we sometimes run into with traumatic brain injury is what’s called a cerebral contusion, which is like bruising of the brain.  That results from broken blood vessels within the brain tissue itself.  Those are pretty common and, again, can cause symptoms like numbness or tingling, but, very frequently, don’t cause any symptoms at all.  These are the kinds of things that are dangerous more because of the swelling that sometimes accompanies them, rather than because of the bleeding itself, and only really require medical treatment if the swelling gets severe enough that their brain pressures start to increase.  Frequently those can just be observed in the hospital for 24 to 48 hours, and if they remain stable or start to get better, the person can go home and doesn’t need any further treatment.


Dr. Linda Austin:  So, then if somebody has a bump on the head, let’s say, in the evening or before bedtime, would you advise that, perhaps, somebody set an alarm for three or four hours later and just make sure they’re arousable?  Otherwise, how do you assess if they’re getting sleepier or not?


Dr. Angela Hays:  It’s a very difficult thing.  We often used to say that somebody shouldn’t go to bed in the hours following a head injury and should be watched very closely.  I would advise that, if there’s any doubt, the person really ought to be seen by a physician, because a CAT scan is a quick simple test that can rule out most of those concerning things pretty definitively without too much investment of time and it’s a noninvasive test.  If the patient is really resistant to going to the emergency room, I wouldn’t leave them alone.  I would keep the person up for the next several hours, make sure that they continue to be arousable, and, certainly, see if you can convince them get seen by a physician if those things don’t continue to be true.


Dr. Linda Austin:  Because a hemorrhage can be a very serious thing.


Dr. Angela Hays:  Absolutely.  It can be life threatening.  And, in the case of the epidural form, it can progress very rapidly.


Dr. Linda Austin:  Dr. Hays, I want to talk some more about the long-term consequences of traumatic brain injury, but let’s do that in another podcast.


Dr. Angela Hays:  Okay.


If you have any questions about the services or programs offered at the Medical University of South Carolina or if you would like to schedule an appointment with one of our physicians, please call MUSC Health Connection:  (843) 792-1414.

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