Traumatic Brain Injury (TBI) - What It Is
A Traumatic Brain Injury is described by the American Brain Injury Association as an insult to the brain, not of a degenerative or congenital nature, but caused by an external physical force, that may produce a diminished or altered state of consciousness, which results in an impairment of cognitive abilities or physical functioning. It can also result in the disturbance of behavioral or emotional functioning. These impairments may be either temporary or permanent and cause partial or total functional disability or psycho-social maladjustment.

In other words, a brain injury occurs when a traumatic force causes damage to the brain. This could be caused by a violent force, like an auto accident or it can be caused by events such as a near-drowning experience. For people under 75 years of age, the most common of these events is an automobile accident, which accounts for almost half of the traumatic brain injuries; 20% of brain injuries are caused by violence, about 3-8% are due to sports, with over half of all brain injuries involving alcohol. For older people, falls are the most common cause of brain injuries. No matter what type of traumatic event it is, the results on the brain can be devastating.
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Types of Traumatic Brain Injury
There are many different types of brain injuries. Depending on the amount of force and the area affected, the injury may be unnoticeable and short lived, or may cause instant death.

The most common and most minor type of injury is a concussion. A concussion is a short loss of consciousness in response to a head injury, but the term has come to mean a minor injury to the head or brain. When you suffer from a concussion the blood vessels in the brain may stretch and cranial nerves can be damaged.  Concussions are very common among contact sports and car accidents and may take a long time to fully recover.

A more severe injury would be a skull fracture. The two types of fractures are a depressed skull fracture, which is when pieces of the broken skull press into the brain, and the other type of fracture is a penetrating fracture. A penetrating fracture occurs when something pierces the skull, leaving a distinct, localized injury. For example, a gunshot wound would create a penetrating fracture.
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Another type of injury is a contusion. A contusion is a bruising of the brain, or an area of swollen brain tissue mixed with blood from the broken blood vessels. This is caused by a skull fracture or it can be the result shaking the brain back and forth inside the skull. When the head is shaken so violently that the brain bounces off the skull, the contusion is called a contrecoup injury. A contrecoup injury most often occurs in car accidents or in shaken baby syndrome (where the baby is shaken so violently that the brain bounces off the skull wall). Injuries like the contrecoup can result in other injuries like hematomas.

Hematoma occurs when there is heavy bleeding in or around the brain due to an erupted blood vessel. There are 3 distinct types of hematomas. The first is epidural hematoma, which is bleeding between the skull and the dura layer of the brain. Subdural hematoma is where the bleeding in confined between the dura layer and the arachnoid membrane.

The last type of hematoma is intracerebral, which is where there is bleeding inside the brain. About half of severely head-injured patients will have to undergo surgery to remove or repair hematomas or contusions, and 25% will develop immediate seizures.
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Diffuse Axonal Injury is another injury that can happen when the brain is shaken inside the skull. Here the nerve cells inside the brain get disconnected and the there is tearing of nerve tissue inside the brain. When the tissue tears it can also release brain chemicals into the brain causing further damage. Problems with brain communication and chemical balance can lead to physical and mental problems, as well as coma or death.

Injuries to the brain can occur in other ways than physical contact with the head. Sometimes an injury can occur that decreases the blood flow to the brain. This decrease in blood means a decrease in oxygen. The two types of injuries related to lack of oxygen are anoxia, where there is no oxygen available to the brain, and hypoxia, where there is an inadequate supply of oxygen to the brain. These types of injury occur most frequently in victims of near drowning events, electric shock, toxic exposure and heart attack victims (during a heart attack there is decreased blood flow, thus decreased oxygen flow to the brain).
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Levels of Brain Injury
There are 3 levels of brain injury used to describe the severity of an injury. They are mild, moderate, severe and very severe. Some categories include a 4th level, very severe. These ratings are based on the responsiveness of a person who may have just suffered a brain injury. The more responsive they are mentally and physically, the higher their score and the less severe their head injury rating.

Mild head injuries are the most common type of injury and many times go undiagnosed. A person who has suffered a mild head injury may have had a brief loss of consciousness or may feel dazed or confused after an accident of some sort. Many times they do not show up on CT scans or MRIs. Symptoms of a mild head injury include headaches, fatigue, sleep disturbance, irritability, balance problems, nausea, change in mood or appetite. Many times sufferes of mild brain trauma recover fully.
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A person who has suffered from a moderate head injury may have loss of consciousness that may last from a few minutes to a few hours. Sometimes the confusion continues for a few days or a few weeks and the physical, cognitive and behavioral changes are permanent. These people usually make a good recovery and through treatment learn to compensate for any permanent disabilities. They may also suffer from the same symptoms of a person with mild head trauma.

Severe brain injury occurs when a person persists in an unconscious state for days, weeks or months. One state they may be in is a coma, where they cannot be awakened and there is no meaningful response to stimulation. A person may recover from a coma but many times they have permanent mental or physical disabilities, and may suffer from amnesia.
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A person may also be in a vegetative state. In this state, the person may be able to open their eyes as a response to a stimulus, they have sleep-wake cycles, respiratory function and digestive functions, and they have general physical responses to pain (like increased heart rate). Someone in a persistent vegetative state has the same symptoms, but has been in that state for over a month. Oftentimes, this level is referred to as very severe, other times it is simply considered in the severe category.

Someone who has suffered a severe brain injury may also be in a minimally responsive state. Here they have some reflexes and are aware of their environment but cannot follow simple commands. A person may move from a coma or vegetative state into this minimally responsive state.
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Akinetic Mutism is another state that can occur from a severe brain injury. These sufferers have little to no body movement, minimal spontaneous speech, eye opening and visual tracking, and infrequent and incomplete ability to follow commands. This differs from the Minimally Responsive State because Akinetic Mutism is not a neuromuscular disorder like the Minimally Responsive State.

The last state is Locked-In State. In this state the person can move noting but their eyes and is conscious and able to think. They can use their eyes to communicate with others. In this state the person is basically trapped inside their body.

If a person is said to be suffering from brain death, that means that their brain shows no signs of functioning.

If the force that hits a person's head is great enough, the skull can fracture or become out of place. When this happens, the person is described as having an "open head injury". This terminology is referring to the condition of the skull and not the brain. Separate terms are used to describe the condition of the brain. For example, a person may be described to have an open head injury with a severe traumatic brain injury.
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Open vs. Closed Head Injuries
An Open Head Injury occurs when an outside force hits the brain and fractures or is put out of place. This type of injury refers only to the condition of the head and not to the brain. When the head receives an impact from an outside source the brain may be injured may swell. If the skull is fractured or displaced, this can allow the brain room to swell and can assist in reducing the pressure on the brain tissue. On the other hand, the bone fragments can get into the brain and the skull cannot protect the brain like it once could, leaving room for further injury. A person with an open head injury may be assigned to wear a helmet to protect the exposed brain from impact and further injury. If a piece of the skull has been displaced during the traumatic event, that piece of skull may be surgically replaced at a later date or an artificial bone flap may be used to cover the open area.
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There are many types of open head injuries, one is the depressed skull fracture which is where the broken piece of skull bone moves in towards the brain. There is a compound skull fracture which is where the scalp is cut and the skull is fractured. A basilar skull fracture is when the skull fracture is located at the base of the skull (neck area) and may include the opening at the base of the skull. This type of injury can cause damage to the nerves and blood vessels that pass through the opening at the base of the skull. A Cribiform Plate Fracture is when the cribiform plate, which is a thin structure located behind the nose area is fractured. When this happens cerebral spinal fluid can leak from the brain area out the nose.

Battle's Sign is when the skull fracture is located at the ear's petrous bone. This produces large black and blue marks on the areas below the ear, on the jaw and neck and it may include damage to the nerve for hearing. Sometimes blood or cerebral spinal fluid may leak out of the ear.

Another type of open head injury is Racoon Eyes, which sometimes occurs when the skull fracture is located in the anterior cranial fossa. This produces black and blue mark looking areas around the eyes. Cerebral spinal fluid may leak into the sinuses. Nerve damage for the sense of smell or eye functions may occur.
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A Closed Head Injury occurs when a person receives an impact to the head from an outside force, but the skull does not fracture or displace. After a closed head injury the brain has no place to expand if it starts to swell. This can cause an increase in pressure inside the skull, causing brain tissues to compress, which causes more damage.

If the brain starts to swell, it may expand through any available opening in the skull, including the eye sockets. When the brain expands through the eye sockets, it can compress and impair the functions of the eye nerves. For instance, if an eye nerve is compressed, a person's pupil will appear dilated (big). One reason why medical personnel may monitor a person's pupil size after and accident is to ensure that there is not too much intracranial pressure.
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Other Effects of Traumatic Brain Injury
Many times the brain is not the only part of the body that is damaged from a traumatic brain injury. Since the brain is the main control center for the body, anything that goes wrong inside the brain, will likely have effects on the rest of the body. Polytrauma is term used by physicians to explain injuries in other parts of the body. Popular complications include lung, heart and gastrointestinal dysfunction, plus excessive blood clotting ns nerve injuries. Some trauma victims develop hypermetabolism, where their body needs so much energy to keep the body functioning that it starts to pull energy from muscles and other tissues. Many brain trauma victims can develop permanent behavioral and mental disorders like depression and increased irritability, that can cause problems at home and in the work force. Others retain the inability to think and reason like they could before the accident. Some have permanent physical disabilities or lose senses like taste and smell. Alzheimers, Parkinsons and dementia can be some of the long-term effects of a traumatic brain injury.
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Ways to Prevent Brain Injuries
The Center for Disease Control and Prevention recommend the following tips for preventing a brain injury:

• always wear a seatbelt, and buckle your child into a seatbelt
• be sure you and your children wear a helmet when you ride a motorcycle, horse or bike, and when you ski, play contact sports or play baseball
• keep firearms and bullets stored n a locked cabinet when not in use and keep children away from them at all times
• avoid falls by using a step stool with grab bar, using handrails on steps, installing window guards to prevent children from falling and make sure your child plays on shock absorbing material, like mulch or sand (not blacktop)
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Caring for a loved one who is a survivor of a brain injury can be hard, but you are not alone. Organizations that specialize in the care, education and prevention of brain injuries are as follows:

Northern Kentucky - BRain Injury Demands Guidance, Education & Support (BRIDGES) - Meets on the third Thursday of the month with guest speakers, information and guidance regarding brain injury related issues. Time for sharing and caring.
Contact:  Lisa Combs - 859-903-9600.

State Wide Support Groups are available in Kentucky, Indiana and Ohio - The Brain Injury Alliance of Kentucky (BIAK), Brain Injury Association of Indiana and Brain Injury Association of Ohio.  Go to Resources for contact information.
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