Prognosis after Brain Injury

People with traumatic brain injury can suffer from physical, mental and emotional problems long after sustaining the injury.  Generally the prognosis can be based on early findings, such as a low score on the Glasgow Coma Scale; however, even seemingly trivial head injuries, such as concussions can result in long term sequelae.

The amount of time that a head trauma patient lies in a coma makes a difference in how long the patient takes to recover and on how much amnesia they have surrounding the events of the brain injury.   Mild injuries resulting in unconsciousness  that lasts only a few seconds to minutes , or other alterations in consciousness, often recover within a few days, suffering from some post-traumatic amnesia, confusion, headache and gait disturbances.  Things like nausea and vomiting are usually short term and go away after a day or two.

Post-Concussive Syndrome

Headaches tend to be the longest symptom following a concussion.  The headaches can be located to the trauma side site or to the side of the head involved and are mostly musculoskeletal in nature.  A few patients develop a condition known as “post-concussive syndrome”. This involves many months to a few years of the following symptoms:

The headaches can be musculoskeletal in nature or can be migraine-like headaches that only really respond to migraine-related medications.  Neck injuries occurring at the time of the head injury will contribute to ongoing headaches.  For those with post-concussive syndrome symptoms, the loved ones of the injured person may notice things like suspiciousness, being more argumentative, irritability and stubbornness.

The treatment involves treating the symptoms and waiting for the brain to recover.  Some patients end up taking medications for migraine-like headaches for many months.

Coma Length and Severity as predictors of Outcome

In general, the longer the coma, the longer is the recovery time and the longer is the amnesia following the trauma.  Comas of seconds to minutes- long yield recovery times in the range of days to a few weeks.  Comas of several weeks tend to take months or years for complete recovery of physical, mental and emotional suffering.  The type of impairment the patient suffers can also be related to the side  of the brain traumatized.  Areas of the brain such as the parts involved in cognition and behavior will yield different symptoms than if the areas of the brain are motor skills, balance or even sight-related.

One thing doctors can do to prevent worsened long term sequelae is to give medications early on in the treatment that reduce swelling of the brain.  If the brain is swollen, the entire brain can be affected, negatively.  When swelling is minimized, the damaged brain cells begin to work more quickly and overall brain damage is minimized.  Over time, the healthy brain parts can compensate for damaged parts-a concept called brain plasticity.

The Role of Hypoxia and Hypotension

When a person suffers from a severe head injury, they often have  independent findings of hypoxia and hypotension, depending on what other injuries they have.  Hypotension is considered more serious and is found in 35 percent of all severe head injuries.  The rate of mortality in patients with severe head injury and hypotension is 150 percent greater than head injury patients who do not suffer from low blood pressure following the incident.

Hypoxia to the brain and other organs during a time of a traumatic brain injury also affects prognosis.  This is because the brain cells get starved of oxygen and become damaged.  Secondary swelling can occur, leading to further brain damage, herniation of the brain parts through the base of the skull and possible cardiorespiratory death.   In short, because hypoxia and hypotension are very common parts of getting a brain injury and because their presence leads to a poorer outcome, resuscitation efforts should be undertaken that address these issues as well as the brain injury itself.

Concussion Prognosis in Children

Children  get concussions and worsened head injuries from falls, car accidents, child abuse and incidents on playgrounds.  For a child with mild traumatic brain injury, most research studies show a resolution of post-concussive symptoms within two to three months following the injury.  Most studies show no post-injury effects on behavior; however at least one study showed that kids had a higher incidence of hyperactivity after the diagnosis of head injury.

Mental and Emotional Deficits following Acute Brain Injury

Depending on the location and severity of injuries to the brain, the individual can have cognitive defects, including problems with memory, concentration and other cognitive processes.  Some of these can be long-lasting and can affect school and work performance.  These deficits can be elucidated by doing neuropsychometric testing involving IQ tests, memory tests, and other tests of things like reading comprehension and writing.

Emotional changes can also happen after a traumatic brain injury.  The various symptoms include stubbornness, post traumatic anxiety, post traumatic depression and overall irritability.  Emotional changes tend to affect the patient’s relationships and family.

The Range of Head Injury Sequelae

As mentioned, mild head trauma with brain injury is referred to as MTBI and generally does not provide you with longstanding post-traumatic symptoms.  More severe injuries can mean a loss of speech, balance difficulties, loss of motor control, hearing and vision losses, and severe cognitive deficits that cannot be regained, especially if they are still present after about a year post injury.  The area of the brain affected controls which kinds of deficits the patient subsequently has.  Some can return to independent living, while others need to have some kind of help with activities of daily living for the rest of their lives.  It all depends on the degree and location of injury, and the amount of brain damage that has been sustained.

Treating Traumatic Brain Injury with Hypothermia
 
One way of helping reduce long-term sequelae of a traumatic brain injury is to cool the patients externally for about twenty four hours after the injury.  The outcome after doing such a treatment improves over at least twelve months when compared to patients left at normal temperature after the injury.  In one study, 62 percent of patients who were treated with hypothermia suffered no bad outcomes.  The effectiveness of this type of treatment was more noticeable in those with higher Glasgow Coma Scale numbers.  Only 38 percent of patients treated with normothermia could say that they had a good outcome several months down the line.
 
Summary
 
Many people with traumatic brain injury go on to recover their cognition, emotions and behavior but it can take many months or even years.  Those with serious brain injury, however, often have permanent changes going on in the brain that are not recoverable.  The length  of coma and subsequent treatment of brain swelling are important factors in determining who has a poor prognosis and who ultimately recovers from their brain injury.
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