How Is TBI Treated?

National Institute of Neurological Disorders and Stroke
¿Qué cuidados médicos debe recibir un paciente con traumatismo cerebral?

Many factors, including the size, severity, and location of the brain injury, influence how a TBI is treated and how quickly a person might recover. One of the critical elements to a person’s prognosis is the severity of the injury. Although brain injury often occurs at the moment of head impact, much of the damage related to severe TBI develops from secondary injuries which happen days or weeks after the initial trauma. For this reason, people who receive immediate medical attention at a certified trauma center tend to have the best health outcomes. 

Treating mild TBI

Individuals with mild TBI, such as concussion, should focus on symptom relief and “brain rest.” In these cases, headaches can often be treated with over-the-counter pain relievers. People with mild TBI are also encouraged to wait to resume normal activities until given permission by a doctor. People with a mild TBI should:

  • Make an appointment for a follow-up visit with their health care provider to confirm the progress of their recovery.
  • Inquire about new or persistent symptoms and how to treat them.
  • Pay attention to any new signs or symptoms even if they seem unrelated to the injury (for example, mood swings, unusual feelings of irritability). These symptoms may be related even if they occurred several weeks after the injury.

Even after symptoms resolve entirely, people should return to their daily activities gradually. Brain functionality may still be limited despite an absence of outward symptoms. Very little is known about the long-term effects of concussions on brain function. There is no clear timeline for a safe return to normal activities although there are guidelines such as those from the American Academy of Neurology  and the American Medical Society for Sports Medicine  to help determine when athletes can return to practice or competition. Further research is needed to better understand the effects of mild TBI on the brain and to determine when it is safe to resume normal activities.

Preventing future concussions is critical. While most people recover fully from a first concussion within a few weeks, the rate of recovery from a second or third concussion is generally slower.

In the days or weeks after a concussion, a minority of individuals may develop post-concussion syndrome (PCS). People can develop this syndrome even if they never lost consciousness. The symptoms include headache, fatigue, cognitive impairment, depression, irritability, dizziness and balance trouble, and apathy. These symptoms usually improve without medical treatment within one to a few weeks but some people can have longer lasting symptoms.

In some cases of moderate to severe TBI, persistent symptoms may be related to conditions triggered by imbalances in the production of hormones required for the brain to function normally. Hormone imbalances can occur when certain glands in the body, such as the pituitary gland, are damaged over time as result of the brain injury. Symptoms of these hormonal imbalances include weight loss or gain, fatigue, dry skin, impotence, menstrual cycle changes, depression, difficulty concentrating, hair loss, or cold intolerance. When these symptoms persist 3 months after their initial injury or when they occur up to 3 years after the initial TBI, people should speak with a health care provider about their condition.

Treating severe TBI

Immediate treatment for the person who has suffered a severe TBI focuses on preventing death; stabilizing the person’s spinal cord, heart, lung, and other vital organ functions; and preventing further brain damage. Persons with severe TBI generally require a breathing machine to ensure proper oxygen delivery and breathing.

During the acute management period, health care providers monitor the person’s blood pressure, flow of blood to the brain, brain temperature, pressure inside the skull, and the brain’s oxygen supply. A common practice called intracranial pressure ICP monitoring involves inserting a special catheter through a hole drilled into the skull. Doctors frequently rely on ICP monitoring as a way to determine if and when medications or surgery are needed in order to prevent secondary brain injury from swelling. People with severe head injury may require surgery to relieve pressure inside the skull, get rid of damaged or dead brain tissue (especially for penetrating TBI), or remove hematomas.

In-hospital strategies for managing people with severe TBI aim to prevent conditions including:

  • Infection, particularly pneumonia
  • deep vein thrombosis (blood clots that occur deep within a vein; risk increases during long periods of inactivity)

People with TBIs may need nutritional supplements to minimize the effects that vitamin, mineral, and other dietary deficiencies may cause over time. Some individuals may even require tube feeding to maintain the proper balance of nutrients.

Following the acute care period, people with severe TBI are often transferred to a rehabilitation center where a multidisciplinary team of health care providers help with recovery. The rehabilitation team includes neurologists, nurses, psychologists, nutritionists, as well as physical, occupational, vocational, speech, and respiratory therapists.

Cognitive rehabilitation therapy (CRT) is a strategy aimed at helping individuals regain their normal brain function through an individualized training program. Using this strategy, people may also learn compensatory strategies for coping with persistent deficiencies involving memory, problem solving, and the thinking skills to get things done. CRT programs tend to be highly individualized and their success varies. A 2011 Institute of Medicine report concluded that cognitive rehabilitation interventions need to be developed and assessed more thoroughly.

Other factors that influence recovery

Genes

Evidence suggests that genetics play a role in how quickly and completely a person  recovers from a TBI. For example, researchers have found that apolipoprotein E ε4 (ApoE4) — a genetic variant associated with higher risks for Alzheimer’s disease — is associated with worse health outcomes following a TBI. Much work remains to be done to understand how genetic factors, as well as how specific types of head injuries in particular locations, affect recovery processes. It is hoped that this research will lead to new treatment strategies and improved outcomes for people with TBI.

Age

Studies suggest that age and the number of head injuries a person has suffered over his or her lifetime are two critical factors that impact recovery. For example, TBI-related brain swelling in children can be very different from the same condition in adults, even when the primary injuries are similar. Brain swelling in newborns, young infants, and teenagers often occurs much more quickly than it does in older individuals. Evidence from very limited CTE studies suggest that younger people (ages 20 to 40) tend to have behavioral and mood changes associated with CTE, while those who are older (ages 50+) have more cognitive difficulties.

Compared with younger adults with the same TBI severity, older adults are likely to have less complete recovery. Older people also have more medical issues and are often taking multiple medications that may complicate treatment (e.g., blood-thinning agents when there is a risk of bleeding into the head). Further research is needed to determine if and how treatment strategies may need to be adjusted based on a person’s age.

Researchers are continuing to look for additional factors that may help predict a person’s course of recovery.

Posted on BrainLine September 1, 2015.

Source: Traumatic Brain Injury Hope Through Research, NINDS, Publication date September 2015. http://www.ninds.nih.gov

NIH Publication No. 15-2478

Prepared by:
Office of Communications and Public Liaison
National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892

NINDS health-related material is provided for information purposes only and does not necessarily represent endorsement by or an official position of the National Institute of Neurological Disorders and Stroke or any other Federal agency. Advice on the treatment or care of an individual patient should be obtained through consultation with a physician who has examined that patient or is familiar with that patient's medical history.

All NINDS-prepared information is in the public domain and may be freely copied. Credit to the NINDS or the NIH is appreciated.

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