Diagnosis & Treatment

Often the tests used to diagnose an injury help determine the appropriate course of treatment.

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What If Your MRI is "Clean" Post-Brain Injury?

What If Your MRI is "Clean" Post-Brain Injury?
So, one of the challenges we have in the field is that it's estimated that more than 95 percent of all brain injuries in the U.S. have completely clean or normal CTs and MRIs that are done. This is a big challenge for families when they're looking for an answer because their child is not recovering from a concussion, maybe. I mean, in the severe injuries we're very good at characterizing damage, but those injuries only account for 5-10 percent of what we see overall. And when we're seeing more than 3 million a year, that's a large denominator to completely miss. So the role of imaging becomes much more research-generated rather than clinically oriented, and we are moving to try and make some of the technologies clinically applicable. So, for instance, at pretty much every major medical center in the U.S., we are using diffusion tensor imaging in our standard clinical imaging protocols now. So in terms of what do you do when your standard MRIs are negative? You keep pushing, because if your child is still developing symptoms, we still are not very good at really characterizing the damage that's been done. And you can always ask for an MRI. You can always ask to go see a TBI specialist. Seeing a family doctor is a great first step, but if you're continuing to have symptoms, it's really important to go see somebody who really understands the intricacies of TBI.

Neuropsych Exam Versus Imaging for Brain Injuries

Nadia Webb, PsyD: Neuropsych Exam Versus Imaging for Brain Injuries
If you suspect a child sustained a brain injury, there are ways to evaluate it. And often it's not an MRI or a CAT scan. People will often say, "Well, the CAT scan was normal." And that really doesn't mean much. CAT scans are done in emergency rooms because they're cheap and quick and what they'll spot is blood. So if you have blood, that may mean they need to call the surgeon in quickly, but it doesn't preclude a brain injury. A normal EEG doesn't preclude a brain injury. MRIs don't tell you how the brain is functioning; it tells you if all the cells are there. So it's a little like--since we're in New Orleans--when Bush flew over New Orleans and said, "You're doing a great job, Brownie, and all the buildings are there," that does not mean that everything is fine inside the buildings. So for a lot of these kids, the structures are there but chemically it's not working as well. The connections between neurons are off. Chemically, they can be less efficient. It can take literally more fuel to do the same task. So the best way to do it is actually to have a neuropsychological evaluation. The neurosurgeons will send kids to me if they want to get a sense of how is this child doing functionally? Do they need extra help? Are they showing particular problems with memory, learning, attention, judgment, visual motor skills, reading, language, perception? And we basically can do almost like a scouting report. We go through and we look functionally at the brain and see how each area is doing and look at the integrity of the circuitry and then also what you can do about it.

Treatment of TBI in the Emergency Department

Dr. Jeffrey Bazarian
Early identification of traumatic brain injury is crucial, because we have found that the sooner we can diagnose and treat this problem, the better the patient's chances for full recovery. This is really true for moderate-to-severe traumatic brain injuries. So, for the patient who is in a coma, the quicker we can get them to a center that can control their airway, their breathing, their circulation, and get that CT scan, the sooner we can take care of their brain, especially if we need a neurosurgeon to evacuate some blood. Now, in the case of mild traumatic brain injury, I still think that early diagnosis is important, because a small percentage of concussion patients, or mild TBI patients, will have--will be harboring a small clot there. They'll look like you and I sitting here and looking fine, but they'll be harboring a small clot that's slowly getting bigger and bigger. Only about 5% or so of all concussion patients will have this, but it's hard to know just by looking at someone whether they're going to be that 5%. So, getting them to a place that can do a CT scan quickly, is important for identifying that potentially life-threatening blood clot. But, I think, it's also important to get patients to some medical facility so that they can get a CT scan, and even if it's normal, have the emergency provider talk to them about what to expect, because they're going to have a variety of symptoms that they've never had before, and we want them to understand this is probably related to getting hit in the head and in most cases, patients will feel better in three to six months. We think that this helps people just accept some of these symptoms and not think that they're nuts. We don't want people thinking that they're crazy. We want them to understand that they've had a head injury, they probably will get better, and this is what to expect. So, if we see a concussion patient who comes in, they look fine, but we do a CT scan and we find a collection of blood, then we have to make a decision here. Is this the kind of blood that needs an operation or is this the kind of blood that we won't be able to get out with an operation? In a small percentage of cases, we can tell just by looking at the CT scan, this is the kind of blood collection that needs an operation, and these are called epidural hematomas and subdural hematomas. So those, generally, need an operation, and we just--we get the neurosurgeons, and they're excellent at helping us sort, sort through those issues. But unfortunately, the vast majority of these abnormal CT scans in concussion patients are bruises. They're collections that aren't amenable to being taken out by a surgeon. So, what we do with those patients is we watch them for 24 hours, because sometimes that bruise gets a little bit bigger, and then patients start to get sleepy, and we need to do airway, breathing, circulation. So 24 hours gives us that window of opportunity to see whether that's going to happen, and we also repeat the CT scan. So, we bring them into the hospital, watch them for 24 hours. if there's no change in their level of alertness, their CT scan looks the same, then we can discharge them safely. If families of patients who are brought into emergency are not pleased with the advice they're getting or they're wanting more, there are several resources that they can turn to. I think the first one that comes to my mind is the Brain Injury Association of America, and I know they have a website that has a lot of information on what you can expect after a traumatic brain injury. And most states have chapters of BIA that can tell you about local resources. So, which physicians in your area specialize in taking care of traumatic brain injury? What sources are there if you were looking to get your child to school or some help with work or school? So, the chapter of-- the state chapters of BIA are often helpful in that regard. I believe you can get to the state chapters from the national BIA website. But as that aside, the American College of Emergency Physicians is working on a standard set of discharge instructions that would--we recommend it to all emergency care providers. Now, it still doesn't protect against the possibility that some rogue physician would not want to use them, but, I think, that would really help in standardizing the care that we give, at least from an emergency setting, and maybe minimize the circumstance you discussed where maybe a family didn't really get much advice from the emergency care provider.

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