Diagnosing TBI in the ER

Okay, is it easy to tell if a person has a brain injury? I mean, what are you looking for? That's a very good question. When someone comes in in a coma, it's more obvious that they have a brain injury. [Jeffrey Bazarian, M.D.] [Emergency Medical Physician] Their brain is not working because they're not awake, so our physical exam, it just helps us confirm how severe that is. But at the milder end of things, at the concussion end of things, it is difficult to know whether someone's had an underlying brain injury. Honestly, the tools that we have in the emergency department to understand that, to figure that out, are pretty limited. Well, what are some of the tools that you use to detect a brain injury, and then how effective are they? Good questions. We have really 2 main tools to detect a brain injury, and I'm talking more now at the milder end of things. One is our physical exam, so kind of our diagnostic acumen, and that's pretty limited, though, because concussion patients look like we all do sitting here, look pretty awake and alert. Normally, the physical exam is not revealing. A CAT scan, which is a picture of the brain, is also a fairly crude tool for seeing the nerve cells we suspect are injured. And most of the time, people with a concussion have a normal looking CAT scan, so it doesn't really help us in that regard. Is there anything on the horizon that could improve your ability to detect a brain injury in the ER? Yes, there is. It appears that when people have had a concussion, there are some proteins that may be released when the nerve cells get damaged that find their way into the blood. We could take a sample of blood from a patient's arm and tell them whether some of those proteins are in the blood, and that will help us know whether they have had a brain injury. There's at least 1 test being used in Europe in this regard. It's called S100B, and there are many groups in the United States that are studying it now, and I think in the future you're going to be seeing blood tests being used to help diagnose brain injury just like blood tests are used now to figure out if you've had a heart attack.

For mild TBIs, making a clear diagnosis can be difficult. There are CT scans and physical and neuropsych evaluations. But in the future there may be simple, revealing blood tests.

This is an excerpt from BrainLine's webcast After the Injury: Acute Care and TBI. See full webcast here.

Posted on BrainLine December 1, 2011.

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Comments (1)

My adult daughter has been diagnosed 7 years now with Encephalomalacia. She has sustained 2 additional head injuries. The 1st being August 5, 2017. The 2nd and more severe occurred September 14, 2017, when she lost consciousness and dropped to the floor from a standing position. She hit her head & VP Shunt, & her neck on a steel stool & her spine hit the floor. They did a sternal rub to bring her back aware. She gasped coming back claiming she initially couldn't feel her legs. A CT Scan of head & neck was done within 1 hour. No spine evaluation. Then maybe an additional CT head 24 hours later. However, my daughter's head injury was severe enough to cause immediate vision decline in an already existing 3 TBI related Eye Disorders: Exophoria, Accomodating Disorder, & Convergence Insufficiency. That 2nd head injury resulted in at least a decline in her Accomodating Disorder. On October 3, 2017, her Neuro-Opthalmologist confirmed with a cursory simple exam determined a decline in her Accomodating Disorder. He stated it could upwards of 1 year for any improvement. He stated in his narrative that he did not think based upon his exam, that she has increased ICP, however her ICP could be mild to moderately high. Now, here's MY thought. There are TESTS to determine this. Right?
There was a recent return visit back to him. This time I made requests for tests to determine what in her brain was injured to cause the vision loss. We waited to be seen from 3:45 pm until 6:30pm that evening. My daughter in pain was in & out of her agitative state. When he came in to see her he didn't examine her..but I know he surely read the nursing notes and my requests for testing. He said, " We can give her a first appointment at a future date." As of today, no tests have been done on her brain since her last CT Scan September 15, 2017. My daughter has also a 10 year history of her VP Shunt in overdraining status. I just reviewed records ibdicating this. It was found blocked the 1st week of August, 2013. Its been in place since October 19, 2007. The last 3 settings on the Medtronics Strata 2 VP shunt were ruled out. The 1.5 for overdrainage. The 2.5 ruled out for contributing to cyst formation. The 2.0 was ruled out for overdrainage. It appears too, the proximal catheter was placed in the most unfavored spot. There are 4 placements, her proximal catheter terminates in the Genu of Corpus Callosum. Repositioning this catheter was considered when it was found blocked causinv right ventricle edema, frontal lobe edema. Then she was sent home with no repositioning. Her Encephalomalacia occurring has 1st multiple head injuries
(+10), she is also a Chiari Malformation patient. She has had 2 decompression surgeries. 1 shunt placement, a surgery to resolve a huge Pseudomeningocele right after her2nd Chiari decompression revision. So multiple layers. Amazing that she is still having some good days with intermittent agitation with aggressive tendencies. She is in alot of pain which is not being treated. I would appreciate any helpful suggestions as nobody is giving me any answers.