Exploring Your Brain with Garrick Utley

♪ The Broken Brain ♪ Garrick Utley: The fragile dwelling place of the soul--that's what the brain has been called. Fragile, indeed. More than 2 million Americans sustain brain injuries every year from falls, competitive sports, car crashes, and gunshots. More than 50,000 die. And for many survivors, life is never the same again. Scientists are now taking up the challenge of trying to heal the broken brain. Head injuries can happen to anyone, but thrill seekers like Randall Chesnut are most at risk. He's always loved extreme sports--skiing, rock climbing, and above all mountain biking. RC: When you're screaming downhill on a bumpy, muddy course, it's hard to let the daily troubles of the world stay in your mind. GU: It's young adults who sustain brain injuries most frequently. They drive too fast, play too hard, take too many risks. RC: I'm not sure it's the risk that's the appeal of sports that some people would call extreme. I think it's the challenge. But when we met Chesnut at this hospital in Portland, Oregon, it wasn't because he'd injured his head--though he did break his neck once while rock climbing-- it's because Doctor Chesnut is Director of Neurotrauma here and one of the top neurosurgeons in the country. RC: Traumatic brain injury is the leading cause of death in patients between 15 and 45--in the most productive years of their lives. GU: For those who survive, a brain injury can undermine everything that makes us human--our ability to think, to learn, to remember, and to relate to the people we love. RC: Trauma is something that happens to people who don't deserve it. It comes out of the blue. They took off that day--drive across town, go climbing, go riding, and in a microsecond, out of the blue, comes a trauma that changes their life forever. He looks at first like any other dad teaching his 3-year-old son how to skate. But this father in Greenwich, Connecticut, knows his way around the ice. It's Pat LaFontaine, who might be the best American-born hockey player ever. He played 14 years in the NHL and scored 468 goals. He'd still be playing now except for one problem--during his career, Pat sustained at least 6 concussions. PL: You play with injuries. You play sick. It's kind of a ritual of a hockey player that you don't complain. You know--you're there and play and overcome the adversity and the injuries and just push through it. GU: But then came a concussion that even Pat couldn't ignore. PL: I remember trying to make a drop pass to one of my teammates who was cutting behind me, and just at the last second I looked up, and that was it. It wasn't until later that I found out that the player who hit me was 6'6", 235, and the only part of my body that was hit was my head. And I had lost my helmet and my forehead had slapped off the ice. GU: Sports are a major cause of brain injury from youth leagues up to the pros. Studies show that every year 7 to 10 percent of all football players sustain a concussion. Most of us think a concussion means being knocked unconscious, but neurologists define it much more broadly as any change in mental status resulting from trauma. James Kelly is a nationally recognized neurologist who has helped Pat LaFontaine and many other athletes. JK: The players commonly will withhold information about the symptoms they are having in order to get back at it. I even know of one young high school football player who died after having told a teammate, "Don't tell the coach that I have a headache and I feel like I'm going to throw up." And in the second half of that football game, he died. GU: After his concussion, LaFontaine tried to soldier on. He played 6 more games, but his symptoms soon got worse. PL: I couldn't sleep. I started getting headaches--migraine headaches--and I became very symptomatic. I was wiped out physically. I was emotional. I was depressed, and--uh--total personality change. GC: How was this being manifested--felt--in the family? PL: At point I was reading a story to my daughters and had trouble focusing in on the words and then skipping over words and then having to look at my daughters and say, "Daddy--Daddy's just going to have to read this story another time." GU: Over the next 6 months, his symptoms receded, and Pat yearned to play again. Dr. Kelly told him bluntly of the risks, but then he cleared Pat to play. JK: When I examined him, in some detail, I couldn't find anything I was worried about. And, as a physician, those are the individuals that I can say honestly to, "I think it's okay to go back, but you understand you run a statistical risk of this coming back and maybe even being worse, even with a relatively lesser force." And then it's up to the individual. Pat played 67 more games for the New York Rangers , but then in March 1998 he banged into a teammate and got hurt again. It was a lesser collision this time--Pat wasn't even knocked out--but the effects --headaches and chronic sleep problems--lingered for months. This time, Dr. Kelly told Pat it was time to quit. JK: One additional concussion could indeed tip him over the threshold into a permanent condition of memory deficits, difficulty with concentration, and organizing his thinking. And it's just not worth the risk because it has taken so long for him to recover from relatively mild forces, and I don't think that his brain can tolerate much more. GU: For professional athletes, and for the rest of us, the biggest risk is having repeated concussions spaced closely together. RC: As long as you're going to be slamming into each other, you're going to get hurt. We just need to make it so that when people have a concussion they don't go right back out and play again. You can play for 10 years, have 5 concussions, and do fine. If you play for 10 years and have 5 concussions in one season, you may never be the same. GU: Pat feels fine now, but Dr. Kelly says we need to take concussions much more seriously. JK: And so we are advocating that at least some form of standardized mental status or neuropsychological testing be performed in athletes before their return to play. It's simply not enough to ask them, "How do you feel?" and "How many fingers?" GU: Instead, after every concussion we should be testing the ability to absorb new information. Dr. Kelly asks injured athletes to remember three random objects. JK: These athletes commonly are able to tell you who's the mayor, who's the team across the field, what day of the week is today, all those sorts of things and then look at you as if you are from Mars when you ask them, "What are those things we pointed to?" because they could not encode it. They didn't even remember that you asked them to remember something. If these problems persist, you should be sent not just to the sidelines but to a doctor. But prevention is still the best approach to brain injury. RC: I'm not going to advocate that we not do sports with some element of danger. However, those sports should be done as safely as possible. You're going to ride a bicycle? Wear a helmet. If you're going to ski hard, consider wearing a helmet. Maybe someday, if you're going to drive your automobile, we'll be considering wearing a helmet. PL: Okay, you gotta put your helmet on now. GU: Helmets and seat belts are essential, but they're no guarantee. The harder question is, "Should we change our attitude to risk?" We asked Dr. Kelly if he'd let his own son play a contact sport, given the current level of risk. JK: I played football, and I wrestled, and I recognize now how unsafe those activities were that I engaged in, and I simply would not allow my son to be subjected to those--those risks now. And Pat LaFontaine, whose career was cut short by six concussions? Would he let Daniel play professional hockey? PL: Well, if he--if he continues to show the love of the game and enjoys it, seeing him and seeing his face and his competitiveness, I have a feeling he's going to play sports, and watching the enjoyment he gets out just skating, he might be out there playing. But if he chooses to play at that level, I don't think I'll have a problem. GU: In talking about brain injury, doctors focus on prevention because they still don't know how to repair the damage caused by brain injury. That's the challenge for basic researchers like Ronald McKay. Ronald McKay: Generally, in the adult nervous system, the neurons that you have when you're born are the neurons that you're going to have throughout your life. So if you should injure them seriously, then--then there's no way that you can normally replace them. GU: But recent research suggests that even adults have a reserve of unused cells that might be available to replace damaged or dead cells. RM: And that's raised some very interesting ideas about how those cells might be activated or how they may be grown in the lab and placed into the nervous system to slowly rebuild the structures of the brain. GU: At the University of Pennsylvania, Tracy McIntosh is looking for new drugs that will actually repair injured cells. He's also testing a revolutionary form of surgery, taking cells from a healthy brain and transplanting them into the brain of an injured patient. TM: Right now, we're working with models of brain injury in experimental animals, showing that in fact memory and motor function, which is the ability of the animals to coordinate and move, can be significantly improved with these transplants. In the injured mice, we typically see a behavioral deficit whereby they cannot successfully traverse this pole. They'll slip. They fall off. They have a right-sided neurological deficit. GU: But after transplant surgery, the injured mice perform much better. Even optimists like Dr. McIntosh can see that it might take 10 years for basic research to deliver results to human patients. One reason is that no study can easily replicate the real-life conditions of brain injury. RC: The patient may be inebriated before trauma; they have their trauma; they laid at curbside for half an hour becoming cold and their blood pressure dropping, bleeding. They have not only a head injury but a leg injury, chest injury, belly injury. They are transported in an ambulance that's dark and bouncy, and all of these other variables have never been seen in the laboratory. And they make a huge difference in outcome. GU: Car crashes are the leading cause of brain trauma. These serious injuries are hard to treat because the damage spreads throughout the brain. Theresa Rankin knows what that's like. I'd lost everything. I'd lost my position at my university. I'd lost my relationship with my family. And more important than that, I'd lost my baseline of being an individual. Theresa's life changed forever in 1977, when she was 21 years old. Her boyfriend, Steve, was taking her to San Francisco so she could meet his parents for the first time. He was driving a brand-new Porsche. TR: The car just propelled right off the cliff and traveled 75 to 100 feet through the air and then rolled down into the ocean. [siren wailing] GU: Steve broke his ribs and punctured his lung, but he recovered in 3 months. Theresa injured her hip, her jaw, and her brain. She fell into a coma that lasted for 3 days with drastic consequences. RC: The lesion was in the frontal area. She had swelling, which probably represented cell injury or cell death. And there are these little white spots suggesting that there's been some injury to the axons. GU: Before the crash, Theresa was an honors student and a champion debater, but for years afterward, her injured brain betrayed her. She couldn't concentrate, couldn't read, couldn't think clearly. TR: I couldn't figure out how it was that people stayed in motion, how you figured out what it was that you were going to do next. I was fascinated just with watching people. It was like a mystery, how people talked and laughed and knew what to do. For Theresa, and for many people with severe brain injuries, the road to recovery begins here, in the hospital emergency room. RC: There's two injuries that occur when the brain is traumatized. One is the impact itself, the damage to the brain. And the second is what we call secondary insults. The impact can set off a chemical cascade that can destroy cells throughout the brain. RC: And those, when you apply them to an injured brain, multiply the damage several-fold. It's not additive; it's one and one equals five. GU: The first hour after an injury is critical; doctors call it "the golden hour." Thanks to brain imaging, doctors can now identify the damage more quickly and respond more precisely with drugs or with surgery. Many brain injuries cause severe damage to the axons, the millions of vines that send messages from one part of the brain to another. Dr. John Myseros: All these little vines are packed together very tightly, millions of them, with little blood vessels in them. And if you took a bundle of these vines and just tore it, like this, like a shear--just like a scissor--then you'd be looking end-on on a million little holes--well, some of those little holes are what are bleeding. GU: Bleeding and bruising cause the brain to swell, and that can be dangerous. JM: The brain is in a closed space. It's unlike an arm or a leg, where if you bruise it it can swell almost indefinitely. The brain has almost nowhere to go, so it swells and basically presses on itself, and that can cause progressive neurologic injury, and it can kill you. GU: Because controlling pressure is so important, surgeons sometimes insert a probe into the brain to monitor the pressure. In extreme cases, Dr. Chesnut will even open the patient's skull just to relieve the pressure. With improvements in critical care, we've gotten better at arresting the damage to the brain, but the next step is often a problem. RC: There's a hand-off here that needs to be smooth. We need to-- as acute caregivers, we need to smoothly hand the patient to the longer-term caregivers--the physiatrists, the rehabilitation specialists. For Theresa, as for many patients, that hand-off to rehabilitation never happened. She was discharged from the hospital just 9 days after the crash. When she got to a point where she looked pretty good, they let her go just like they would a broken arm. But the broken brain doesn't heal that fast. GU: Like Pat LaFontaine, Theresa suffered from headaches, depression, and memory loss. But perhaps the worst problem of all was something that doesn't show up on a medical chart. RC: What people really complain about, when you talk to patients 5, 6, 10 years out, is social isolation. What they really want is friendship, a significant other, etc., and social interactions are so delicate and so multi-faceted that these deficits can take a person who should be fully functional and make them into a social isolate. GU: Theresa drifted away from her friends and family and lost her relationship with Steve. For 13 years she wandered around the country in search of help. Theresa finally settled in Washington D.C., where she met neuropsychologist Celeste Campbell. CC: The kinds of difficulties that a person like Theresa has tend to be somewhat invisible. She can walk. She can talk. She can--you know--put ideas together in a conversation, so it's hard to convince people that she's still having difficulty, and it's very hard for her to maintain the level of cognitive functioning that she would need to maintain a job. GU: Dr. Campbell has given Theresa the chance to use voice-activated software and other special tools, and she has helped Theresa to compensate for some of her cognitive problems. CC: A lot of what the rehabilitation process is doing is waking up some of the other pathways in your brain, finding different ways for you to do what you used to do. GU: But what about new paths for treating brain trauma? Theresa participates in a research program funded by the National Institutes of Health. She's being treated with neurotherapy, a kind of EEG or brainwave biofeedback. It's designed to stimulate brain activity and promote more fluid thinking. Dr. Mary Lee Esty: When Theresa came in, she had very little energy. Her speech was very, very slow, and I felt as if I could hear the gears in her brain working to find the next clump of words. GU: We don't know yet how neurotherapy works or even if it works reliably. The premise is that when a person's brain is injured, millions of connections are disturbed, and the brain slows down. MLE: We put a sensor somewhere on the head that's picking up the signal, reading the brainwave signal into the computer, which is studying the activity of the brainwave. And then a signal is sent back to the glasses so there's a matching between the brainwave of the individual being treated and the feedback that goes in, and the brain likes this rhythmic input. GU: Dr. Esty emphasizes that this treatment is still experimental. It'll take much more testing to determine whether neurotherapy is safe and effective. But so far, Theresa has gotten much better at solving problems and speaking fluently. These days, Theresa devotes most of her time to helping other survivors of brain injury. TR: This is the library that really serves as my strategy room for all of the work that I'm involved with--the Centers for Disease Control and the National Institute of Health. GU: It looks an awful lot like a kitchen. TR: Well, it would be except that I-- GU: Theresa still needs a lot of support from employment counseling to psychotherapy. She still can't work full-time. But 20 years after the crash, she is slowly creating a new life for herself. TR: It's like my brain is no longer pushed up against the bony structures inside my skull, so that looking and listening and walking and having a conversation is no longer bone on bone or rock against rock but more like watching a stream flow. [birds chirping] JK: What people don't really fully acknowledge is that the brain is truly the organ of the psyche and that the things we think and the things we feel, not just memory and concentration and all those sorts of cognitive functions, but the true core parts of us, who we are, emanates from the brain. And injury to the brain changes who we are. GU: If the brain is who we are, we're now learning a lot about ourselves, and with remarkable speed. Thanks to brain imaging, gene mapping, and other dramatic advances we're beginning to learn how the brain works, why it breaks down, and how we can heal it. The brain remains the ultimate mystery, but brain research is revealing some of its most compelling secrets and offering hope to people in need. I'm Garrick Utley.

Exploring Your Brain with Garrick Utley. Learn more about traumatic brain injury through the eyes of doctors and survivors. This video is one in a series created to unravel the mysteries of the brain.

Transcript of this video.

Posted on BrainLine November 24, 2008.