Doctor examining a brain CT scan
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MRI is better at detecting lesions from Mild TBI than CT Scans

A clinical trial at 3 large, urban hospitals with Level I trauma services showed that MRIs are better at predicting long-term outcomes for people with mild traumatic brain injuries than CT scans. The hospitals which participated in this study were the University of Pittsburg Medical Center, UCSF and the San Francisco General Hospital and Trauma Center. The lead author of the study was UCSF neuroradiologist Esther Yuh, MD, PhD .

The study was published in the December 2012 issue of the Annals of Neurology. The central finding on 135 patients followed for mild TBI was that 99 of the patients showed no brain abnormality on the CT scan adminsitered in the Emergency Department but just one week later 27 of these 99 patients showed focal lesions on MRI demonstrating pockets of microscopic bleeding in the brain. About 15 percent of people who have mild traumatic brain injuries do suffer persistent, long-term neurological consequences. MRI done one week post-trauma should help doctors better predict which patients will fall into the 15% group.

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White Matter Damage Persists After Pediatric MTBI

Is the brain of a child more vulnerable to mild traumatic brain injury (MTBI) than an adult? In the December 12, 2012 issue of the Journal of Neuroscience researchers published a study showing that damage to the white matter of the brain first detected 2 weeks after MTBI in children (ages 10-17) was still visible 3 months post-injury on DTI brain scanning. The damage was present even though the children had stopped reporting symptoms. This study contradicts the assumption that the brains of children heal rapidly and completely from MTBI. The white matter of the brain consists of long nerve fibers (axons) that carry messages from one part of the brain to another. Thus the persistence of visible white matter damage 3 months after MTBI is a concern that warrants further investigation.

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APOE-e4 allele predicts worse outcome after TBI

The APOE-e4 allele is a gene mutation associated with incresed risk of Alzheimer’s disease. Does possession of this gene mutation contribute to worse outcome following TBI? In the Journal of Neurotrauma 25:279–290 (April 2008) Zhou and colleges carried out a comprehensive survey and meta-analysis of cohort studies of sufficient rigor to determine whether the presence of the APOE4 allele contributes to poor outcome following traumatic brain injury (TBI). They 100 identified studies between 1993 and 2007 they selected 14 cohort studies for analysis based on comprehensive quality assessment. These studies included a total of 2527 participants, 736 with and 1791 without the APOE4 allele. The studies showed that possession of the APOE-e4 allele was not associated with initial injury severity of TBI.

However, the APOE4 allele was significantly associated with a poor outcome of TBI at 6 months after injury. While knowing that a victim of TBI has the gene mutation does not create any new or improved treatment options, it can explain in litigation why a mild or moderate TBI has more severe consequences than ordinarily anticipated.

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Preventing Epilepsy from Contusive Brain Injury

The most common cause of acquired epilepsy in teens and young adults is traumatic brain injury resulting from head contact. This year Associate Prof. of Neurosurgery Raimondo D’Ambrosia at the University of Washington performed an experment to test the cooling hypothesis. He gave a contusive brain injury to a group of rats. Half the rats received mock cooling for 5 weeks while the other half received head cooling within (but not exceeding) 2 degrees Celsius for 5 weeks. The sham-cooled rats showed a high degree of post-traumatic epilepsy, while the rats who had their heads cooled showed almost none. Dr. D’Ambrosia will seek permission to try the cooling treatment on humans to see if he gets the same highly protective effect.

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TBI Patients Should Not Drink Grapefruit Juice While Taking Zoloft

Depression is a common consequence of traumatic brain injury. Zoloft is one of the most commonly prescribed anti-depressants for mild depression. If you have suffered depression or an aggravation of pre-existing depression from a TBI and your doctor has prescribed Zoloft, make sure you do not drink any grapefruit juice. Compounds within the juice not only interfere with this drug but can cause serious adverse effects when the juice in consumed by a person using the drug. The same problem has been found with the anti-anxiety drug BuSpar. In general the adverse effects involve difficulty breathing on a spectrum from mild to severe.

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TBI Influences Dementia Symptoms Later in Life

Some studies have indicated that TBI sustained early in life raises the risk of dementia during one’s elderly years. Researchers at the Icahn School of Medicine at Mt. Sinai wanted to know if patients with dementia who had a TBI earlier in life had a distinct clinical profile from dementia patients with no prior history of TBI. After carrying out a study they found certain significant differences.

The results of the study indicate that compared to older adults with dementia with no history of TBI, those with a history of TBI had higher fluency and verbal memory scores and later onset of decline. However, their general health was worse, they were more likely to have received medical attention for depression, and were more likely to have a gait disorder, falls, and motor slowness. Lead study author Kristen Dams-O’Connor, Ph.D. said that in light of these differences it is important for a doctor diagnosing dementia to find out if the patient had a TBI earlier in life.

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Voice Changes Help Diagnose TBI

The Notre Dame team Athletic Dept. has developed a tablet-based testing system that captures the voice of an individual and analyzes the speech for signs of a potential concussion anytime, anywhere, in real time. The benefit of this technology is that nearly 90 percent of concussions go unrecognized when they occur. The way it works is that an athelete speaks into a tablet equipped with the Notre Dame program before and after an event.

The two samples are then compared for TBI indicators, which include distorted vowels, hyper nasality and imprecise consonants. The systems has been validated independently by physicians in football and boxing matches. The testing was done in cooperation with James Moriarity, the University’s chief sports medicine physician, who has developed a series of innovative concussion testing studies.

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Surgical Cure For Post-Concussive Headache

Ivica Ducic, MD, Associate Professor of Plastic Surgery and the Director of Peripheral Nerve Surgery at Georgetown is a pioneer in surgery to eliminate or reduce headaches following concussion. Dr. Ducic says that two different kinds of pain-producing nerves may be affected by a concussion: intracranial nerves that traverse the membranes covering the brain (which she does not touch) and peripheral nerves that lie outside the skull in the muscles of the forehead, temple, and base of the head. With regard to the peripheral nerves of of the face and head, Dr. Ducic says they may be damaged by stretch injury occuring during the event that causes the concussion by means of whiplash, head rotation or even contact between the face or head with a hard surface.

When medication fails to stop post-concussive headaches after three months, she will evaluate the patient to see if one or more peripheral nerves are tender to the touch and if the headache can be stopped temporarily by a pain block injection to the involved nerve(s). The areas of interest lie just above the eyebrows; on the sides of the head by the ear and jaw; and along the sides of the base of the head at the junction with the neck. If the nerve is tender and if the pain can be relieved by a nerve block injection, she will discuss surgery with the patient.

According to Dr. Ducic: “What we do with surgical intervention depends on the mechanism of the injury. If the mechanism of the injury has caused direct trauma with cuts and open skin requiring sutures in that anatomical region, I might need to remove that nerve although it is a sensory nerve. The only deficit after that would be numbness in that respective area because these nerves have nothing to do with any motion of the face, arms, or legs and besides that they’re not in the brain.

We don’t go into either the brain or the spine; incisions made over the front part of the head, side, and back part of the head are rather superficial and scars are mainly hidden by hair. If the trauma has not directly damaged the nerves and scarred them, but rather just disturbed them to the degree that they can cause some swelling and different three-dimensional spacing that can cause malfunction of the nerve, what they would do then is decompress those nerves. It’s the equivalent of unbuttoning shirt and tie because it’s too tight and you can’t breathe or speak normal. So that phenomenon in the example has been done for carpal tunnel for centuries and it can now be applied very easily in the treatment of the post-traumatic headaches and migraines.”

Dr. Ducic has done the decompression surgery more than 1,200 times. He says this surgery relieves headaches in many patients. The way He describes it is as follows: “What we do is make an incision after the opening which is accessing just plain sub-cutaneous, and then you are approaching the areas were nerves actually live; in her case in the back of the head. Then you would go ahead and free the fascial layer which is just a coat over the muscles but due to trauma it gets to be stiffer. So instead of just being a nice envelope around the nerve, it starts pinching the nerve and pressing it, and obviously the nerve protests and gives you the headache or migraine. If intra-operatively atomically variations or pressure by any other structure of vessels or a portion of the muscle, are identified, we would free up that as well.”

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Brain MRI Can Detect Streaks of Blood Hours After Mild TBI

On March 20, 2013 neurologist Gunjan Parikh, M.D. presented a paper at the Annual Meeting of the American Academy of Neurology on MRI evidence of brain damage following mild TBI. Dr. Parkh works at the University of Maryland Shock Trauma Unit in Baltimore. He used MRI to evaluate 256 people with an average age of 50 who were admitted to the emergency department at Suburban Hospital in Bethesda and Washington Hospital Center in the District of Columbia after mild head injuries. Of those, 104 had imaging evidence of hemorrhage in the brain (67 percent reported loss of consciousness, and 65 percent reported amnesia, or temporary forgetfulness). Patients with hemorrhage underwent further MRI an average of 17 hours post-injury.

Two-third of these patients showed tiny, wide-spread micro-bleeds representing droplets of blood from broken brain capillaries. One-third showed streak-like or linear injuries which Dr. Parikh said represent a type of blood vessel injury similar to those seen in brains after severe head trauma. Dr. Parikh says that typically many patients with mild traumatic brain injury will not get this kind of scan. Accordingly MRI scans can be useful in finding patients who need additional treatment. Dr. Parikh has suggested making MRI standard protocol for evaluation of concussion patients.

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Mild TBI Temporarily Raises Risk of Alcohol Addiction

A study published in the March 2013 issue of the American Journal of Psychiatry shows that mild TBI significantly increases the risk for alcohol addiction for a period of six months following injury with the risk gradually declining to normal thereafter. The findings come from a study of 5065 active-duty airmen who had sustained a mild TBI resulting in transient confusion or disorientation, memory loss, and/or brief loss of consciousness, and a comparison group of 44,733 airmen who had sustained other types of injury. After accounting for factors such as gender, marital status, ethnicity, age, deployment status, education level, rank, and career field, the team found that the risk for alcohol dependence was significantly increased in individuals with a mild TBI at 1-30, 31-179, and 180 days post diagnosis compared with those in the comparison group, at hazard ratios (HR) of 3.48, 2.66, and 1.70, respectively.

The study authors Whitehead et al. commented that: “Any alcohol use after TBI is concerning given the potential for reduction in spontaneous healing, risk of seizure or repeat TBI, and exacerbation of residual cognitive, emotional, and behavioral impairments.” They concluded that: “Screening for addiction-related disorders should be considered as part of routine care for mild TBI and might best capture the first 30 days post-mild TBI, with repeat alcohol screening thereafter for at least 6 months following the injury.” Families of people who have sustained a mild TBI should be vigilant in watching their drinking habits.