Traumatic Brain Injury, Concussion, and Brain bleeds…Who needs a brain scan?

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What is a traumatic brain injury?

A traumatic brain injury (TBI) is caused by an injury to the head or neck that results in brain injury that interrupts the normal way the brain functions. It can range from a mild presentation to a very severe presentation, often illustrated through a rating system called the Glasgow Coma Scale (GCS). An example of a mild presentation with a higher number in the GCS (13-15) would be a brief change in mental status or some mild confusion. An example of a severe presentation with a lower number in the GCS (3-8) is prolonged unconsciousness without any response to verbal or physical stimuli.

A concussion is classified as a type of traumatic brain injury that is purely functional and thus causes no kind of structural injury to the brain (such as a intra cranial bleed)

What is a traumatic brain injury with a structural lesion?

A structural lesion often presents as a bleed in the brain, skull fracture, or other post traumatic changes. Although they do not appear that often, an expanding bleed in the brain can be life threatening.  Milder bleeds or contusions to the brain can still cause many residual side effects after initial recovery from the injury.

What are the red flags that tell us there may be a structural lesion or a bleed?

There are many signs and symptoms that can be noticed in your child that point to a more severe injury. Some but not all signs include:

  • Focal neurologic deficits (such as asymmetric weakness or numbness)
  • Recurrent vomiting
  • Rapidly worsening symptoms (deterioration)
  • Severe 9-10/10 headache
  • Seizure like activity
  • Prolonged loss of consciousness or unresponsiveness
  • Slurred speech, difficulty staying awake
  • Pupils that are not equal to each other
  • Persistent inability to recognize familiar people or places (prolonged amnesia)
  • Deformity of the skull or obvious bruising under the eyes or behind the ear

What needs to be done if red flags are present?

If any of these symptoms are present, the child needs to be taken to the emergency room. CT scan and/or MRI will be done if there is concern for a TBI with structural lesions such as a bleed or skull fracture.  Observation versus possible intervention will be determined based on emergency room assessment.

What can you expect as a parent for recovery?

After the initial recovery from the injury, many residual symptoms can remain in children and adolescents.  All TBI’s that result in structural lesions also result in a concussion (often overlooked in the setting of an intra-cranial bleed) that typically causes global symptoms of brain dysfunction.  Cognitive function (our attention and memory), and emotional changes such as anxiety or a short-temper are often lingering symptoms. These symptoms may not be apparent to the child, but are often recognized by their parent or guardian. It is important to compare post injury to pre-injury state and understand one’s baseline pre injury status when making assessments.

Vestibulocular symptoms (the way that our eyes and balance work together) often display outward signs as well. These symptoms often manifest as the inability to focus or pay attention due to the extra work that it subconsciously takes. This can also play into the impaired cognitive function as well. Often school accommodations need to be made to academically support the child/student in a learning environment.  An example of this may be limiting reading, projection/screen time, and postponing testing.

Another strategy that is used to help the healing process is eye exercises. Sometimes, the child’s eyes need to be reminded how to work together. The provider can teach this to the child and parent or formal visual therapy can be done with a vision therapist. This may also help regain the deficit in balance as well.

Exercise is an important aspect of healing. Under certain circumstances mild exercise can begin with the direction of an expert. It gives the child a sense of improvement and healing as well as an outlet for some energy that they are used to.

These injuries can be difficult process to work through because it may not exhibit obvious outward signs. It is important to encourage and support your child in this journey.

By Emily Markle and Mo Mortazavi MD