Traumatic Brain Injury

Traumatic Brain Injury (“TBI”) is a common injury in transport accidents.

TBI’s are probably the most commonly undiagnosed injuries in a hospital setting. A mild TBI or concussive head injury often goes undiagnosed as the symptoms of the injury are often quite subtle and can mimic the side effects of pain killing medications. Further, transport accident victims often present to a hospital with a range of injuries, some of which are very obvious, for example fractures. It is not surprising that mild TBI’s are not always diagnosed. In the case of mild TBI’s there is no effective treatment that is available in any event.

More severe TBI’s are nearly always diagnosed in hospital. People with such injuries often present in an altered conscious state that can range from being completely unconscious through to being somewhat unresponsive. This range of presentation is measured by ambulance paramedics and hospital doctors using the rating system known as the Glasgow Coma Score (GCS). The GCS measures the accident victim’s state of consciousness and awareness on a scale of 1 to 15, with 15 being normal.

The actual injury to the brain caused by a transport accident can range from visible physical trauma such as would be seen where an accident victim suffers a compound (open) fracture of the skull with obvious damage to the brain matter, to a bump on the head which might be producing some subtle cognitive changes. A person who sustains a TBI will always be unable to remember the actual cause of the injury. It is commonly the case that victims of TBI suffer from Retrograde Traumatic Amnesia (RTA).

This is a loss of memory for events that occurred prior to the brain trauma. It is one of the measures used to determine the severity of the TBI. In some cases people can lose a year or more of memory for events that pre-dated the accident. It is not at all unusual for the victim of a TBI to be unable to recall anything about the accident or circumstances surrounding it. TBI victims also suffer from Post Traumatic Amnesia (PTA). This is a loss of memory for events that occur after the trauma. The TBI victim can be conscious and may well appear to be quite normal following the trauma, however, if the TBI victim is still in PTA, the memory tapes will not be operating and the TBI victim will have no memory at all of events occurring after the accident. The period of PTA varies from accident victim to accident victim. Sometimes the PTA might only be a few seconds in duration. In other cases. the length of the PTA could run into months.

It is not unusual when questioning persons with a TBI to learn that family members visited them in hospital the day after the accident yet the TBI victim has no memory whatsoever. This is despite the fact that the close family members say that the person appeared quite normal and was able to converse with them.

The actual injury to the brain that gives rise to long term problems invariably involves some level of damage to the structure of the brain itself. That damage can range from loss of brain substance in the case of a compound skull fracture through to microscopic bleeding within the brain substance itself. In between the two it is not unusual to find that CT and MRI scanning will show up collections of blood in various parts of the brain caused by haemorrhaging of blood vessels. These intracerebral haemorrhages, shown up by sophisticated radiological scanning, also play a role in determining the severity of a TBI.

Where a hospital diagnoses a TBI resulting from a transport accident (or from some other cause), it is standard practice to keep the person in hospital for a period of observation. The period of observation is required to monitor the person’s level of consciousness and awareness. If there is a significant bleed in the brain, this increases the pressure within the skull. An increase in pressure can compress parts of the brain substance which in turn can lead to an alteration in the person’s state of consciousness or awareness. Where alterations in consciousness or awareness are observed, urgent treatment is required to reduce the level of pressure on the brain. This invariably involves surgery.

If internal bleeding is not diagnosed and an alteration in the person’s conscious state or level of awareness is not detected, the person can progressively deteriorate and even die as a result. It is possible to suffer a TBI even in the absence of a head strike (i.e. your head hitting part of the vehicle). The reason for this is that the human brain floats inside the skull. The brain is surrounded by fluid called cerebro spinal fluid (CSF). The CSF is contained inside the dura, which is a bit like a plastic bag. The dura provides a sealed environment for the brain and spinal cord, both of which are surrounded by CSF. When travelling as a seat belted occupant of a motor vehicle doing 60kph, the body travels at that speed as does the brain which is floating in the CSF inside the dura. If that vehicle came to an instantaneous stop, such as by hitting a solid object, the body comes to an almost instantaneous stop on account of the operation of the seat belt. However, the brain, which is floating in the CSF inside the dura, continues to travel at 60kph. As a consequence, the front of the brain hits the back or inside of the forehead and this sets off a vibration that travels through the brain substance. The impact and subsequent vibration can cause small or even microscopic blood vessels to burst within the brain itself. These small bleeds can interfere with the electrical activity that goes on within the brain and is accountable for normal brain functions.

As the brain is such an important organ in the human body, any damage that it suffers can translate into significant changes for the individual concerned. The sort of changes seen commonly in TBI cases include poor short term memory, reduced concentration, shortened attention span, fatigue, personality change, irritability, tearfulness, word finding difficulties, altered speech, aggressive behaviour, inappropriate behaviour and speech, headaches and numerous other changes.

The brain is entirely responsible for who we are. Damage to the brain can change who we are and this can be of great distress to the accident victim and to the relatives and friends of that person. It is not unusual to hear the spouse of a victim of TBI to describe the person as being completely different from the person they married. There is no medication or surgical treatment that can be offered to restore or make good the various changes that have occurred as a result of the TBI. Neuropsychological counselling and treatment can assist the victim of TBI to adjust to the changed circumstances and to modify behaviour so as to reduce the impact of the changes. However, there is no cure available.

The period of recovery from a TBI is generally regarded as two years. In the majority of cases, the level of recovery achieved 12 month after the trauma is considered a fairly good guide as to the long term outcome. The long term effects of TBI can be very serious. Every case is different because every individual victim of TBI is different.

Some people might only experience a mild blunting of certain cognitive function such as memory or concentration. Others might experience a major personality change with emotional and behavioural changes that can impact upon employment, relationships etc. Persons with severe TBI can end up profoundly disabled, both physically and cognitively.