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SusannaMelkas

Sequelae of Traumatic Brain Injury

Essentials

  • For the evaluation of long-term sequelae and planning of rehabilitation it is of utmost importance that the initial diagnosis at the acute stage was performed with due care.
  • In most cases, traumatic brain injury (TBI) is mild, and patients usually recover, becoming asymptomatic in a few weeks or months.
  • The prognosis of mild TBI has been found to be better in patients who were provided with appropriate information about the injury and the prognosis based on the initial examinations.
  • If the patient is recovering from a more severe injury, the need for rehabilitation should be assessed and a rehabilitation plan written, as necessary, often including both medical and vocational rehabilitation.
  • TBI is not progressive in nature but some symptoms may only appear with increasing stress, such as after returning to work or to studies. Follow-up is important, and gradual return to ordinary tasks should be arranged, as necessary.

Evaluating the severity of TBI sequelae

  • The severity of TBI sequelae should not be assessed until at least one year has elapsed since the injury. The sequelae of an injury sustained during the period of growth can only be reliably assessed after a considerably longer time because the sequelae may still change over several years.
  • The clinical diagnosis of the sequelae must be based on the initial severity of the injury, i.e. accurate information on
    • the event causing the injury
    • the depth and duration of a lowered level of consciousness
    • pre- and posttraumatic amnesia
    • the neurological status
    • imaging findings.
  • As the sequelae are logical consequences of the initial injury, after severe injury they may be mild but after a mild TBI the sequelae cannot be severe.
  • When assessing the sequelae of a TBI, the possibility of other conditions/disorders causing similar symptoms should also be considered. A whiplash injury of the neck coinciding with the TBI, for example, may cause similar symptoms as the TBI.
  • Neuropsychological examination is needed to define the severity of the injury and to evaluate the patient's functional capacity and ability to work, ability to drive and the need for rehabilitation.
  • Find out about local regulation and practices with regard to defining the level of permanent disability. In Finland, it will be defined by the insurance company paying the compensation, based on the medical record and a description of the patient's functional ability; in most cases, the patient's doctor should not provide a numerical assessment of the disability category. Any permanent disability should not be assessed until at least 2-3 years have elapsed since the injury.

Symptoms of TBI sequelae, their treatment and management

  • The main symptoms of TBI sequelae are usually cognitive symptoms, as well as disturbances of sleep and alertness, emotional and behavioural disturbances.
    • Of physical symptoms, headaches and vertigo are the most common but many patients also have visual disturbances and sensitivity to stimuli.
  • Symptomatic treatment of patients with TBI is important to support recovery and to prevent the symptoms from becoming prolonged. It is important to treat symptoms such as headaches and other pain because these impair cognition by decreasing alertness.
  • The possibility of post-traumatic stress disorder should be kept in mind and therapy provided, as necessary.
  • In severe TBI, the risk of post-traumatic epilepsy may be as high as 40-50% but after mild TBI, the risk of epilepsy is at the same level as in healthy adults in general. The treatment of post-traumatic epilepsy follows the general principles of treatment of focal epilepsy. The need for antiepileptic drug therapy is permanent.
  • Physical exercise as a non-pharmacological treatment helps for many symptoms. Despite fatigability, patients should be encouraged to do physical exercise gradually increasing their activity.
  • Cognitive symptoms. If the TBI is more severe than mild, neuropsychological rehabilitation will form an essential part of multidisciplinary rehabilitation, which has been shown to speed up recovery and to improve functional ability. In contrast, the usefulness of pharmacotherapy, such as acetylcholinesterase inhibitors, in patients with TBI is insufficiently documented. In most mild TBIs, initial psychoeducation and follow-up are sufficient interventions.
  • Disturbances of sleep and alertness. Daytime fatigability may sometimes be due to a sleep disorder or to a disrupted daily rhythm, which should be treated. The primary hypnotics are melatonin and mirtazapine. Some patients, at least, may benefit from venlafaxine to improve their alertness.
  • Emotional and behavioural changes. Irritability, mood swings, depression and anxiety are common. SSRIs and other newer antidepressants are recommended for depression.
  • Headache. Nortriptyline or gabapentin can be tried for post-traumatic headaches. Patients with TBI may also have migraines and cluster headache, which should be treated normally.
  • Vertigo. Benign paroxysmal postural vertigo should be recognized and treated using the canalith repositioning procedure. Some patients with TBI have a concomitant whiplash injury of the neck causing balance problems through disturbed proprioception, for instance. Such patients should be referred to a physiotherapist and to a physiatrist, as necessary.

Rehabilitation Fitness Training for Cardiorespiratory Conditioning after Traumatic Brain Injury, Multi-Disciplinary Rehabilitation for Acquired Brain Injury in Adults of Working Age, Pharmacological Treatments for Preventing Epilepsy Following Traumatic Head Injury

  • If the TBI is mild, the patient will normally become asymptomatic within a few weeks or months. Any prolonged symptoms of mild TBI are often due to factors preceding the injury or to other concomitant injury, such as whiplash injury of the neck.
  • Most patients with moderately severe TBI return to work within one year and a considerable part of them within a few months, already.
  • Even after a severe TBI, return to a part-time job, at least, may be the goal.
  • If, in the case of a severe TBI, return to work is not possible, rehabilitation should be aimed at finding meaningful activity after initial individual therapies. Therapies are not intended to be the whole life of a handicapped person but a means of helping them to resume independent and rehabilitating everyday activity.
  • Follow-up should be continued in a specialized care unit (outpatient TBI clinics, in particular) until the condition has become stable and the main aims of rehabilitation have been achieved. Individual rehabilitation interventions, such as neuropsychological rehabilitation, may be performed elsewhere in outpatient care but in close cooperation with a public health care unit monitoring the situation.

References

  • Donker-Cools BH, Daams JG, Wind H et al. Effective return-to-work interventions after acquired brain injury: A systematic review. Brain Inj 2016;30(2):113-31. [PubMed]
  • Sigurdardottir S, Andelic N, Wehling E et al. Return to work after severe traumatic brain injury: a national study with a one-year follow-up of neurocognitive and behavioural outcomes. Neuropsychol Rehabil 2018;():1-17. [PubMed]
  • Stulemeijer M, van der Werf S, Borm GF et al. Early prediction of favourable recovery 6 months after mild traumatic brain injury. J Neurol Neurosurg Psychiatry 2008;79(8):936-42. [PubMed]
  • Wäljas M, Iverson GL, Lange RT et al. Return to work following mild traumatic brain injury. J Head Trauma Rehabil 2014;29(5):443-50. [PubMed]

Evidence Summaries ⬆