Traumatic brain injury series – Introduction

Colette Griffin, MBBS, MD, FRCP, is the Editor of ACNR’s traumatic brain injury (TBI) series. She is a Consultant Neurologist who developed and runs the traumatic brain injury service at St George’s University Hospitals NHS Foundation Trust, UK. She qualified from The Medical College of St Bartholomew’s Hospital before training in London. She undertook her research at the Institute of Neurology under the supervision of Professor David Miller. She is involved in TBI clinical research projects and continues to support TBI patients through the Headway charity. 

I was delighted to be asked by ACNR’s editorial team to help bring a series of articles on traumatic brain injury (TBI) to the wider neuroscience community. I hope that the experienced authors in the field will help cover a range of topics that readers will find both stimulating and educational. Hopefully as well as being clinically relevant, the articles will encourage the development of further specialist TBI services countrywide. Topics that will be covered in the series include the acute neurological management of TBI, TBI and the criminal justice system, pre-hospital care and TBI prevention, mild TBI and the sporting arena, the acute neurosurgical management of TBI,  secondary ADHD following TBI, neuroendocrinology post TBI, the overlap between mild TBI and FND, TBI blast injury, sleep disorders post TBI, neurodegeneration post TBI and the role of biomarkers in TBI. 

TBI may be an expanding area of sub-speciality interest for neurologists, but the pathology is not new. The case of Phineus Gage [1] was documented one hundred years ago, yet there are still only a handful of specialist TBI services countrywide at the present time. 

Patients who have sustained a TBI present with neurological challenges that can include post traumatic amnesia, cognitive impairment, behavioural and mood changes, headaches, visual changes, vertigo, high level balance issues, insomnia, anosmia, seizures, spasticity and SIADH.  

Stroke services have undergone extensive re-organisation and the HASU/stroke unit hub and spoke model delivers excellent care to stroke patients. Whilst major trauma services have been redesigned with the development of Major Trauma Centres and Trauma Units to improve the care of trauma patients in the UK, the subsequent development of TBI services has not been as comprehensive. 

In hospitals where there is a dedicated TBI team, the care of these patients improves hugely. A recent publication advocated for the re-design of TBI services [2].  

The role of biomarkers in TBI is of great interest. It is currently unclear whether biomarkers will be of more diagnostic interest within the sporting arena, or whether they will allow increasingly bespoke predictions within the moderate-severe TBI patient group in addition. 

The current classification system used is the Mayo TBI Classification System. There has been much recent interest in using alternative systems which may allow other factors such as biomarkers to be used in the scoring system. There is optimism this may increase sensitivity and diagnostic accuracy. 

There is also much interest in the measurement of head acceleration events (HAEs) within the field of sport. This research will hopefully shed new light on the mechanisms of TBI, especially in the mild TBI group. Imaging research illustrating changes in connectivity will also help develop a greater clinical understanding of this patient group. Patients with mild TBI can often pose difficult diagnostic and treatment challenges. The importance of embedding neuropsychiatry specialists within TBI services will also be underlined. 

I hope that this ACNR TBI series will increase both your knowledge and appetite to learn more. We are delighted to see so many doctors in training developing an interest in TBI. Now that TBI is an integral part of the neurology training curriculum, all doctors in training should receive teaching and training within this field. We hope that with increased interest will come increased awareness and knowledge, leading to an improvement in patient care for this largely ignored and very vulnerable patient group. 

References

1. O’Driscoll K and Leach JP. “No longer Gage”: an iron bar through the head. Early observations of personality change after injury to the prefrontal cortex. BMJ. 1998 Dec 1998;(19)317(7174):1673-1674. https://doi.org/10.1136/bmj.317.7174.1673a  
2. Li LM, Dilley MD, Carson A et al. Management of traumatic brain injury (TBI): a clinical neuroscience-led pathway for the NHS. Clin Med (Lond). 2021;21(2):e198–e205. https://doi.org/10.7861/clinmed.2020-0336 

The acute management of traumatic brain injury: A clinical introduction 

Abstract

The early rehabilitation of patients with traumatic brain injury (TBI) has been demonstrated to be both clinically and economically effective [1,2]. Neurologists, neuropsychiatrists, neurosurgeons and neurorehabilitation specialists all have a role to play in the assessment and management of this patient group. 

This article draws on the clinical experience of two neurologists working in different major trauma centres. This is the first article in a series of TBI related articles. 

TBI is a major public health issue and is the leading cause of death and disability in people under the age of 40 years old. There is evidence that early intensive rehabilitation in TBI improves outcomes [1]. It has been shown to reduce care needs in the longer-term [2]. The importance of vocational rehabilitation services cannot be understated. Most TBI patients are unable to access such services. The percentage of moderate-severe TBI patients who return to paid work remains very low [3].The TBI services that the authors have developed at university teaching hospitals (one in Scotland and one in England) consist of multi-disciplinary teams (MDTs) working in an inter-disciplinary way. The teams consist of a consultant neurologist, consultant neuropsychiatrist, neuro occupational therapist, neuro physiotherapist, neuro speech and language therapist, neuropsychologist, social worker, dietician and discharge coordinator. A clinical nurse specialist is also a vital part of the MDT. 

Whilst it is impossible to set up highly specialist teams in every hospital, it is possible for each hospital to appoint a lead TBI professional. This enables mapping of unmet need with business cases written to develop TBI services over time. The organisation of stroke care into hyperacute stroke units (HASUs) and stroke units (SUs) enables stroke patients to flow within the system between the specialist unit and their local hospital. This has led to substantial improvements in care for this group of patients. 

Patient classification and admission 

The most widely used classification system is The Mayo Classification System [4]. There is research underway to develop a potentially more clinically accurate classification system [5]. 

The decision regarding whether a patient requires admission is made by communication between ED teams and neurosurgery teams. The latter may be on site (in a Major Trauma Centre) or off site (in a Trauma Unit). It is important to recognise that it is very difficult to predict the clinical presentation of the patient just by reviewing scans. The clinical history, examination and imaging all form important parts of this complex decision making. 

When setting up a TBI service it is important to provide MDT clinical review of patients who are discharged from ED, as well as those who require hospital admission. The decision regarding which patients are accepted into specialist acute TBI beds varies from unit to unit. Both the units the authors work in have individualised inclusion and exclusion criteria.  

Patient assessment and formulation

The initial assessment of TBI patients must incorporate a detailed clinical history. This needs to include information about mode of injury, factors such as drug or alcohol use, pre-morbid psychiatric symptoms or diagnosis, social situation, whether the patient drives (a car or a HGV), occupation, family support. This information is helpful for the MDT assessments. 

As part of the initial assessment, post traumatic amnesia (PTA) is assessed. There are various methods of measuring PTA [6]. Units vary in the method they use, reflecting the fact that each system has strengths and weaknesses. PTA is the time from injury until the point at which the patient can lay down memories. PTA has been shown to be an accurate predictor of long-term outcome [7]. 

Imaging findings give some guidance as to what deficits the patient might be expected to have. One of the many challenges of developing TBI services is that each case consists of a subtly different clinical presentation and scan findings. A “one size fits all” service is not sufficient. Each case requires a bespoke and individualised formulation and treatment plan.  

The heterogeneity of injury type is reflected by the fact that patients may have sustained skull fractures, facial fractures, extra-dural haematomas, sub-dural haematomas, sub-arachnoid haemorrhages, diffuse axonal injury, contusions or a combination of the above. In cases where there is a mismatch between CT scan appearances and clinical presentation, an MRI brain scan may illustrate more severe injury. CT scans are the main diagnostic imaging of choice. MRI becomes an important diagnostic tool in patients with a presentation not wholly explained by the initial CT findings. Occasionally other co-existing pathology can be uncovered. 

If the TBI occurred due to a fall, then medical causes of an unexplained loss of consciousness must be ruled out. A fall may be the first presentation of other co-morbidities such as Parkinson’s disease or cognitive impairment. A collateral history from family and friends is critical in such cases. Subtle abnormalities often go unnoticed in the community. 

Post traumatic headache 

This is the most common symptom in all severity groups [8]. Patients who have premorbid headaches, a family history of headache, or a personal history of motion sickness are more likely to develop post traumatic headache. Paracetamol and codeine containing compounds are often used in both major trauma wards and ITUs. These compound post traumatic headache and should be discontinued at the first available opportunity.  

There are few randomised trials in this area [9]. Experience reveals that Amitriptyline can be helpful in the acute setting due to the ease of rapid titration, positive impact on sleep and impact on associated MSK cervical pain. It can impact cognitive performance, so it is advisable to reduce and stop when the headaches come under control.  

If headaches become more severe in the acute setting, it is always important to consider the need for repeat imaging. Traumatic haemorrhages can increase in size within the first few days post injury.  

Post traumatic vertigo 

Both vertigo and disequilibrium are common sequelae in up to 50% of TBI patients [10].  BPPV can easily lead to falls or a reluctance to sit up and move.  Patients should be assessed for BPPV as soon as it is safe. It is treatable, improves confidence and safety of mobilisation. Early occupational therapy and physiotherapy input to regain function is essential. 

Behaviour of concern to others 

When TBI patients become agitated, moving them to a side room to reduce sensory stimulation is critical. 1:1 nursing allows the patient to remain safe and the nurse can help with re-orientation. This also safely allows the patient to walk outside the side room in a supported way. An orientation booklet is helpful, as is a behavioural chart. Patients often find the presence of a family member reassuring, especially when they are in PTA [11]. 

Education of ward staff, family and friends is critical. Regular family meetings can reassure family and friends that this is likely to be a transient phase of recovery. 

In practice, most agitated patients have a delirium [Diagram 1]. Common reversible causes must be excluded. These include constipation, infection (commonly urine or chest), dehydration, metabolic abnormalities, poly-pharmacy and pain. Alcohol and drug withdrawal should be treated in ED. It is important to check that this has been comprehensively completed. Patients may have been sub optimally treated [12]. 

The sleep-wake cycle is disrupted in TBI, so encouraging engagement in therapy during the day helps. Not waking the patient unnecessarily in the night to check observations is very important.  

Where possible supportive behavioural methods should be used as opposed to pharmacological treatment. There is little evidence to guide pharmacological treatment [13]. Agents such as Haloperidol, Benzodiazepines and typical antipsychotics should be avoided. 

If a patient has agitation, early recognition of the challenges and early referral to a specialist neuro-behavioural unit are very important. Inter-disciplinary team working is critical. 

A consultant neuropsychiatrist is a very important integral member of a TBI team and can advise on both the pharmacological and non pharmacological management of agitation and mood abnormalities. 

The Mental Capacity Act and Deprivation of Liberty 

Patients post TBI may be cared for under the umbrella of the Mental Health Act or the Mental Capacity Act, depending on their individual circumstances. It is important that all members of staff, regardless of seniority, feel confident in assessing capacity. This may be required daily, with regards to decisions such as treatment, the need to remain an inpatient, and discharge destination. Insight is usually lacking in patients in PTA, so detailed documentation and communication are both the cornerstones of excellent patient care. Each hospital trust will have MCA and Deprivation of Liberty (DoLs) processes and procedures that must be followed at all stages to keep patients safe. A trust wide comprehensive missing persons policy is also required [14]. 

Seizures

Seizure risk is an important point of discussion with TBI patients, especially regarding driving. Each specialist unit will have a bespoke anticonvulsant drug (AED) policy. In most cases AEDs are not required [15]. 

Conclusion

The sub-speciality of TBI is rewarding, interesting and challenging. Peer reviewed research into acute care pathways is limited, hence the development of UK wide networks to share best practice is very important. The authors are pleased that TBI is now part of the neurology training curriculum, and hope that the increasing interest in this field will continue to grow over time. Inter-disciplinary team working must be the cornerstone of treatment in this very vulnerable patient group. 

References

1. Turner-Stokes L, Dzingina M, Shavelle R, Bill A, Williams H, Sephton H. Estimated Life-Time Savings in the Cost of Ongoing Care Following Specialist Rehabilitation for Severe Traumatic Brain Injury in the United Kingdom. J Head Trauma Rehabil 2019;34(4):205-214. https://doi.org/10.1097/HTR.0000000000000473 
2. Lorenz L and Doonan M. Value and Cost Savings From Access to Multi-disciplinary Rehabilitation Services After Severe Acquired Brain Injury. Front Public Health. 2021;9 https://doi.org/10.3389/fpubh.2021.753447 
3. Wang W, Fort E, Beaudoin-Gobert M, Ndiaye A, Fischer C, Bergeret A, Charbotel B, Luauté J. Indicators of long-term return to work after severe traumatic brain injury: A cohort study. Annals of Physical and Rehabilitation Medicine. 2019;62(1):28-34. https://doi.org/10.1016/j.rehab.2018.08.003. 
4. Malec J, Brown A, Leibson L, Flaada T, Mandrekar N, Diehl N, Perkins P. The Mayo classification system for traumatic brain injury severity. J Neurotrauma.  2007;24(9):1417-24. https://doi.org/10.1089/neu.2006.0245 
5. Wilson M, Ashworth E, Hutchinson P. On behalf of the British Neurotrauma Group. A proposed novel traumatic brain injury classification system – an overview and inter-rater reliability validation on behalf of the Society of British Neurological Surgeons. British Journal of Neurosurgery. 2022;36(5):633-638. https://doi.org/10.1080/02688697.2022.2090509. 
6. Vile A, Jang K, Gourlay D, Marshman L. Posttraumatic Amnesia: A Systematic Review and Meta-Analysis. Proposal for a New Severity Classification. World Neurosurgery. 2022;162:e369-e393 https://doi.org/10.1016/j.wneu.2022.03.018. 
7. Ponsford J, Spitz G, McKenzie D. Using Post-Traumatic Amnesia To Predict Outcome after Traumatic Brain Injury. J Neurotrauma. 201;33(11):997-1004. https://doi.org/10.1089/neu.2015.4025 
8. Mavroudis I, Ciobica A, Costina Luca A, Balmus I. Post-Traumatic Headache: A Review of Prevalence, Clinical Features, Risk Factors, and Treatment Strategies. J Clin Med. 2023;12(13):4233.  https://doi.org/10.3390/jcm12134233 
9. Blumenfeld A, McVige J, Knievel K. Post-traumatic headache: Pathophysiology and management – A review. Journal of Concussion. 2022. https://doi.org/10.1177/20597002221093478 
10. Smith R, Burgess C, Beattie J, Newdick A, Tahtis V, Sahu B. Treating benign paroxysmal positional vertigo in acute traumatic brain injury: a prospective, randomised clinical trial assessing safety, feasibility, and efficacy. BMJ Neurology Open. 2024 https://doi.org/10.1186/ISRCTN91943864 
11. Phyland R, Ponsford J, Carrier S, Hicks A, McKay A. Agitated Behaviors following Traumatic Brain Injury: A Systematic Review and Meta-Analysis of Prevalence by Post-Traumatic Amnesia Status, Hospital Setting, and Agitated Behaviour Type. J Neurotrauma. 2021;38(22):3047-3067. https://doi.org/10.1089/neu.2021.0257 
12. Stewart S, Swain S. Assessment and management of alcohol dependence and withdrawal in the acute hospital: concise guidance. Clinical Medicine. 2012;12(3):266-271. https://doi.org/10.7861/clinmedicine.12-3-266 
13. Hicks A. The Efficacy and Harms of Pharmacological Interventions for Aggression After Traumatic Brain Injury-Systematic Review. 2019. Frontiers Media S.A. https://doi.org/10.3389/fneur.2019.01169 
14. Ferguson, L. Risk factors and missing persons: advancing an understanding of ‘risk’. Humanit Soc Sci Commun 9. 2022;101 https://doi.org/10.1057/s41599-022-01113-8 
15. Houston A, Wilson C, Gilbert B, ‘Antiseizure medication practices in the adult traumatic brain injury patient population’, American Journal of Emergency Medicine. 2024;86:125-128. https://doi.org/10.1016/j.ajem.2024.10.