More than two million closed head injuries (CHI) occur in this country in a year.Earlier studies had estimated the incidence rate of about 220/100,000 persons (1). Recent study by Sosin et al. (1996) estimates the incidence of mild to moderate head injury to be about 610/100,000 persons per year in a non-institutionalized population (2).This is almost three times what the earlier studieshave indicated. The earlier studies were based on retrospective reviews of hospital records. The highest rate ofCHI is for males at all ages (except 75 years and older) and peak rates are noted for males aged 15 – 24,rate for males being twice as high as that for females. The ratio of males to females decreases to nearly 1:1 after age 75 because mostof head injuries occur due to falls. The most common causes of CHI are motor vehicle accidents (MVA) (42%) and falls (20%).In almost 50% of head injury cases, intoxication is a contributing factor (1). About 85% ofCHIs are classified as mild. The rate of injury is inversely correlated with family income, the highest rates being in the lowest income group and were more often caused by MVA or assaults (3).
Mechanism of injury and pathophysiology CHI causes trauma to the muscles, bones, ligaments, blood vessels, nerves in the neck and head in addition to an injury to the brain. All CHIs do not necessarily involve trauma to the brain. There are multiple physical forces involved, in addition to the neuro-chemical changes in the brain, which determine the severity of injury. The physical forces impacting on the brain include direct trauma to brain, coup-counter coup injury, rotational forces, pressure gradients, stretching of brain stem and spinal cord, changes in intra-cranial pressure, cerebral edema, contusions, and hemorrhages.CHI causes shear strain and diffuse axonal injury to the brain and hence, producing “multi-system” neurobehavioral symptoms. Frontal lobes are the most common site of injury (4) and temporal lobes are the next common site. Cerebral contusions and hematomas can be seen even after mild head injury. Severity of head injury is usually determined by Glasgow Coma Scalescore (GCS) (5) (Mild – GCS score of 13 – 15; Moderate – GCS score of 9 – 12, and Severe – GCS score of8). Clinical Features
Common post concussion syndrome symptoms are physical, emotional, and cognitive(see table 1). Headache, sleep disturbance, dizziness, irritability, anxiety, cognitive slowing, difficulty in handling information, and short term memory problems (manifesting as forgetfulness, misplacing things, difficulty in learning new materials etc.) are commonly seen. Most of these symptoms abate in a few weeks to three months. In about 50% of patients, a few symptoms may persist beyond six months and about 10 -20% patients may go on having Persistent Post-Concussion Syndrome ( PPCS) i.e. two or more symptoms persisting beyond one year (6). These patients need comprehensive neuro-psychiatric evaluation and treatment focussed on head injury and its associated symptoms for proper rehabilitation and return to work.
Following are some of the common neuropsychiatricconditions seen after closed head injury.
Headache is the most common complaint after CHI. It is reported to have a greater frequency and duration after mild CHI compared to moderate or severe head injury. Cause for post- traumatic headaches is multi-factorial. These factors include soft tissue injury, neuroma formations, tissue scarring, entrapment of nerves in bony or fibro-muscular tissues, direct injury to nerves such as greater occipital nerves, vascular, and myofacial injuries. Post-traumatic headachesare of multiple types, and patients usually have more than one type. Essentially all types of headaches could be seen after CHI.Following types of headaches are commonly seen after CHI-migraine, tension-type, occipital neuralgia, cervicogenic, basilar artery migraine, and dysesthesia due to posterior cervical sympathetic nerve injury. Detailed history should be taken to evaluate the headaches and look for psychological and social factors, including legal issues. Treatments should be based on the type of headache and also eliminating or minimizing the exacerbating factors.Psychological and legal issues should be addressed as needed. Avoid use of narcotics and other medications with addicting potentials.
Depression is reported in 25 to 50% of patients after head injury (7).It is one of the most disabling conditions after head injury that the patients experience. Depression negatively affectsthe family and social relationships. It also have impact on cognitive functioning and ultimately delays return to premorbid level of funtioning. Depressed patients cannot effectively participate in rehabilitation services. There is some controversy about the underlying cause- whether it is psychogenic, biological, or both. The frontal lobes are the most common site of injury to the brain after a CHI (4) and frontal lobe dysfunction is commonly seen in patients with endogenous depression. Other factors contributing to depression may be physical, social, and cognitive changes following injury which include headaches, insomnia, inability to work, dependency, social withdrawal, discouragement, and demoralization along with cognitive difficulties described above. Because of all of these changes going on concurrently, it is difficult to separate biological from psychogenic factors. There may be a difference in the degree of contribution of these factors in each patient and at different stages of recovery.
Anti-depressants and other treatment modalities can be used for treatment of depression including electroconvulsive therapy (ECT). ECT has been effective in treating depression after head injury. We have successfully treated 13 such patients with ECT (8,9). In some cases, depression becomes chronic, refractory, and is difficult to treat. Careful attention should be paid in selecting an anti-depressant because of their cognitive side effects. Anti-cholinergic side effects of the tricyclic anti-depressants (cause dry mouth, constipation etc.)can impair memory, concentration, and attention span.
Anxiety is another common condition seen after head injury.There are no prospective studies to estimate the incidence of anxiety syndromes, but it has been reported to occur in 10 to 50% of patients.Generalized anxiety manifests as fearfulness, worry, persistent tension, and intense feeling of anxiety.Obsessive-compulsive behaviors have been seen, at times manifesting as a full-blown syndrome of an obsessive-compulsive disorder (10). At times, a person may have a catastrophic reaction to an acute situation. Post traumatic stress disorder (PTSD) is also seen in some patients, especially those who did not lose consciousness.PTSD in itself can lead to symptoms of depression, cognitive deficits, behavior changes such as anger and irritability, and somatic symptoms of sleep and appetite disturbance. Treatment usually involves educating the patient and the family, providing a supportive environment, and at times medication.Anti-anxiety medications should be selected very carefullybecause of their potential of dependance and worsening of cognitive deficits.
Personality Change Personality changes are one of the most significant problems seen after head injury. Family members frequently complain that the patient is a totally changed person after the injury. Sometimes this is an exacerbation of a person’s pre-morbid personality traits. Some patients become aggressive and disinhibited on one extreme while others may become apathetic and lack initiative on the other extreme. Apathetic patients look depressed and hence mistakenly treated with antidepressants. We conducted a study to estimate the incidence of apathy after CHI. We found that apathy occurs in about 11% of patients seeking treatment for neuro-psychiatric problems after head injury (11). At times patients become very labile and paranoid, and some patients develop childish behavior. These extreme changes are seen after moderate to sever CHI. Personality changes can also be secondary to temporal or frontal lobe seizures. Some of these symptoms can be treated by behavior modification and medications, while for others, patient and family education and environmental changes are needed.
Cognitive changes involve problems with short-term memory, attention, concentration, information processing, difficulty making decisions, and executive functioning. Long term memory usually remains intact after mild to moderate CHI. Patients are forgetful about simple things such as telephone numbers, names, faces, and daily tasks. They get confused in over stimulating environments such as malls, large grocery stores, and large crowds. Patients have difficulty learning new materials. This in itself causes a lot of frustration, anger, and other emotional difficulties. At times, it is difficult to carry out simple tasks because of executive dysfunction. This leads to despondency, self-doubt, and frustration.Treatment of underlying conditions such as depression, anxiety, insomnia, chronic pain etc. improves the cognitive status. Some patients may need cognitive retraining and/or medication interventions for improving their cognitive status.
Perceptual changes are commonly seen in the early phase of brain injury, especially in the subacute phase.However, psychotic symptoms can also happen a few months to many years after the injury. It can manifest as hallucinations, delusions, paranoia, or any other perceptual disturbances.Sometimes psychotic symptoms are secondary to temporal lobe seizures. Overall, incidence of perceptual disturbances is very low, except for in the acute and sub-acute phase.
Other Some unusual or late sequelae ofclosed head injury include anosmia, chronic pain syndrome, seizures, endocrine disorders due to injury to hypothalamic – pituitary axis,dystonia,hydrocephalus, cortical atrophy, aneurysms, sleep-wake cycle alteration(12), movement disorders including hemiballismus (13),and somatization disorders. Clinicians should be aware of these conditions and should not label the patient as malingering or having conversion reaction without proper evaluation.
Wait and see approach should be employed in the first few weeks after injury except for conservative symptomatic treatments for pain and insomnia. Patients with continued disabling symptoms of cognitive, behavioral, or emotional changes four weeks or so after injury or if symptoms are getting worse, should be referred for comprehensive neuro-psychiatric evaluation. It is very important to establish the baseline severity of symptoms early and follow the progression of symptoms. It is especially important in patients with mild head injury because their primary disability usually arises from neuro-psychiatric symptoms.
Evaluation should be done by someone who is familiar with and have experience in evaluating and treating patients with head injuries. Comprehensive evaluations may include neuro-psychiatric evaluation, neuro-psychological testing, neuro-imaging such as MRI and/or SPECT scan of brain, EEG, and neuro-rehabilitation evaluation. Also, assess for individual and/or familytherapy, cognitive retraining, chronic pain program, and vocational retraining.
Treatment process involves educating the patient and his/her family members, on-going evaluations, and comprehensive treatment strategies which may involve identifying and treatingphysical, emotional, cognitive, and neurological symptoms. Appropriate referrals to neuro-psychology, rehabilitation, and neurology should be considered. Careful selection of medications is very important as some of the commonly used medications can have significant negative effects on the motor and/or cognitive recovery process. Outcome measures should be utilized to measure the baseline severity of symptoms, progression, and response to treatments.
Following factors favor good outcome – young age, no past CHIs, no history of substance abuse, good family support, married, no past history of disabilities, stable and high skill job, and above average intellectual functioning.
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13.Kant R, Zeiler D. Hemiballismus following closed head injury ‑ case report. Brain Injury. 1996;10:155‑8. Table 1Common Post-Concussion Syndrome Symptoms
3. Sleep disturbance
4. Diplopia and blurring of vision
5. Light and sound sensitivity
6. Neck pain
7. Tinnitus (ringing in ears)
12. Mood lability
13. Slowed thinking
14. Short-term memory problems
15. Impaired concentration and attention span
16. Periods of confusion
17. Difficulty learning new material