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The absence of a significant or identifiable period of loss consciousness does not mean that an injured person has not suffered a permanent brain injury. Likewise, permanent brain injury can occur without a person having hit his or her head. While seemingly not as dangerous as injuries involving loss of consciousness, bleeding in the brain, and surgery, these injuries can be life altering, and in some cases as disabling as many coma injuries.
One of the most significant medical authorities pointing to the potential severity of brain injury without a significant period of unconsciousness is the definition which came out of meetings of the American Congress of Rehabilitation Medicine [Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine, published at J Head Trauma Rehabil 1993:8(3):86-87] The definition still uses the term "mild" traumatic brain injury but it establishes clear cut authority that these non-coma type injuries can be serious and permanent. Such definition, establishes that a permanent brain injury can occur if any of the following four conditions occur as a result of trauma, or accident:
1. any period of loss of consciousness;
2. any loss of memory for events immediately before or after the accident (amnesia);
3. any alteration in mental state at the time of the accident (eg,
feeling dazed, disoriented, or confused); or
4. focal neurological deficit(s) that may or may not be transient; [N.B. a focal neurological deficit is a problem in nerve function that affects a specific location -- such as the left face, right face, left arm, right arm, left leg, right leg, even just a small area such as just the tongue OR a specific function - for example, speech may be affected, but not the ability to write. The problem occurs in the brain or nervous system. It may result in a loss of movement or sensation. The type, location, and severity of the change can indicate the area of the brain or nervous system that is affected. In contrast, a non-focal problem is NOT specific -- such as a general loss of consciousness. but where the severity of the injury does not exceed the following:
- post traumatic amnesia (PTA) not greater than 24 hours
- after 30 minutes, an initial Glasgow Coma Scale (GCS) of 13-15; and
- loss of consciousness of approximately 30 minutes or less;
This definition includes: 1) the head being struck, 2) the head striking an object, and 3) the brain undergoing an acceleration/deceleration movement (ie, whiplash) without direct external trauma to the head. It excludes stroke, anoxia, tumor, encephalitis, etc. Computed tomography, magnetic resonance imaging, electroencephalogram, or routine neurological evaluations may be normal. Due to the lack of medical emergency, or the realities of certain medical systems, some patients may not have the above factors medically documented in the acute (immediate) stage. In such cases, it is appropriate to consider the sort of symptoms that, when linked to a traumatic head injury, can suggest the existence of a mild traumatic brain injury.
SYMPTOMS OF MILD OR SUBTLE BRAIN INJURY
Symptoms of brain injury may or may not persist, for varying lengths of time, after such an event. It should be recognized that patients with mild traumatic brain injury can exhibit persistent emotional, cognitive, behavioral, and physical symptoms, alone or in combination, which may produce a functional disability. These symptoms generally fall into one the following categories, and are additional evidence that a mild traumatic brain injury has occurred:
1. physical symptoms of brain injury (eg, nausea, vomiting, dizziness, headache, blurred vision, sleep disturbance, quickness to fatigue, lethargy, or other sensory loss) that cannot be accounted for by other causes;
2. cognitive deficits (eg, involving attention, concentration, perception, memory, speech/language, or executive functions) that cannot be completely accounted for by emotional state or other causes; and
3. behavioral change(s) and/or alterations in degree of emotional responsivity (eg, irritability, quickness to anger, disinhibition, or emotional lability) that cannot be accounted for by a psychological reaction to physical or emotional stress or other causes.
Some patients may not become aware of, or admit, the extent of their symptoms until they attempt to return to normal functioning. In such cases, the evidence for mild traumatic brain injury must be reconstructed. Mild traumatic brain injury may also be overlooked in the face of more dramatic physical injury (eg, orthopedic or spinal cord injury). The above symptoms are referred to as minor head injury, post-concussive syndrome, traumatic head syndrome, post brain injury syndrome and post traumatic syndrome.
The systems described earlier for trying to cope with the effects of traumatic brain injury are equally applicable here even though you may "only" have suffered a mild or subtle brain injury.
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