Part XI Neurobehavioral dimension
Chapter 47 Neurobehavioral Conditions in TBI/Concussion
Chapter 48 What is the tendency of the brain?
Chapter 49 A Bright Future Ahead?
WHILE READING THIS book, if not already aware, you may realize that you or someone you know has suffered a traumatic brain injury (TBI) or concussion, in many cases without full knowledge that this condition exists. TBI is occurring at a rate much higher than previously believed and is now classified as one of the worst silent medical epidemics of our times. Poor surveillance systems worldwide, underreporting, and an improper definition of what constitutes an injury to the brain are all reasons for the limited focus on this condition. So, wake up, world, let’s pay attention!
The human brain is the one element in the universe that can both preserve and destroy mankind as we know it. It is a highly organized structure with over a hundred billion nerve cells (neurons) and about a thousand trillion connections between those nerve cells. This highly organized structure is the most important “computer processor” known to the universe, which defines who we are and what others perceive us to be. As highly organized as it is, the human brain can be damaged or destroyed by external forces in an instant.
The Brain Hierarchical Evaluation and Treatment (BHET) methodology has been developed by a board-certified neurologist, Dr. Kester J. Nedd, who has been treating persons with TBI and concussion in the USA for over 3 decades. Through his career, Dr. Nedd has had over 250,000 patient encounters with individuals who had a TBI or concussion. Dr. Nedd is an associate professor in the Department of Neurology at the University of Miami Miller School of Medicine and is the Medical Director of the USports Concussion Clinic, along with formerly being the Medical Director of the Neurological Rehabilitation and Intermediate Head Injury Unit at Jackson Memorial Hospital in Miami. At the time of publication of this book, Dr. Nedd was serving as Medical Director and Managing Partner of Design Neuroscience Center in Doral/Miami Florida, a center of excellence in TBI and concussion.
This work simplifies the complex subject of TBI and concussion, a subject that has been recently popularized by the media in conjunction with consumers and certain healthcare professionals. In its attempt to provide answers for complex unresolved questions, the BHET method deviates from the current linear approach in favor of a multi-dimensional approach. BHET is a transformative approach for the evaluation and treatment of patients by considering the hierarchical organization of the brain and how this hierarchy is impacted by injury and during recovery. It redefines the nature of TBI and concussion in the context of signs and symptoms, some of which are often missed in conventional intervention while also utilizing case reports of patients to illustrate important clinical principles. Based on the experience of Dr. Nedd and his colleagues, this method questions the current approaches and offers evidence-based, practical solutions that can be utilized by clinicians, patients and their families, the legal system, media, researchers, social scientists, medical professionals, individuals involved in the sports world, students, and policymakers when considering TBI and concussion.
PEOPLE WITH CONCUSSION and/or traumatic brain injury (TBI) and their loved ones know the reality of facing a radical change in an instant. Can you imagine being a fully functional human being, caring for your family, holding down a job, or performing as a student in school, then suddenly not being able to do any of these at a level you were previously able to perform?
Meet Mario (Case #1), a 24-year-old dental student from Venezuela, an avid sportsman who lived for the thrill and exhilaration that only a few experience while participating in extreme sports. Mario suffered a form of TBI that is rarely seen – second impact syndrome (SIS). I came across Mario and his family when they were desperately in search of a neurologist who had experience caring for individuals with severe TBI. About 10 days after suffering a cerebral concussion while wakeboarding, Mario returned to the sport while having persistent dizziness, vertigo (sensation of spinning), and headaches. He received medical care from a neurologist following his first cerebral concussion and was told that the CAT scan of his brain was normal, even though his condition was labeled as a cerebral concussion. Unfortunately, when he returned to the sport, he suffered a second injury as he was thrown off the wakeboard moving at a high speed. For the second time, his head impacted against the water, which when traveling at a high speed, feels equivalent to an impact against a brick wall. Mario’s friend lifted Mario out of the water and onto the boat, realizing he was limp and unable to help himself. His friend noted that he was minimally conscious but still breathing. On his way to the shore, Mario had a grand mal tonic-clonic seizure with intense violent jerking movements involving both sides of the body. When the paramedics arrived on the shore, he was intubated (a tube placed in his windpipe through his mouth) and placed on a ventilator – a device that facilitated his breathing. He was taken to a local hospital and the initial CAT scan of his brain showed diffuse cerebral edema (brain swelling) and a small right subdural hematoma (bleeding under the coverings of the brain). At the hospital, he was minimally responsive to pain, able to spontaneously move his extremities, but not able to communicate. Within a few hours of arrival at the hospital, he became totally unresponsive. His neurological exam showed a dilated pupil on the right eye. A dilated pupil that does not react to light especially on one side is usually indicative of compression of the third cranial nerve in the brain. The third cranial nerve is responsible for the contraction of the pupil when the eye is exposed to light. Further, a dilated pupil is generally an ominous sign of brain herniation from swelling or the effect of a mass, such as a subdural hematoma, causing the shifting of the brain from one side to the other. The effect of the edema and of the mass (subdural hematoma) also known as mass effect, caused the shift in Mario’s brain, which resulted in compression of the third nerve. Since this change was considered a neurological emergency, a follow-up CAT scan of the brain was carried out, which showed increased diffuse swelling of the brain with a shift of the brain from the right to the left, due to the massive expansion of the subdural hematoma on the right.
| Image # 1 – What Mario’s brain looked like before surgery |
Mario was taken into surgery, and a decompressive craniectomy (removal of a portion of the skull) was performed to drain the subdural hematoma and reduce the pressure in the brain. This gave the brain room to expand due to the swelling process, a sign of severe brain injury.
It was clear that Mario had SIS, a condition rarely diagnosed in TBI. But when diagnosed, SIS is most common in concussion and TBI due to sports-related injuries.
Despite having symptoms