Introduction
Traumatic brain injury (TBI) remains a complicated insult that has diverse ranges of signs and restrictive conditions. Therefore, TBI effects can be devastating to the patient and relatives. Studies attempt to highlight management processes from shock and despair when a brain injury occurs and provide coping mechanisms and solutions to emerging problems. There are discoveries and breakthroughs about brain injuries, quality standards of treatments, and emerging best places of care and information centers.
There are escalating cases of TBI resulting from accidents, terrorists’ activities, and war zones among others. These cases indicate that TBI continues to be a major source of health care concern. TBI recovery may vary depending on the extent of the injury and age of an individual. However, any effort to show the extent of outcomes is still a challenge. TBI recovery periods range from months to several years. Physicians rely on indicators like the duration of the coma, post-traumatic amnesia, and age for the medical prognosis. Duration of the coma and amnesia should be short to enhance chances of quick recoveries. TBI patients of 60 and two years may have bad prognoses. However, there are progress in the field, but there is a need to understand various forms of imaging in TBI so as to enhance outcomes of management processes. This review focuses on various forms of imaging and knowledge in this field. We look at imaging modality and their justification from different perspectives, such as ethical, financial, subjective, practical, professional, and errors that may occur and subsequent actions about them.
Selected Annotated Bibliography
Amen, DG, Wu, JC, Taylor, D. and Willeumier, K. 2011. ‘Reversing brain damage in former NFL players: implications for traumatic brain injury and substance abuse rehabilitation’, J Psychoactive Drugs, vol. 43 no. 1, pp. 1-5.
American football players usually suffer from brain injuries. These players experience the challenge of getting an effective rehabilitation strategy. As a result, patients and retired players and TBI patients have difficulties coping with the condition.
These authors conducted pragmatic clinical intervention in the neuropsychiatric clinic. The subjects were 30 retired NFL players. They showed signs of brain damage and cognitive weaknesses. The study variables were fish oil, weight loss, a high-potency multivitamin, and brain enhancement supplement. The supplement included nutrients that increased flow of the blood, acetylcholine, and antioxidant activity. The research experiment lasted six months.
The study outcomes reviewed “the brain SPECT imaging and Microcog Assessment of Cognitive Functioning”. Results for the “brain SPECT scans indicated an improved brain perfusion” (p. 1). These areas included the “parietal lobe, cerebellum, prefrontal cortex, anterior cingulate gyrus, and occipital lobes” (p. 1). In Microcog, there were statistically significant scores that indicated an increase in “reasoning, rates of processing information, memory, attention and accuracy” (p. 1). The journal indicates that cerebral blood flow and cognitive improvements have potential through several interventions.
Auxéméry, Y 2012, ‘Mild traumatic brain injury and postconcussive syndrome: A re-emergent questioning’, Encephale, vol. 38 no. 4, pp. 329-35, Web.
The article looks at the devastating effects of blast injuries, both physical and psychological effects. The study focused on the combat-related TBI from exposure to explosions in the war zones. Thus, this condition continues to grow among the military personnel currently participating in wars. The journal shows that TBI is responsible for the high rates of neurological damages and brain disabilities among veterans and soldiers. Further, it shows that majorities of patients with TBI experience mild cases occasioned with a transient loss of consciousness. The author notes that the outcome of concussion remains a controversial issue in managing TBI.
The author shows that cerebral imaging provides opportunities for understanding various mechanisms that relate to cranial trauma. Thus, we can relate these mechanisms to co-morbid post-traumatic psychiatric conditions like depression.
The journal shows that the psychopathological method offers additional insight in cases where other methods like neuroimaging struggle to identify the exact anatomy clinical mutual relationship between PCS, neutraumatic lesions, and the state of post-traumatic stress.
The author also focuses on the subjectivity of the Post-concussion syndrome (PCS). He shows that PCS can show positive results in subjects who have no past cases of head trauma and show pure cases of psychic conditions. This is the case of subjective post-head injury syndrome. However, the relationship with somatic symptoms remains unclear. Thus, this case shows the complexity in interaction between neuroimaging and other methods. However, the case also shows that neuropathological affection is important in order to identify the cause and objectify lesions. He shows that the best approach should be a forensic method. Further, the author notes that the process becomes subjective during treatment as the “theoretical separation of the brain and the mind becomes less operative” (p. 1). Therefore, the indivisibility of the subject shall get support from psychotherapeutic management.
Bernat, J 2009, ‘Ethical issues in the treatment of severe brain injury: the impact of new technologies’, Ann N Y Acad Sci., vol. 1157, pp. 117-30.
The article shows that advancements in technology present ethical issues in functional neuroimaging during the provision of care for TBI patients. The author notes that PET and fMRI responses to stimuli indicate that the patient is completely not aware of the process. Therefore, the physician gains confidence in achieving “minimally conscious state or vegetative state” during diagnosis. Such similar and repeated results can increase doctors’ confidence and lead them to commit a mistake by declaring a correct prognosis. Physicians should insist on surrogate decision-making so that they can obtain consent for treatment of brain-injured patients. This is an attempt of getting consent that a patient can make in a normal situation.
Doctors should discuss their levels of surety with the substitute decision-maker regarding diagnosis and prognosis in order to manage difficult and unknown clinical conditions. Sharing of decision-making process between the surrogate and the physician is the best method of obtaining informed consent. Advance care planning is important in making arrangements for information about surrogate decision-making. However, the article indicates that the habit is not common among young and previously healthy TBI patients.
The author also indicates that practical neuroimaging technologies also affect the TBI patient in terms of “treatment, rehabilitation, and palliation” that result in ethical problems. Therefore, physicians should inform the families of the TBI patient that these technologies are still under investigation. In addition, physicians must comment about proactive publications about improvement in technologies. Such technologies are still under study and have not been sufficiently proven for effectiveness.
Follmann, A, Korff, A, Fuertjes, T, Kunze, SC, Schmieder, K and Radermacher, K 2012, ‘A novel concept for smart trepanation’, J Craniofac Surg., vol. 23 no. 1, pp. 309-14.
These authors show concern about trepanation of the skull. They note that it is a general practice in neurosurgical and craniofacial interventions as it provides opportunities to access the inner cranial sections. The article demonstrates that though there are careful improvements, still there are cases of insults to the dura mater during cranial procedures. Avoidance of dura complications during and after cranial opening can be through technology of computer-assisted surgery. These technologies offer various tools such as “surgical robots and other navigation tools” (p. 309).
These authors present a technical approach that can control cutting depth in both image and sensor-based manual cutting procedures. The study conducted demonstrated that errors that arise from “the CT or MRI segmentation and registration, optical tracking and mechanical tolerances of up to 2.5 mm” (p. 309) can be controlled through the use of a cutting tool that does not damage the dura. They concluded that computer-controlled trepanation systems can offer efficient and safe trepanation. Therefore, such procedures offer alternatives to avoid injuries to the dura and reduce the “bone cutting gap to 0.5 mm with the possibilities of the bone flap reintegration” (p. 309).
Goldberg, J, McClaine, RJ, Cook, B, Garcia, VF, Brown, RL, Crone, K and Falcone, RA 2011, ‘Use of a mild traumatic brain injury guideline to reduce inpatient hospital imaging and charges’, J Pediatr Surg., vol. 46 no. 9, pp. 1777-83.
These authors note that mild cases of TBI are common in “children and responsible are for majorities of head injuries of between 70 to 90 percent” (p. 777). They observe that lack of proper guidance can lead to exposing children to unnecessary radiation during imaging. Therefore, the study aimed at evaluating the effect of mild TBI guidelines in lowering hospital costs and the number of imaging in patients.
The study involved 742 children who had at least a case of head computed tomography. Subjects were admitted in “level 1 of trauma centre with Glasgow Coma Scale (GCS) of 13 to 15 and a blunt TBI” (p. 777).
Results indicated that implementation of guidelines reduced the number of CT performed and the overall hospital charges. In addition, there were “children no readmitted due to missed injuries” (p. 777).
These authors concluded that the implementation of simple guidelines can reduce “hospital charges, length of stay, and exposure to radiation among children with mild cases of TBI” (p. 777). Therefore, increased use and implementation of such guidelines shall enhance efficiency and quality of healthcare in managing mild TBI in patients.
Kim, J and Gean, A 2011, ‘Imaging for the Diagnosis and Management of Traumatic Brain Injury’, Neurotherapeutics, vol. 8 no. 1, pp. 39–53, Web.
These authors show that the basic to comprehend the role of imaging in TBI lies in understanding others factors that relate to TBI. These include intracranial injuries and subsequent insults during impacts and harmful effects of insults that may need favorable surgical and medical management. The journal shows the need for various forms of imaging depending on the insults the patient has suffered.
The article shows that the first imaging is critical in identification of acute, primary injury that is necessary for diagnosing TBI. In addition, serial imaging surveillance is also necessary for identification of “secondary insults such as swelling and cerebral herniation” (p. 9). This procedure is important in managing neurocritical cases.
Computed tomography (CT) is the most important in handling acute cases of TBI. Magnetic resonance tomography (MRI) is also useful in cases that are sensitive to shear-strain injuries and non-hemorrhagic bruises. Further, physicians have shown interest in combining these techniques in advanced cases in order to enhance the sensitivity of the MRI and CT during both diagnosis and prognosis of TBI.
Lescot, T, Galanaud, D and Puybasset, L 2009, ‘Exploring altered consciousness states by magnetic resonance imaging in brain injury’, Ann N Y Acad Sci., vol. 1157, pp. 71-80.
TBI happens without warning and causes serious impacts. Managing the case requires many specialized teams, emergency management, managing the well-being of the patient and engaging the family for a long period. Health care providers who are in charge of TBI patients face many concerns related to medicine such as predicting the effects of management of neuroimaging on the comatose patient. They also face ethical challenges relating to the effects of intensive care on the minimally conscious state or vegetative state of the patient on a long-term survival basis. There is also the influence of the law on the idea of proportionality of care. Finally, social issues relating to TBI patient management are mainly high costs of pathological procedures on the patient.
These authors note that increased availability of MRI and improvement in equipment and imaging techniques have transformed the paradigm of neuroimaging intensive care based on predicting the outcome of TBI patients in a coma. These developments include magnetic resonance spectroscopy and diffusion tensor imaging in managing TBI patients.
Therefore, these developments have rendered old paradigm obsolete. As a result, the idea of no single prognosis could be made in the sub-acute phase is no longer relevant. However, these new changes also come with new ethical challenges. The journal focuses on applications of new techniques in managing TBI so as to enable physicians to predict the outcome of a coma. These are “MRI, diffusion tensor imaging, and magnetic resonance spectroscopy” (p. 71). They can provide multimodal approaches in assessing the brain status in order to predict the outcome of a coma. These authors insist that such assessment shall become “mandatory in the near future in order to guide proportionality of care among TBI patients” (p. 71).
Mezue, WC, Erechukwu, AU, Ndubuisi, C, Ohaegbulam, SC and Chikani, MC 2012, ‘Severe traumatic brain injury managed with decompressive craniectomy’, Niger J Clin Pract, vol. 15 no. 3, pp. 369-71.
Severe cases of TBI may cause intractable conditions, which can lead to high cases of mortality and morbidity. These outcomes are possible from reviewing the patient’s clinical condition and results of the imaging. This is possible even if intracranial monitoring is not available. These authors suggest that it is possible to control outcomes through early and enhanced control of Intracranial Pressure (ICP). In addition, surgical decompressive craniectomy is also necessary for controlling the outcomes.
These authors note that decompressive craniectomy is still under evaluation. This implies that it is not effective tool in managing TBI conditions. However, they also acknowledge that decompressive craniectomy may be useful in cases where facilities for monitoring raised ICP are not readily available. They conclude that bone flap should be stored in a subcutaneous anterior of the abdominal wall pocket rather than custom bone cranioplasties.
Saatman, K, Duhaime, A, Ross, B, Andrew, M, Alex, V and Geoffrey, M 2008, ‘Classification of traumatic brain injury for targeted therapies’, Journal Of Neurotrauma, vol. 25 no. 7 , pp. 719-738, Web.
These authors look at heterogeneity in TBI and how it makes it difficult to find effective interventions in managing TBI in patients. As a result, several organizations concerned with the management of TBI have convened meetings so as to provide an outline that can be useful in linking specific cases of neurovascular injury and TBI with appropriate and effective therapeutic measures.
They note that the Glasgow Coma Scale (GCS) has been the “main selection criteria used in the inclusion of TBI patients during clinical trials” (p. 719). GCS continues to be a useful tool in prognosis and managing TBI. However, it does not indicate specific information regarding “pathophysiologic mechanisms, which are the main sources of concerns in neurological deficits and which interventions focus on in TBI” (p. 719).
Participants in developing therapeutic intervention measures proposed that brain injuries that demonstrate the same “pathoanatomic elements are likely to have general pathophysiologic mechanisms as a result, they proposed that they should be a new, multidimensional approach to TBI clinical trials” (p. 719). This is because preclinical approaches are useful in determining pathophysiologic mechanisms that are relevant to a given pathoanatomic feature of brain injury. This should also confirm that a specific therapeutic intervention enhances outcomes in managing a specific TBI condition.
The journal concludes that there is a need to implement discoveries made in the past regarding the management of TBI so as to enhance the provision of health care. In addition, it is necessary to develop a new tool for the classification of TBI so that a case can have its relevant and specific interventions. However, this approach should not eliminate the traditional classification systems such as symptom-based, prognostic, and etiologic classifications. In addition, a new classification system should be in place within the next five years, but it requires coordination and effort of stakeholders.
Siebers, C, Stegmaier, J, Kirchhoff, C, Wirth, S, Körner, M, Kay, MV, Pfeifer, KJ and Kanz, KG 2008, ‘Analysis of failure modes in multislice computed tomography during primary trauma survey’, Rofo, vol. 180, no. 8, pp. 733-9, Web.
Managing TBI depends on the quick identification of life-threatening injuries and conditions. These authors show that there has been no formal study on computed tomography in trauma (FACTT). As a result, the authors aimed at finding effects of FACTT on survival among TBI patients with primary trauma.
FACTT used in managing trauma offers a quick way of responding to life-threatening conditions and improving a thorough assessment of brain injury and the severity of the case. In addition, FACTT can be useful in discovering hidden or unexpected cases that may require significant therapeutic intervention. Implementation of FACTT needs a team of trauma specialists and coordination of the workflow.
These authors highlight that a well-integrated FACTT in primary trauma has no harmful effects on the patient. It only serves the purpose of enhancing chances of survival in patients with major cases of trauma. However, the challenge of FACTT relates to radiation exposure.
Conclusion
The review shows that TBI is complex and needs multidimensional approaches to manage. There are also increasing cases of TBI due to blasts, accidents, and other explosions. These approaches depend on the extent of the insult that the patient suffers. However, these interventions raise concerns related to ethics, finance, professional usage, and legal among others. Some researchers have noted that implementing discoveries made in TBI remains a challenge in enhancing the quality of health care provided to TBI patients.
The review indicates that implementing simple steps and procedures in managing TBI can reduce costs, numbers of imaging, and exposures to radiation. Costs can increase because most cases of TBI present difficulties in recognizing the extent of injuries. Costs can also increase for patients undergoing rehabilitation. In addition to costs, long-term consequences also result in emotional burdens to the patient and family. Still, it also strains medical facilities due to cases of lifelong dependency.
Technological breakthroughs present opportunities in managing TBI. However, the challenge is that most of these discoveries are still under evaluation. As a result, they present challenges related to professional standards, ethics, and legal.
We must also note that available solutions to managing TBI do not work for all patients. However, these interventions may enhance the effectiveness of care in minimizing effects of insults on patients. Therefore, early management using appropriate interventions, prevention and treatment of TBI can be effective measures.
CT and MRI remain are the mainstay of neuroimaging though there are other forms of scan such as CAT scan, SPECT and PET. These scans are necessary for performing a detailed neurological assessment so as to identify the extent of insult to the brain.
However, their usages depend on the severity of the insult. GCS is effective in rating brain trauma, but the heterogeneity of TBI in most cases shows the need for other rating scales so that interventions can focus on specific conditions.
Search Criteria
The search criteria involved the inclusion and exclusion of materials. The method involved searching through titles, journal abstracts, reviewing body text, and conclusions.
Reference List
Amen, DG, Wu, JC, Taylor, D. and Willeumier, K. 2011. ‘Reversing brain damage in former NFL players: implications for traumatic brain injury and substance abuse rehabilitation’, J Psychoactive Drugs, vol. 43 no. 1, pp. 1-5.
Auxéméry, Y 2012, ‘Mild traumatic brain injury and postconcussive syndrome: A re-emergent questioning’, Encephale, vol. 38 no. 4, pp. 329-35, Web.
Bernat, J 2009, ‘Ethical issues in the treatment of severe brain injury: the impact of new technologies’, Ann N Y Acad Sci., vol. 1157, pp. 117-30.
Follmann, A, Korff, A, Fuertjes, T, Kunze, SC, Schmieder, K and Radermacher, K 2012, ‘A novel concept for smart trepanation’, J Craniofac Surg., vol. 23 no. 1, pp. 309-14.
Goldberg, J, McClaine, RJ, Cook, B, Garcia, VF, Brown, RL, Crone, K and Falcone, RA 2011, ‘Use of a mild traumatic brain injury guideline to reduce inpatient hospital imaging and charges’, J Pediatr Surg., vol. 46 no. 9, pp. 1777-83.
Kim, J and Gean, A 2011, ‘Imaging for the Diagnosis and Management of Traumatic Brain Injury’, Neurotherapeutics, vol. 8 no. 1, pp. 39–53, Web.
Lescot, T, Galanaud, D and Puybasset, L 2009, ‘Exploring altered consciousness states by magnetic resonance imaging in brain injury’, Ann N Y Acad Sci., vol. 1157, pp. 71-80.
Mezue, WC, Erechukwu, AU, Ndubuisi, C, Ohaegbulam, SC and Chikani, MC 2012, ‘Severe traumatic brain injury managed with decompressive craniectomy’, Niger J Clin Pract, vol. 15 no. 3, pp. 369-71.
Saatman, K, Duhaime, A, Ross, B, Andrew, M, Alex, V and Geoffrey, M 2008, ‘Classification of traumatic brain injury for targeted therapies’, Journal Of Neurotrauma, vol. 25 no. 7 , pp. 719-738, Web.
Siebers, C, Stegmaier, J, Kirchhoff, C, Wirth, S, Körner, M, Kay, MV, Pfeifer, KJ and Kanz, KG 2008, ‘Analysis of failure modes in multislice computed tomography during primary trauma survey’, Rofo, vol. 180, no. 8, pp. 733-9, Web.