Health

Other Injuries

Often patients will have other injuries in addition to the traumatic brain injury (TBI). These include fractures, injury to nerves in the body and even injury to the spinal cord. In most cases, these other injuries are found early on. However, in some cases the injuries may not be discovered until later. This is because the symptoms of these other injuries can be mild and because most of the attention is initially on keeping the person alive and protecting his brain. Once the patient is stable and better able to communicate, more time can be spent investigating any unexplained pain or weakness.

Basic Bodily Functions

During the time that someone’s brain is recovering, the patient will need help with basic body functions such as food (nutrition), water (hydration), bowel/bladder function (elimination), breathing (respiration), sleep, and preventing skin breakdown or ulcers.

Feeding tubes:

Before starting to feed someone by mouth, it is important to see if they can swallow safely, without either food or water going into their lungs (aspiration). It is usually the speech therapist that will perform this evaluation. Often, they will do a test where they take x-rays of the person as they are swallowing to see how safely the person is swallowing (modified barium swallow study). If the patient is still not conscious or cannot swallow safely, then food and water can be given through a feeding tube. Temporary feeding tubes are inserted through the nose but they are for short-term use only. If it is expected that someone may not be able to swallow safely for a while, then a longer lasting feeding tube can be placed in the stomach or small intestine. Inserting these feeding tubes usually does not require major surgery. Most often, it is done endoscopically by either a gastroenterologist or a surgeon. The procedure is referred to as a percutaneous endoscopic gastrostomy (PEG) and the tube is called a PEG tube. Use and care of the tube is fairly simple and can be easily managed at home. Most tubes are easy to remove when no longer needed; they can usually be removed by a physician or nurse. However, most feeding tubes need to remain in for at least four to six weeks before they can be pulled out safely. The feeding solution or formula that is used through the tube is initially given continuously in small amounts (with the use of an electric pump). However, most patients can be switched to being fed just four to five times a day (bolus feeding) fairly soon.

Tracheostomy tubes:

Early after a TBI, the use of a ventilator is necessary for all unconscious patients. At first the ventilator is connected to a tube that is inserted in a person’s mouth (endotracheal or ET tube). However, there are risks to using these tubes for more than two to three weeks. When someone might need a ventilator longer than that, the patient undergoes a tracheotomy. This is an opening made directly in the throat by a surgeon. The hole itself is called a tracheostomy. The tube that is placed in the throat is called a tracheostomy tube (often referred to as a trach). In addition to allowing a connection to the ventilator, the trach tube allows the staff to suction phlegm or secretions (using a thin tube called a suction catheter).  Even when the patient no longer needs a ventilator, the tracheostomy tube is not immediately removed. This is because the person may still have problems that require the trach. For instance, if the person still is unconscious or minimally unconscious, the tube is often kept even though the person is breathing on his own. Even in a patient who is more alert, the trach might be kept if he is having a lot of phlegm or secretions that he is unable to cough up on his own.

A patient cannot make sounds with the trach tube in. This is because air escapes through the trach before it has a chance to vibrate the vocal cords. The patient can still mouth words but there will be no sound. Sometimes, if the patient is ready to speak but not yet ready to have the trach removed, the speech therapist will place a speaking valve on the trach (the most common one is a Passy-Muir valve). This is a one-way valve that allows air to come into the trach opening but will not allow it to go out. The air must go out the mouth or nose, which allows it to vibrate the vocal cords and allows the patient to make sounds. Most times, trachs do not interfere with swallowing. If a patient with a trach is having trouble swallowing, it is usually the brain injury itself causing the difficulty, not the trach.

Once it appears that a patient may no longer need the trach tube, there is usually a process followed to remove it. First, the tube is replaced with a smaller tube. If the patient has no trouble with the smaller tube, a cap is placed on the tube. This cap or plug completely closes the trach tube, so that the patient has to breathe through his mouth and nose. If the patient tolerates plugging (capping), the trach is then removed. This is done just by pulling the trach out. It does not require any surgery and should not cause any discomfort.

Bowel and Bladder:

Almost all TBI patients lose control over their bowel and bladder (incontinence) early after the injury. For their bowels, patients usually wear diapers or briefs until they regain control (become continent). Fortunately, almost all patients who regain consciousness will eventually regain control of their bowels. Patients will also often have problems with constipation and may require medications such as stool softeners or laxatives to keep them regular. Some patients will develop diarrhea. Occasionally this is caused by an infection (see the section on medical complications). At other times, the diarrhea is caused by medications or even possibly certain types of tube feeds.

Bladder problems are very common after TBI. Many patients will have trouble with urinary retention. This is when a person has trouble voiding all of the urine that is in his bladder. The patient may not be able to urinate at all or he may only be able to void some of the urine in the bladder. A bedside ultrasound device can check if a patient has fully emptied the bladder. If there is still too much urine left after the patient has voided, the bladder will need to be drained. This is done by inserting and removing a thin tube (catheter) into the bladder. This process is sometimes called in-and-out catheterization or intermittent catheterization. Some patients require this as frequently as every few hours (for instance, if they are not able to void at all). There are advantages to performing intermittent catheterization rather than just re-inserting a longer-term, indwelling catheter (Foley catheter). The primary benefit is that it still allows the patient’s bladder a chance to recover the ability to void naturally. There is a chance of infection with intermittent catheterization, but it is likely less than that of an indwelling catheter. It is also important to realize that there is a risk of infection when the bladder does not completely drain. Most cases of urinary retention after a TBI will resolve with time; only a minority of patients will require catherization in the long term.

Other than urinary retention, the other bladder problem faced by people with TBI is incontinence or lack of control. In these cases, the patient is unable to prevent voiding. Sometimes there is no awareness of the need to void until the patient or caregiver discovers the accident. Other times, they are aware of the need to void but are unable to get to the bathroom in time. As with urinary retention, urinary incontinence does get better with time and the majority of TBI patients regain control over their bladders.

However, a bladder problem that can last longer is urinary frequency and urgency. This is usually caused by a hyperactive (or hyper-reflexic) bladder that starts to squeeze or contract after just a little bit of urine collects in it. These spasms cause a sense of urgency. Urgency and frequency can cause difficulties because patients need to be close to bathrooms during the day (and the problem can disturb their sleep at night). Sometimes medications that relax the bladder are prescribed to help with this problem. All of these medicines help relax the bladder so that it can hold more urine before it starts to squeeze or contract. Examples of these medicines include oxybutynin, tolterodine, trospium and darifenacin.

Table 7. Some Medications Used for Hyper-Reflexic Bladder

(Sample Brand Names in Parentheses)

Darifenacin (Enablex)

Oxybutynin (Ditropan)

Tolterodine (Detrol)

Trospium (Sanctura)

These medications can have side effects such as sedation and are often not used unless necessary.

In any bladder problem, it is important to first make sure that the patient does not have a urinary tract infection (UTI) as this can cause retention, incontinence, urgency and frequency. It is not usually necessary to have the patient seen by a urologist unless the problem does not resolve with time. Reasons to see a urologist sooner would include frequent UTIs, especially if the infection is caused by the same bacteria each time. Another reason to consult a urologist sooner is if the patient has injury to his brainstem. When the brainstem is damaged, there can be complications from urinary retention or incontinence that would need specialized treatment.

Sleep:

Sleep is often a problem after TBI. Patients can have problems both with not sleeping well (insomnia) or sleeping too much. Patients with TBI may also have reduced alertness during the day, even when they seem to have slept enough during the night. This is discussed in another section. It is important that patients are able to sleep well at night, especially during rehabilitation, so that they are alert during the day. If the patient does not appear to be sleeping well at night, a sleeping pill might be prescribed. The most commonly used medications are trazodone, zolpidem and zaleplon.

Table 8. Some Medications Used for Sleep

(Sample Brand Names in Parentheses)

Ramelteon (Rozerem)

Temazepam (Restoril)

Trazodone (Desyrel)

Zaleplon (Sonata)

Zolpidem (Ambien)

Zopiclone( Lunesta)

There is little risk of dependence with any of these medications, and their benefits (at least in the short term) are well accepted. It is unusual for these particular medications to cause daytime sleepiness (sometimes called “hangover” drowsiness). Occasionally patients will seem to be sleeping well at night but are still sleepy during the day. While it is common to require more sleep after a TBI, these patients may benefit from a stimulant during the day, especially during the time that they are actively receiving rehabilitation.

In some cases of sleep problems, a test known as a sleep study may be ordered. The test is either performed at the bedside or at another facility (in a sleep lab). In a sleep study the patient is monitored while he sleeps. One of the things monitored is his brain waves. Brainwaves are the normal electrical activity of the brain. They can be measured by placing electrode stickers connected to wires on the scalp. The other important thing monitored is the patient’s blood-oxygen level. This is also done non-invasively by placing a probe on the patient’s finger. The probe uses a light to measure the blood- oxygen level through the skin. The purpose of the sleep study is to see how the patient’s brainwaves and blood oxygen are related to the amount and quality of his sleep; results may provide some ideas about how to improve the patient’s sleep. Some patients with TBI have a condition called sleep apnea. With this condition, there are periods of sleep when the patient does not breathe enough (known as apneic episodes). During these times, the oxygen level in the blood can be lower than normal; although this is not dangerous, it can interrupt sleep.

The most common treatment for sleep apnea is to use a machine called a CPAP (continuous positive airway pressure) machine. This machine blows air into the person’s nose and mouth while he is sleeping to help keep the blood oxygen level up. This machine is not a ventilator and there is no risk that someone might become dependent on it or not be able to breathe without it.  However, many patients find the machine very uncomfortable and often are unable to use it. It is especially difficult for patients who are still confused to use the machine. Because there is a good chance that patients will not be able to use the CPAP machine, clinicians will not always order a sleep study, even if they suspect that the patient might have sleep apnea.

Decubitus ulcers:

Any patient who is unable to move (immobile) is at risk of developing skin breakdown or ulcers (bedsores). Patients with TBI are at most risk for developing these ulcers early after their brain injury, when they are comatose or minimally conscious. During this phase, it is very important to regularly check the skin for any signs that an ulcer is developing. The most common early sign is simply persistent redness. The most common areas that develop ulcers are on the lower back (the sacrum) and the backs of the heels. In addition to regular inspection, it is important to prevent the patient from staying in any one position too long. This can be done simply by moving the patient to different positions regularly. For instance, every two hours, patients can alternate lying on their back with lying on each side. If the patient is re-positioned regularly, it is almost never necessary to need a special mattress to prevent skin breakdown.

For patients who do develop decubitus ulcers, it is especially important to minimize the time they spend lying or sitting on the area. In selected cases, a special, pressure-reducing mattress may be helpful to speed up healing. In addition, the staff will treat the ulcers like any other skin wound. The focus is on keeping the wound clean, both of contamination and also of the extra fibrous tissue that can form in wounds. It is rare to need antibiotics either directly in the wound or by mouth.

 

Medical complications

Infections:

Infections are common early after TBI. The most common parts of the body to become infected are the bladder (urinary tract infection or UTI) and the lungs (pneumonia). Most infections are discovered because the patient develops a fever. Patients can have other symptoms as well, however, depending on where the infection is. For instance, if the infection is in the lungs, there might be a change in the amount or color of their secretions (phlegm) or they might have more trouble breathing. If the infection is in their bladder, they may have problems with worsening urinary retention or incontinence. Sometimes these other symptoms appear before the patient has a fever and can be the first clue that there is an infection. In fact, one of the most common early signs of an infection in a person with a TBI is that there is a subtle change in how they are doing. This might mean that they are not as alert or as interactive as they normally are. It is important that any decline in the patient’s condition (even if it is very mild) be reported so that the cause can be found. This might include running tests to look for an infection.

The most common test for an infection is to check the blood to see if the white blood cell count is high (it usually increases above normal during an   infection). Also, tests of other parts of the body are run to see where the infection might be. For instance, the urine could be collected and sent to the laboratory (urinalysis or UA). Or the patient could have his phlegm or sputum sent to the lab as well as have a chest x-ray. In addition to detecting infections, these tests can also help identify the bacteria causing the infection so that the right antibiotics can be started.

In TBI it is unusual to develop an infection in the brain itself, especially after the patient has left the ICU. The patients who are at highest risk of developing a brain infection are ones who have had any sort of brain surgery or those who have had fractures at the bottom of their skull (skull base fractures). Sometimes it is difficult to find out where the infection is, and the patient may be started on antibiotics even before the cause of the infection is found.

Occasionally a fever may be caused by conditions other than infections. For instance, a blood clot in the leg (deep venous thrombosis or DVT) can cause a fever. The treatment is to start the patient on a blood thinner, if possible. This condition is discussed more in the paragraph that follows. Also, sometimes people develop reactions to medications, which can cause fevers (a drug fever). The treatment is to stop the medication. Rarely, injury to a particular part of the brain itself can cause fevers. This condition is known as central fever. The treatment mainly involves keeping the fever down with medications such as acetaminophen, although other medications are sometimes used. In all of these cases, it is important to make sure that the patient does not have an infection (through tests) before deciding that he has a condition such as a drug fever or central fever.

Deep Venous Thrombosis (DVT)/Pulmonary Embolus (PE):

A deep venous thrombosis (DVT) is a blood clot in the veins of the legs or, occasionally, the arms. These blood clots are dangerous because a part of them can break off and be carried in the blood to the lungs (causing what is called a pulmonary embolus). A pulmonary embolus (PE) can be deadly. For this reason, it is important to try to prevent DVTs and treat them if they occur. Unfortunately, DVTs may not cause any symptoms, so they can be hard to discover. When they do cause symptoms, it is usually pain or swelling in the involved arm or leg. For this reason, any new swelling in a patient’s arm or leg should be reported and evaluated. The test for a DVT is usually an ultrasound of the limbs (sometimes known as Doppler ultrasound). This test is non-invasive. Sometimes, a blood test is done instead (known as a D-dimer); if it is abnormal, then an ultrasound can be done as a follow up. Many treatment centers will do Doppler ultrasounds of the legs of all patients just to screen for DVTs.

A pulmonary embolus is more likely to cause symptoms. Most often, it can cause the patient to feel short of breath, have chest pain, or cause a cough. In addition, the patient’s pulse can rise and his blood pressure might change (often it drops). These symptoms usually appear suddenly. If the staff believes that the patient might have had a PE, there are several tests that can be done. One is a special type of computed tomography (CT) scan of the lungs (called a spiral CT). The spiral CT requires that the patient receive a dye through an IV line. Or he might get a test known as a ventilation-perfusion (VQ) scan. The VQ scan also requires the injection of a medication.

Should a patient have either a DVT or PE, the treatment is a blood thinner. Initially the blood thinner is given either through an IV (heparin) or as an injection (low-molecular weight heparin). Soon a medicine is started that can be taken by mouth (warfarin). The dose of warfarin required varies from person to person, so blood tests to check the thinness of the blood are needed frequently to determine the right dose. The main risk of a blood thinner is that it can increase the risk of bleeding, either if the patient hurts himself or even spontaneously. For instance, if the patient has an ulcer in his stomach it can create heavy bleeding. TBI patients are also at higher risk of bleeding in the brain because of their injury. Sometimes, the physicians will decide that the risk of bleeding is too high to start a blood thinner. In that case, the patient will probably have a filter inserted in the vein above the blood clot to prevent it from going to the lungs. This filter is called an inferior vena cava (IVC) filter and is usually inserted by a radiologist with the patient under mild sedation.

It is important to try to prevent these blood clots if possible. The most common form of prevention is to give a patient a low dose of a blood thinner daily (much lower than if one were actually treating a blood clot). The most commonly used blood thinner is a low molecular weight heparin injection. Typically, this medication is continued for weeks or until the patient is more mobile. If the patient cannot have even a low dose of blood thinner (because of a high risk of bleeding), an IVC filter can be placed as a preventive measure. In the past, these filters were often permanent, but more recent filters are designed to be removed after several weeks.

Heterotopic ossification:

Heterotopic ossification (H.O.) refers to the formation of bone in abnormal places. Almost always the bone appears in or around joints such as the elbows or hip. The reason why TBI patients develop H.O. is not known. The symptoms include redness, swelling, and pain around the joint. However, some cases can develop without symptoms. In these cases, the first clue that H.O. has developed is that a joint doesn’t move as much as it should. For instance, the person may not be able to fully straighten out his elbow. The first test when H.O. is suspected is an x-ray of the joint. However, x-rays may not show the H.O. if it has just developed. In this case, the physician may order a triple phase bone scan (TPBS). This test starts with an injection of a medicine into an IV; then pictures are taken of the body.

If H.O. is diagnosed, the patient is usually started on medications to slow down or stop the growth of the bone.

Table 9. Some Medications Used to Treat Heterotopic Ossification

(Sample Brand Names in Parentheses)

Etidronate disodium (Didronel)

Indomethacin (Indocin)

However, these medications will not dissolve the extra bone that has already formed. If the extra bone is causing problems (for instance, preventing the patient from lifting his shoulder), an orthopedic surgeon can surgically remove the bone. However, the surgery is rarely done early after an injury because the risk of the bone growing back is too high. In most cases, the surgeon will wait a minimum of 6-12 months before operating to remove the bone.

Complex Regional Pain Syndrome (CRPS):

CRPS is a condition of the arms or legs that is sometimes seen after TBI. The symptoms include significant pain, often appearing to be more severe than one would expect. For instance, many times even light touch to the affected limb can cause severe pain. In addition, there can be swelling and changes in color of the affected area. There can also be changes in temperature and sweating. Later on, there can be loss of hair and changes in the texture of the skin. Many times, the diagnosis is clear based on the symptoms. However, during early stages when just a few of the symptoms are present it may be harder to make a diagnosis. There is no definitive test for the condition. However, many physicians obtain a triple phase bone scan (TPBS). This test starts with an injection of a medicine into an IV. Pictures are then taken of the body.

The treatments for CRPS do not work for everyone. However, some combination of physical or occupational therapy and medications is often successful. In therapy, it is important to keep the limb moving as much as possible. This includes bearing weight (through the leg and arm) as much as possible. The therapists may also try other treatments such as hot wax baths or applying a medication to the skin and using electric pulses to help the medication spread through the skin. Other medicines to be put on the skin may also be prescribed. In addition, many oral medications are available that have helped some (but not all) patients. These include standard pain medicines, steroids, anti-seizure medications and anti-depressants.

Table 10. Medication Types Used to Treat Complex Regional Pain Syndrome (CRPS)

(Examples in Parentheses)

Anti-Convulsants (Gabapentin)

Anti-Depressants (Duloxetine)

Narcotics (Hydrocodone)

NSAIDs (Ibuprofen)

Steroids (Prednisone)

If the CRPS persists despite medications and therapy, injections can be tried. There is some evidence that injection of botulinum toxin into the affected limb can help. More commonly used is a nerve block performed by a pain specialist. These are known as sympathetic ganglion blocks. CRPS can be a difficult condition to treat. In most cases, one or more of the treatments described will be successful. However, the condition can be chronic in some cases.

Hormonal abnormalities:

The hormonal or endocrine system is ultimately controlled by the brain, and some patients with TBI can have abnormalities in the hormones that their glands produce. The symptoms of these abnormalities can be very subtle and vary depending on the hormones affected and the patient’s condition. Some of the hormones that are commonly abnormal are listed in the table below.

Table 11. Possible Hormonal Abnormalities after TBI

Adrenal Hormones (such as Cortisol)

Growth Hormone

Sex Hormones (such as Testosterone)

Thyroid Hormones

Many times, the physician will order blood tests to screen for some of these hormonal abnormalities. While the treatments for some of the hormonal abnormalities are widely accepted (for instance, thyroid deficiency), others are more controversial (for instance, growth hormone deficiency).

Neurological complications

Seizures:

A seizure is caused by sudden abnormal electrical activity in the brain. Normally, the brain has electrical currents flowing through it all the time. However, this occurs in a very organized way. Sometimes, a part of the brain starts generating electrical impulses on its own. If this abnormal electrical activity spreads to the whole brain (like an electrical storm), a person will lose consciousness and start having jerking movements that most people recognize as seizures. This type of seizure is called a generalized tonic-clonic seizure (sometimes called a grand mal seizure). The patient can hurt himself if he falls during the seizure, or he can bite his tongue. If the seizure only lasts a few minutes, it should not hurt the brain at all. However, a prolonged generalized tonic-clonic seizure can possibly hurt the brain. This is partly because a person does not breathe as deeply during a seizure and so the blood-oxygen level can drop. Also, there is reason to think that excessive electrical activity itself can hurt the brain if it lasts too long. For this reason, doctors will use medications to try to stop a generalized tonic-clonic seizure that lasts more than a few minutes.  If this is the patient’s first seizure, the patient may get certain tests done to make sure there is not a new condition that might have caused the seizure (for instance, blood work, CT scan of the brain, etc.). It is normal to be confused and sleepy right after a generalized, tonic-clonic seizure (post-ictal state).

If the patient has a seizure outside of the hospital, providing first aid is very simple and basically involves keeping the patient safe during the seizure.

Table 12. Managing a Seizure at Home

1.        Stay calm

2.        Time the seizure with your watch

3.        Prevent injury:·   clear the area of anything hard or sharp·   put something flat and soft, like a folded piece of clothing, under the head.

Loosen tight clothing, especially around the person's neck

Do not hold the person down

Do not put anything in the person's mouth

Turn the person to the side after the seizure to reduce the risk of choking if he vomits

Do not give the person water, pills, or food until fully alert

Call 911 if: ·   this is the person’s first seizure ·   the seizure lasts more than five minutes ·   another seizure starts soon after a seizure ends ·   the person is injured during the seizure ·   the person is pregnant or has diabetes ·   the person doesn’t start to wake up afterwards (he may be confused for awhile).

The patient should go to the emergency room if it is his first seizure, if he is injured during the seizure, if the seizure lasts more than 5-10 minutes or if he does not start to wake up after the seizure.

Grand mal seizures are the most severe type of seizures because the abnormal electrical activity has spread and temporarily hijacked the whole brain. However, if the abnormal electrical activity does not spread and stays in the part of the brain that it started in, then a patient’s symptoms will be milder. The exact symptoms will depend on what part of the brain is affected. For instance, if the abnormal electrical activity is in the part of the brain that controls the right arm, then the person’s only symptoms will be shaking of the right arm. If the seizure is in the part of the brain that controls smell, persons may smell things that are not there (for instance, that something is burning). These types of seizures are known as partial seizures (in contrast to grand mal seizures, which are generalized). In some partial seizures, the person is also confused (called complex partial seizures).

If someone has had a grand mal (generalized tonic-clonic) seizure more than one week after his injury, anti-seizure medications will usually be started. There are many anti-seizure medicines available; some of the most commonly used ones are listed in the table below.

  Table 13. Some Common Anti-Convulsants (Sample Brand Names in Parentheses)

All patients with a TBI are at risk of having a seizure. It is estimated that people with severe closed brain injuries have about a 10-15 percent risk of having a seizure in the first five years after a brain injury. Despite this risk, there is no evidence that giving someone an anti-seizure medication for more than a few weeks after his brain injury can help prevent seizures. So, most TBI patients will have their anti-seizure medications stopped if they have never had a seizure (unless the physicians believe that there are special circumstances that place the patient at a higher risk). The situation is a little different for penetrating injuries (for instance, from a gunshot wound). In these cases, the risk of having a seizure might be as high as 50 percent. For that reason, some physicians might choose to leave the patient on an anti-seizure medication for a longer period of time, even if he has never had a seizure.

Dysautonomia (Storming):

In dysautonomia, patients have episodes of elevated heart rate, high blood pressure, sweating, muscle tightness, and sometimes fever. Another name for this condition is sympathetic storming. It is most commonly seen early after TBI and in those patients who remain in a vegetative or minimally conscious state for a long period of time. After the doctors decide that there is nothing else causing the symptoms (such as agitation, pain, seizures, etc.), they will start medications to try to control the symptoms. Unfortunately, no single medicine works for all patients, so the doctors may have to try several of them before finding one that works best in a particular patient. The most commonly used medications are listed in the table below. 

  Table 14. Some Medications Used to Treat Dysautonomia (Sample Brand Names in Parentheses)

Almost all cases of dysautonomia get better over time.

Hydrocephalus:

Hydrocephalus refers to a condition in which there is too much fluid in the brain. Brains have hollow spaces inside them called ventricles.  The ventricles are always filled with cerebrospinal fluid (CSF). After TBI, however, the fluid sometimes builds up because the brain injury damages the parts of the brain that help drain the extra fluid. If the fluid accumulates, the ventricles grow in size and put pressure on the brain. The condition is not dangerous but it can slow recovery. The fluid almost always builds up over time, so the symptoms of hydrocephalus rarely come on suddenly.

One of the most common symptoms is for the patient to have a mild decline in his overall condition. Just as often, however, the patient does not decline but rather just stops getting better (plateaus). More specific symptoms can include increased confusion, more spasticity, trouble walking, and worsening problems with bladder control. Sometimes the hydrocephalus is just discovered accidentally when a follow-up CT scan or MRI is done. A CT scan is the easiest way to make the diagnosis. In hydrocephalus, the scan will show enlarged ventricles.

In many cases, the diagnosis of hydrocephalus is obvious: the patient is having symptoms and the ventricles are much larger than normal. In other cases the diagnosis is not as obvious. Two situations might make it harder to decide if the patient needs to be treated. One is when the ventricles are only mildly enlarged. Since many of the symptoms of hydrocephalus can be caused by the brain injury itself (problems with thinking, walking, bladder control, etc.), it is hard to know if the mildly enlarged ventricles are truly causing the patient’s symptoms or not.

Another issue that sometimes confuses the decision as to whether to treat or not is that, in severe TBI, a certain amount of ventricular enlargement is normal, especially after a few weeks. This is because the brain shrinks (atrophies) after brain injury. As the brain shrinks, the ventricles enlarge to compensate for the extra space. This is not considered true hydrocephalus; it is called hydrocephalus ex vacuo (since the extra fluid is there to fill the vacuum that was caused by the brain shrinkage). If the enlarged ventricles are due to hydrocephalus ex vacuo (and not true hydrocephalus), the patient would not benefit from treatment. In fact, since the treatment involves surgery, the patient would be exposed to unnecessary risks if he were treated. Because it is sometimes hard to tell if enlarged ventricles are caused by real hydrocephalus or hydrocephalus ex vacuo, some doctors will perform extra tests to help them distinguish the two conditions. Unfortunately, there is no definitive test and there are differences of opinion between brain injury doctors about which tests, if any, can help in the diagnosis.

One test that is commonly performed is sometimes called the “tap test.” This involves performing a spinal tap (lumbar puncture) on the patient to drain CSF (since the CSF in the back is directly connected to the fluid in the brain). Then the patient is monitored over the next few days for any signs of improvement. If improvement does occur, it indicates that the patient probably has true hydrocephalus and would benefit from treatment. However, if he does not get better, it does not mean that he would not benefit from treatment, since almost half of patients who do not improve with a tap test still benefit from treatment.

The standard treatment of hydrocephalus is to put in a ventriculoperitoneal shunt (VP shunt). This tube is surgically placed inside the ventricle and extends from the ventricle through the neck and into the abdomen. The tube is entirely inside the body and only rarely can the outline of the tube be seen on the surface of the neck. The tube is constantly draining the extra fluid from the ventricles into the abdomen, where it is absorbed by the body. The shunt has a valve that controls the amount of fluid that is drained. Newer shunts have adjustable valves so that the pressure setting can be adjusted by a computer without having to re-operate to change the shunt. The older shunts require another operation if the setting on the valve needs to be adjusted.

Although relatively minor as far as brain surgery goes, the placement of a VP shunt does have some risks. In addition to the risks of anesthesia, there is a small risk of some injury or bleeding to the brain when the shunt is placed. The shunt itself can also get infected or malfunction over time. In some case, if the shunt drains too much fluid off (over-drains), a patient can develop bleeding in the brain (known as a subdural hematoma).  However, in skilled hands and in appropriate patients, the probabilities of these risks are very low and patients with hydrocephalus can significantly improve after successful treatment with a VP shunt.

Dizziness:

Dizziness is common after a TBI. When someone reports that he is dizzy, it is important to distinguish between light-headedness and vertigo. Light-headedness refers to feeling faint, often after sitting or standing up. One feels like one might pass out. In vertigo, however, the patient feels as if the room is spinning around him, whether or not the patient is moving or standing still. Often the vertigo is triggered by movement of the head. The patient can also have trouble seeing and feel nauseous at the same time as he feels the vertigo. Vertigo is caused by damage to the vestibular system, which is made of the inner ear (which controls balance) and the areas of the brain that control balance. It is important to distinguish where the problem is, because the treatment will differ depending on whether the problem is in the inner ear or in the brain. Most of the time, one can decide between these two causes by the physical examination. Occasionally diagnostic tests might be required. In either case, the treatment is fairly effective and usually just involves certain exercises done with a therapist or physician with some knowledge of vestibular dysfunction.

Vision problems:

Problems with vision are common after a TBI. The most common problems that patients report are not seeing as well or seeing double. People see double when the two eyes are not exactly aligned with one another. For instance, one eye may not move all the way to the right. So, when the patient looks to the right, only one eye will move and the patient will see double in that direction. The problem is not in the eye itself but in the muscles and nerves that move the eye. Early on, the treatment is usually to place a “pirate’s patch” over one eye so that the brain only receives one image. Patients usually alternate wearing the patch over each eye, regardless of which one is not moving as well. If the problem persists for a long time, other treatments might include botulinum toxin injections to the eye muscles or even surgery. Unlike double-vision, problems with one’s vision (that is, not seeing clearly) are usually due to problems with the eye, the nerve that goes from the eye to the brain, or the parts of the brain that control vision. In all cases of visual problems, it is helpful to have a neuro-optometrist or ophthalmologist evaluate the patient to determine what is causing the problem and what can be done to improve it.