How long can a person with severe TBI live? Brain injury Features of recovery of patients with traumatic brain injuries

One of the most dangerous injuries for a person is a head injury. The body often suffers various injuries. But some of them are absolutely not life-threatening, while others, on the contrary, can significantly affect the entire body, especially if it is the head.

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The condition of the victim and further treatment depend on the complexity of the injury. Causes of pathology: falls, accidents, physical impact.

Trauma to the skull and back

Mechanical impact on the head area can lead to a bruise or fracture of the skull. But cases of damage to the brain or spinal cord are often diagnosed. In most cases, head injury provokes pathologies in the neck area, which leads to complications.

Scull

TBI leads to impaired brain functionality.

Two types of damage: open and closed.

1. In the first case, a rupture of the skin and a fracture of the skull bones occurs.
2. The second type is characterized by bruising, squeezing or.

Signs of pathology depend on the complexity of the damage (from dizziness to falling into a coma). After receiving even a minor head injury, you must go to the hospital for diagnostics.

Complications may occur as a result of injury:

• encephalitis,
• traumatic meningitis,
• intracranial hematoma,
• epilepsy, etc.

Back

Injuries to the spine are just as dangerous as brain injuries, as complete or partial paralysis of the musculoskeletal system can occur. There are various forms of damage, all of them divided by degree of complexity.

Symptoms of spinal cord injury are similar to signs of brain injury, however, pain is observed in the spinal area. The injury is most often observed in the cervical region, located next to the head.

The consequence of the pathology can be complete paralysis, which cannot be treated. If injured, the victim must be provided with assistance and taken to a medical facility.

Common damage

The most common type of head injury is blunt.

Pathology is observed as a result of a blow with a blunt object or a fall on a hard surface. The damage can be either closed or open.

Such an impact on the head area leads to the formation of bruises and abrasions with minor damage, but with a strong blow, complete destruction of the head is possible.

Blunt trauma is often the cause of death of the victim. For mild forms of damage, complex treatment is carried out. To eliminate the pathology, conservative and surgical treatment methods can be used.

In most cases, after contacting a medical institution, the patient has to provide an explanation to the police about the injury, since this injury is considered as an injury to the victim by another person.

Possible echoes

As a result of a head injury, various complications can occur. The damage never goes away without a trace, since the brain is injured, and in some cases the spinal cord. In severe cases of pathology, the victim may remain disabled. First aid and treatment play a big role in a person’s future condition.

The consequences of traumatic brain injury include:

• headaches of varying intensity;
• loss of hearing, smell, vision, etc.;
• memory loss;
• paralysis.

Other pathologies may be observed that are caused by disruption of the brain, nervous system or other organs (systems). The most common symptoms experienced by patients are headaches and epileptic seizures.

Pain

90% of victims experience constant headaches and dizziness during the first two to three weeks. Such symptoms are a sign of serious problems in the brain. Pain varies in nature: acute and chronic.

Acute indicates the following pathologies:

• hematoma: local in nature pain, nausea, vomiting, psychological and neurological disorders;
• hemorrhage in the brain: head movements provoke an attack of severe pain, an increase in temperature, epileptic seizures and convulsions are observed;
• head injury: general symptoms of pathologies in the brain.

As a result of the damage, some victims are diagnosed with chronic headaches. If discomfort do not disappear two months after the injury, the painful sensations take on a chronic form. Some people cannot get rid of the pathological condition even after years.

The disease is accompanied by other disorders:

• noise in ears,
• dizziness,
• irritability,
• weakness.

In the absence of proper treatment, the symptoms only intensify, thereby debilitating the person and weakening his body.

Epilepsy

Head trauma is one of the causes of epilepsy. But this pathology is observed only in 20% of victims, since the progression of the disease is influenced by several factors.

Epileptic seizures that occur as a result of head trauma are medically called post-traumatic epilepsy after injury. The pathology is characterized by socio-psychological deviations. Treatment should be carried out in the form of drug therapy, provision of psychological assistance.

The disease is treatable, but full recovery may take a long time. After several years, a person may experience symptoms of epilepsy again. If the injury occurs again, the situation may worsen.

Video

A long rehabilitation period is required. Depending on how complex the damage was, recovery lasts from several months to several years. Sometimes the rehabilitation period lasts a lifetime.

The consequences of injury are eliminated by therapeutic methods, which include medication, physiotherapy and exercise therapy. There are cases when a person loses his sense of smell after suffering a trauma. Some patients, especially those with spinal cord injury, may experience arm paralysis. Rehabilitation for such pathologies takes place with special attention.

Smell

Losing the sense of smell greatly complicates a person’s life, so the patient tries to regain sensitivity. But you shouldn’t take risks and self-medicate. Traditional methods can not only help, but also lead to serious complications. It is best to trust the specialists.

To restore the sense of smell, special medications and physiotherapy procedures are used. Adequate hormonal therapy and a course of B vitamins are recommended. Without treatment, it is very difficult to restore the sense of smell.

Physical activity

Impaired functionality of the limbs is observed very often. Besides drug treatment and other additional methods, the patient will definitely need to regularly perform special courses of exercise therapy.

Choose your own methodology, including necessary exercises, is not worth it, as there may be contraindications.

It is recommended to perform the first classes in the presence of a specialist who will determine the intensity and frequency of the exercises. Don't overstrain your muscles. If there is severe pain, it is better to stop performing gymnastics until the patient feels better. Exercise therapy is the most effective method combating limb dysfunction.

You can reduce the risk of complications if you contact a medical professional for help immediately after receiving an injury. Do not put off visiting a doctor or neglect treatment.

First aid

Anyone can find themselves in a situation where there is a person nearby with a head injury. Knowing the rules for providing first aid, you can alleviate his condition and even save his life.

1. Signs of a serious traumatic brain injury include blood or clear fluid (CSF) leaking from the nose or ear and bruising around the eyes. Symptoms may not appear immediately, but after several hours, so if there is a strong blow to the head, you must call an ambulance immediately.
2. If the victim has lost consciousness, breathing and pulse should be checked. If they are absent, you will need to perform artificial respiration and cardiac massage. If there is a pulse and breathing, the person is placed on his side before the ambulance arrives, so that possible vomiting or a sunken tongue will prevent him from suffocating. You cannot sit him down or lift him to his feet.
3. In case of a closed injury, ice or a cold wet towel should be applied to the site of impact to stop tissue swelling and reduce pain. If there is a bleeding wound, you should lubricate the skin around it with iodine or brilliant green, cover the wound with gauze and carefully bandage your head.
4. It is strictly forbidden to touch or remove fragments of bones, metal or other foreign bodies protruding from the wound, so as not to increase bleeding, damage the tissue even more, or cause infection. In this case, a gauze roll is first placed around the wound, and then a bandage is made.
5. The victim can only be transported to the hospital in a supine position.

The hospital conducts an examination, determines the severity of the patient’s condition, and prescribes diagnostic procedures. For open wounds with bone fragments or other foreign bodies the patient requires urgent surgery.

Prognosis for traumatic brain injury

Concussion is a predominantly reversible clinical form of injury. Therefore, in more than 90% of cases of concussion, the outcome of the disease is the recovery of the victim with full restoration of ability to work. Some patients, after the acute period of concussion, experience certain manifestations of post-concussion syndrome: disturbances in cognitive functions, mood, physical well-being and behavior. After 5-12 months, these symptoms disappear or are significantly smoothed out.

Prognostic assessment in severe traumatic brain injury is carried out using the Glasgow Outcome Scale. A decrease in the total score on the Glasgow scale increases the likelihood of an unfavorable outcome of the disease. Analyzing the prognostic significance of the age factor, we can conclude that it has a significant impact on both disability and mortality. The combination of hypoxia and arterial hypertension is an unfavorable prognosis factor.

Consequences of head injury

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Traumatic brain injury (ICD-10 – S00-S09) is a whole complex of contact intracranial injuries. According to statistics, TBI is the third most common cause of death in our country (after oncology and cardiovascular pathologies). Injuries of this type occur in accidents and traffic accidents, while participating in sports competitions, during fights, during everyday falls and blows.

Almost always, after brain damage, the life of an adult or child changes completely. Again, according to statistics, approximately half of all those who have a traumatic brain injury recorded in their medical records are disabled. Such people need high-quality recovery and rehabilitation (which is often underestimated by patients and their relatives).

After receiving a severe or moderate TBI, after undergoing treatment and rehabilitation, not all people are able to lead a normal life. Many lost functions are restored over time, but some consequences of TBI haunt victims until the end of their days.

It is widely believed that in the absence of external damage, one can count on a favorable outcome. But any head injury is extremely insidious, therefore, if damaged, even if the person remains conscious and at first glance everything is fine with him, it is necessary to send him for a full examination to the hospital.

Consequences of traumatic brain injury

The severity of symptoms, their duration, and recovery time from the consequences of TBI will largely depend on the severity of damage to the skull and brain structures directly at the time of injury and during its initial treatment. Many neurologists note that our brain is an extremely plastic structure, highly flexible, which can fully recover even after severe damage. Immediately after the victim is admitted to the hospital, ultrasound, CT and other necessary examinations are carried out to establish the severity of the injury in accordance with the generally accepted classification and to detect damaged brain structures.

Therefore, even if therapy for the consequences of TBI occurs quickly and successfully, no doctor will draw any conclusions prematurely. It is very difficult to predict the presence or absence of any consequences after receiving a traumatic brain injury (regardless of the severity of the injury).

Many disorders and pathological changes that develop after TBI may not appear for a long time (several days, weeks or even months). This is especially true if the injury was received by a small child - the consequences in this case can only be felt after a few years.

In this case, we can highlight a whole list of consequences that are observed in people after TBI of varying severity:

• Paralysis of the limbs (complete or partial). It can develop on one side or both.
• Constant migraine pain in the head (not necessarily in the place where the injury was sustained).
• Damage to blood vessels, important brain structures, and parts (therefore, it is necessary to remove fragments and foreign objects from the head immediately after a head injury).
• Problems with the senses (as a result of damage to the auditory, visual, speech centers).
• Loss of sensation in the limbs and in different parts of the body.
• Loss of the ability to swallow and breathe independently.
• Loss of the ability to control the pelvic organs (in whole or in part). In this case, a person cannot regulate bowel movements.
• Epileptic syndrome (even if there were no symptoms of epilepsy before).
• Cerebral atherosclerosis.
• Trembling of limbs ().
• Disturbances in the functioning of the spinal cord.
• Memory problems, noticeable personality changes in character (a person becomes withdrawn, he cannot speak on his own, shows aggression, irritability, indifference, etc.), changes in gait and a number of other consequences that are associated with the work of the central nervous system.

After a traumatic brain injury, even some of the listed consequences will not always develop. The results of trauma to the brain structures and skull are individual in each case, so they are difficult to predict and track with high accuracy.

Much will depend on which parts of the brain (temporal, occipital, etc.) and systems were damaged, and in which structures blood circulation was impaired. At the same time, a number of symptoms (for example, paralysis, problems with breathing, hearing, vision) appear immediately after the injury, but during the treatment they completely disappear even without specialized treatment. Others (for example, headaches, epileptic seizures, tremors, etc.) never make themselves felt immediately, but appear several months after treatment during rehabilitation.

Few people know that the concept of “concussion” also directly refers to TBI. This mild degree such damage. Traditional symptoms that help distinguish a concussion from anything else are: temporary loss of consciousness, attacks of nausea, darkening of the eyes. In the absence of such symptoms, you do not need to consult a doctor. But if the patient loses consciousness for at least 1-2 minutes, and does not remember exactly how he hit his head, it is recommended to call an ambulance, or get to the clinic on your own and consult with a neurologist.

Principles of recovery for people with TBI

Stroke, gastrointestinal pathologies, cancer and many other well-known diseases in most patients develop according to a similar universal scenario. But in the case of a traumatic brain injury, the options become numerous. Everything will depend on the method of injury, the presence of concomitant injuries, affected parts of the brain, the severity of the injury and a combination of other factors.

In a number of situations, a person immediately falls into a coma after receiving a TBI, and sometimes after several days or even weeks. Coma in this case is a protective reaction of the body, which thus tries to put the person into an “energy-saving” mode to prevent the death of the patient.

Statistically, many people with TBI will improve rather than worsen with treatment. It is by the rate of improvement that doctors make a preliminary prognosis. In this regard, rehabilitation must be provided even before the person is discharged from the hospital. In order to prevent the development of the consequences of TBI years later, from the first days of treatment the patient needs to work with a psychologist, engage in early physical activity, physiotherapy, and attend specialized massage. All this will significantly increase the chances of a person’s full return to normal life without hazardous health consequences.

If rehabilitation is started too late, then even the highest quality and professional rehabilitation procedures may not bring the desired effect: if several months have passed after the TBI, then during this period all sorts of pathological changes and disorders could occur, which are often impossible to correct. In such situations, the patient’s likelihood of becoming disabled for the rest of his life increases (different degrees of disability are given depending on the impairments manifested).

Therefore, every person who has suffered a traumatic brain injury requires a multifaceted therapeutic approach:

• If a patient has impaired brainstem functions (respiratory system, ability to swallow), then he needs the help of a neuropsychologist and rehabilitation specialist. Often, immediately after a TBI, a person cannot breathe on his own (in this case, he is transferred to artificial ventilation).
• If the ability to speak is lost, priority is given to cooperation with a speech therapist.
• If mental changes are detected, constant severe pain in the head is observed, and there is insomnia, then neuropsychologists and occupational therapists can help.
• In the presence of severe hypertension (and other cardiovascular pathologies), assistance and constant monitoring by cardiologists is required.

Almost all people who are being treated for the consequences of TBI are prescribed special diet(in particular, those patients who, as a result of injury, have developed various disturbances in the functioning of the gastrointestinal tract, kidneys, liver and other internal organs).

Functions lost due to a traumatic brain injury are restored extremely slowly, which is why professional rehabilitation is important. It is necessary to make a choice in favor of a professional approach, rather than folk remedies and self-medication. High-quality and long-term rehabilitation is one of the main conditions for effective recovery in the postoperative period and minimizing the consequences of traumatic brain injury.

Restoration of cognitive functions

Disruption of normal higher nervous activity is a fairly common occurrence in traumatic brain injuries of varying severity. A person who has received a TBI may partially or completely lose memory, lose the ability to focus on something specific, learn something new, make mental calculations, or navigate in space and time. It is extremely important during the treatment and rehabilitation process to try to regain all these lost functions - they are no less important for the patient’s comfortable life than control over the functioning of the limbs.

A neuropsychologist who deals with the work of higher nervous activity in humans can help restore cognitive functions. During the process of rehabilitation and treatment, this doctor must draw up special program, which includes various activities (both psychological and physical) that will be aimed at fully or at least partially (often there is no possibility of complete restoration of lost abilities) to restore previous higher mental functions.

With traumatic brain injuries, people sometimes completely lose the ability to write and read, although they retain the ability to hear, speak, and express their thoughts. Experts note that with a competent approach and appropriate motivation, these functions can be restored fairly quickly.

Traumatic brain injuries sustained in childhood have a serious impact on the psychological and mental development child, therefore it is extremely important for him to be under the systematic supervision of specialists throughout the entire period of growing up.

Restoring speech skills

After a stroke and a number of other dangerous pathologies associated with the central nervous system, some people completely or partially lose the ability to speak and express their thoughts. It is also a common consequence of severe to moderate traumatic brain injury.

Such disorders may manifest themselves differently in different people:

• Problems with articulation (a person cannot normally control his tongue, jaw and other organs involved in speech production).
• Aphasia (due to open or closed TBI, there is damage to speech centers located in different parts of the brain, so the patient is not able to pronounce any words or speak in complex sentences).

In some cases, articulation disorders and aphasia are long-term consequences of TBI, which can appear and develop only some time after the injury (sometimes such disorders appear immediately).

To eliminate problems associated with the work of speech centers, a comprehensive treatment and rehabilitation approach is needed, which will include the help of a number of doctors: a physiotherapist, an occupational therapist, a speech therapist, a massage therapist. Each of these specialists will be able to offer certain ways rehabilitation.

In the process of restoring speech skills, various methods can be used depending on a number of factors: the presence of changes in the patient’s personality, identified mental disorders, examinations and operations completed, their results, the presence of other serious disorders in the functioning of the central nervous system. There is no point in delaying the restoration of speech functions, because pathologies of this type can progress.

If a TBI was sustained by a pregnant woman, this often becomes an indication for delivery through cesarean section.

Restoration of motor skills and functioning of the musculoskeletal system

In the case when, due to a head injury, paralysis or paresis begins to develop, seriously complicating a person’s ability to move independently, he needs the help of a rehabilitation specialist, physiotherapist, or massage therapist. In this situation, specialists can use all sorts of techniques that can help restore the usual tone of the muscles of the limbs, returning the previous sense of balance and equilibrium. In case of such disorders, the massage therapist will massage not only damaged but also healthy limbs for the purpose of prevention.

Exercises prescribed by a specialist in physical therapy and a physiotherapist will help restore the previous coordination of the limbs, relieve the patient of cramps, trembling, and a feeling of weakness in the limbs. You need to understand that restoring such functions is a long and complex process that must be completely under the supervision of doctors. The positive impact of rehabilitation in this case is difficult to overestimate, because it is quite difficult to change something on your own after a TBI.

In situations where rehabilitation measures are started in a timely manner (simultaneously or immediately after treatment), there is a high probability that a patient after a serious injury will be able to move independently and perform simple self-care activities within a few weeks or months. In the absence of the necessary therapeutic actions, a worsening course of disorders may occur, contributing to the complete loss of the ability to walk or move the arms. This stage of pathology develops only in the complete absence of treatment and rehabilitation.

It is important to understand that tremors, numbness, convulsions, paresis, paralysis - all of this is associated with disorders of the nervous system, therefore, in addition to the help of physiotherapists and massage therapists, it is necessary to constantly be in contact with a neuropsychiatrist and psychotherapist.

In particularly complex and advanced cases, when traditional exercises and activities do not bring the desired effect, special equipment can be used in rehabilitation centers (for example, the Exart system, etc.). Such units can help activate the patient’s nervous system and muscles.

Rehabilitation of the patient should begin on the first day after injury, even if he is unconscious in intensive care.

Eliminating pain

Due to the development of hematoma, fractures of the base of the skull, hemorrhage in the brain structures, contusions and other types of injuries after TBI, the likelihood of severe pain syndrome is quite high.

However, they rarely appear immediately after a traumatic brain injury. Usually they begin to bother a person during treatment, while in traumatology or in rehabilitation center(and often even after the entire therapy is completed).

Along with the pain, dizziness is also often noted, which can cause double vision. Pain and dizziness can occur both in the presence of relevant factors (weather, sudden turning of the head, etc.) and in their complete absence (for example, in the morning or evening hours).

Life after a TBI with headaches bothers many patients, so if you have pain, you need to consult a physiotherapist or massage therapist. Doctors can also prescribe special painkillers, magnetic therapy, electrophoresis and other procedures if there are appropriate indications.

If medications and traditional procedures do not help eliminate the pain, the patient is sent for a repeat MRI or CT scan to find out what exactly is causing the pain (impaired vascular patency, hidden hemorrhages and hematomas, pinched nerves, etc.). If the pain syndrome is severe and significantly impairs a person’s quality of life, then surgery may be indicated.

Correcting the psychological state

When undergoing rehabilitation after a traumatic brain injury, it is extremely important to restore not only “basic” functions (limb movement, speech, hearing, vision, etc.), but also psychological ones. Often, after a TBI, the patient’s character changes significantly – he can become irritable, apathetic, aggressive, withdrawn. In the absence of special psychological treatment, it is quite difficult to predict subsequent disorders of the psycho-emotional spectrum that will be observed in the victim.

A psychologist should treat such a situation (usually individual or group sessions are used). A specialist needs to select suitable means and procedures that will correct a person’s psychological state. Modern psychiatry is able to restore the patient’s previous character even with complex traumatic brain injuries.

In this case, close cooperation between doctors and relatives is also important. Close people, seeing the aggressive or indifferent behavior of the patient, may perceive everything incorrectly, thinking that they are doing something wrong. However, with TBI, personality changes are directly related to disruption of higher nervous activity, and not to external factors. Relatives and loved ones must show patience and understanding.

In some cases, a person’s psychological state (if certain parts of the brain have been damaged) never returns to their previous levels.

Occupational therapy

After basic speech and motor functions have been restored and psychological disorders have been eliminated, it is time for occupational therapy. Medical care in this case is aimed at eliminating complications associated with the problematic self-care and performance of the patient.

1. Impaired consciousness

Traumatic brain injury (TBI) in Russia is registered annually in four out of 1 thousand people. The most common types of injuries are domestic, criminal and road traffic injuries. Based on the nature of brain damage, focal, diffuse and combined forms of TBI are distinguished. In terms of severity - mild (concussion and mild contusion of the brain - 83% of all TBIs), moderately severe (moderate contusion of the brain - 8–10% of all TBIs) and severe (severe contusion and compression of the brain - 11% of all TBIs). There are acute, intermediate and long-term periods of the course of a traumatic disease. Mental disorders are observed in almost all cases of TBI, and these disorders are very diverse.

In the acute period of TBI, the main disorders are syndromes of depression of consciousness: moderate and deep stupor, stupor and coma.

Moderate stupor is the mildest depression of consciousness, slowing of movements and speech, lengthening of pauses between the doctor’s questions and the patient’s answers are detected. Reduced active as well as passive attention. The answers to the questions are incomplete, inaccurate, errors regarding orientation in place and time are possible. The face is inexpressive, the gestures are depressed. This condition appears immediately after a mild TBI. Partial congrade amnesia is possible. Fluctuations in clarity of consciousness are characteristic. Synonym: nullification.

Profound stupor or somnolence. It is characterized by increasing drowsiness, lethargy, slowing of speech, movements, and loss of expressive acts (and emotions) after TBI. Contact with the patient is still possible, but you have to repeat questions or bother the victim to get his attention. The answers do not follow immediately and are often limited to the words “yes” or “no.” It turns out that the patient is disoriented in place and time, inaccurately oriented in the environment, but correctly oriented in his own personality and in the situation. The response to pain is preserved, the patient can show where he feels it. Control over the functions of the pelvic organs is weakened. Congrade amnesia is such that the patient remembers very little of what happened and was perceived by him during the period of deafness, which lasts up to 20–30 minutes or more. The recovery from stupor is gradual, with fluctuations in the clarity of consciousness.

Stupor is a depression of consciousness in which verbal contact with the patient is completely interrupted, he does not understand the questions addressed to him and does not answer them. The patient still reacts to a loud sound, painful stimulation, opens his eyes, responds with a grimace of pain, reaches his hand to the place of pain. Elementary recognition is preserved: at the sound of a voice loved one The patient's heart rate increases and the face turns red. Muscle tone is reduced. There are no skin reflexes. Corneal, pupillary and conjunctival reflexes are preserved, tendon and periosteal reflexes are quite lively. Left to himself, the patient lies silently, with his eyes closed, without moving or making simple automated movements. Stupor occurs with a TBI approaching moderate severity and can last tens of minutes. The emergence into clear consciousness is gradual, bypassing the state of stunning. Congrade amnesia is complete.

Coma is a state of complete shutdown of consciousness and mental activity, from which it is impossible to remove the patient. Congrade amnesia is total. There are three degrees of coma. Moderate coma (I degree coma) is manifested by the fact that the reaction to pain is preserved. This is a reaction in the form of defensive movements of flexion, extension of the limbs or uncoordinated dystonia. Difficulty swallowing. Pupillary and corneal reflexes are preserved, abdominal reflexes are absent, tendon and periosteal reflexes are variable, respiratory and cardiovascular disturbances are insignificant. Deep coma (II degree coma) is characterized by an absolute loss of reactions to any external stimuli and inhibition of most reflexes. Pathological reflexes are evoked and meningeal symptoms appear.

There is no swallowing. Pulse weak, arrhythmia, decreased blood pressure. Breathing is impaired, control of the functions of the pelvic organs is lost, disturbances in muscle tone vary from diffuse atony to hormetonia. Mydriasis may be one-sided. Terminal coma (coma III degree) is manifested by severe disturbances of spinal, bulbar and cortical-subcortical functions. Breathing is severely impaired to the point of apnea. Severe tachycardia. Blood pressure is at a critical level or cannot be determined. Diffuse muscle atony, bilateral fixed mydriasis.

Coming out of a coma occurs in the reverse order, and it can stop indefinitely at different stages. To monitor recovery from coma, a scale of stages of this process is recommended (Dobrokhotova et al., 1985; Zaitsev, 1993). The coma state is defined as the first stage. The second stage is eye opening, or vegetative status. The third stage is gaze fixation and tracking, i.e. akinetic mutism. The fourth stage is discrimination between loved ones, i.e. akinetic mutism with emotional reactions. The fifth stage is understanding speech and following instructions, i.e. mutism with understanding speech.

The sixth stage is the restoration of one’s own speech activity, i.e., the syndrome of reintegration of long-absent speech. The seventh stage is the restoration of verbal communication, i.e. amnestic confusion. The eighth stage is mnestic-intellectual deficiency syndrome. The ninth stage is psychopath-like syndromes. The tenth stage is neurosis-like disorders. This scale, with certain reservations, can be used as a basis for describing other mental disorders in TBI (excluding stunned consciousness).

2. Vegetative status

This stage, as well as the next one - akinetic mutism, often represent reversible post-comatose states, even if they last up to 10 years or more. Reversible vegetative status is a state of relative stabilization of viscerovegetative functions, beginning after coma from the moment of the first opening of the eyes and ending with gaze tracking. It was first described by E. Kretschmer (1940) under the name “apallic syndrome”. The reverse development of the vegetative status occurs in stages. The stage of scattered reactions is distinguished by short periods of wakefulness when the patient lies with his eyes open.

Most often he does this during the day. The eyeballs are motionless or “floating”. The arms are bent, brought to the body, the legs are extended. Extrapyramidal phenomena, chewing, sucking, and swallowing movements are possible. Urination and defecation are involuntary. Reactions to various kinds of stimuli are scattered. With positive dynamics, the patient reacts to touching it by chewing more frequently and intensifying, and in response to pain, he makes chaotic movements, and then directed to the place of pain. In other words, he is already demonstrating the simplest sensorimotor act. The reintegration phase of simple sensory and motor responses is characterized by longer periods of wakefulness, which can be supported by feeding and other procedures. There is a clear tendency towards the formation of a normal sleep-wake cycle.

The patient's reactions to close people are guessed - this is, for example, facial hyperemia, increased chewing, vocalization such as mooing, etc. Anxiety appears and then becomes constant before urination, as well as defecation. Movements to the place of pain are also constant. Reactions to the urge to urinate, to the voices and touches of loved ones become more and more vivid and stable; the patient seems to distinguish the latter from strangers. Some spontaneous movements return, sometimes stereotypical ones.

The stage of reintegration of the simplest psychomotor and psychosensory reactions manifests itself in longer daytime wakefulness, persistent revival before urination, defecation and calm after these functions. Facial expressions of suffering and disgust become clear, and the first signs of differentiation of smells, tastes, edible and inedible appear. When touching himself, the patient begins to make certain movements, for example, opening his mouth if his lips are touched with a spoon. He can be taught to bring his hand to his mouth. Spontaneous movements diversify, gradually acquiring the property of arbitrariness.

Reactions to loved ones become clearer. It is on them that he begins to fix his gaze, at first sometimes for a very short time, and gradually - more often and for a longer time. Then gaze tracking is restored. The sleep-wake cycle becomes close to normal.

A number of publications present the results of observation of patients who were in a vegetative state for a long time. It has been established that most often in the future they experience deep disability.

3. Akinetic mutism

This is a condition with akinesia and mutism, in favorable cases resulting in recovery motor activity, understanding speech and one’s own speech activity (or identifying aphasia). First, speech understanding is restored. While awake, patients lie with their eyes open, turning their gaze and head towards the source of sound or light. Their facial reactions to words with different meanings gradually differentiate. The simplest and then more complex requests are fulfilled, and movements are accelerated. Lack of speech understanding indicates the fact of sensory aphasia. Next, one’s own speech is restored. This is happening against the backdrop of an increasing variety of active movements. The first word is rarely spontaneous and is pronounced very unclearly. Episodes of pronouncing phonemes and words gradually become more frequent, then verbalization becomes spontaneous. Phrasal speech appears, and eventually speech contact is restored. As active speech is restored, the forms of voluntary motor activity also expand. The absence of active speech indicates motor or dynamic aphasia.

In addition to akinetic mutism, patients may also experience hyperkinetic mutism. This often happens when the right hemisphere of the brain is predominantly affected. Motor excitation is iterative in nature: patients sometimes repeat the same movement until exhaustion, returning to it after a break and not paying attention to the speech addressed to them. Characterized by inversion of the sleep-wake cycle. Excitement intensifies in the evening and at night. Nevertheless, even in this state, speech is gradually restored. First comes the understanding of individual words, phrases, simple requests, and the fulfillment of the latter. As the understanding of the meaning of words is restored, motor excitement weakens, and the patients' behavior becomes more orderly. Then the patients themselves make attempts to articulate sounds and words. At first, they try to speak in response to speech addressed to them, then their speech gradually becomes more and more spontaneous. In the absence of aphasia, phrasal speech is also restored to varying degrees.

4. Confusion syndromes

This is a group of very heterogeneous disorders, the place of which in the mentioned scale of postcomatose disorders is not indicated. The group also includes clouding of consciousness syndromes, and even the phenomena of depersonalization-derealization. But since we are talking not about the laws of psychopathology, but about the empirical side of the matter, we will briefly describe these disorders, if possible in accordance with the Dobrokhotova-Zaitsev scale.

Amnestic confusion is a fixation amnesia with a predominant lesion of explicit memory and loss of cognitive structures that organize current impressions. The result is amnestic disorientation.

Amnestic-confabulatory syndrome includes, in addition to fixation and congrade, also retrograde amnesia and replacement-type confabulations.

Korsakov's syndrome in terms of mental disorders does not differ significantly from the previous one. Sometimes Korsakoff's syndrome occurs in combination with left-sided hemiparesis, hemihypesthesia, hemianopia and left-sided gaze disturbances. Such patients also exhibit left-sided spatial agnosia associated with focal pathology of the right parieto-temporo-occipital region.

Patients do not notice, ignore the left half of the space, including own body, do not realize, for example, left-sided paralysis, loss of sensitivity on the left. T.A. Dobrokhotova and other authors indicate that Korsakov's syndrome and left-sided spatial agnosia “can be considered intermediate between impaired and clear consciousness” and that they “can complete the restoration of consciousness after a coma.”

Speech confusion is represented by partial or complete aphasia (sensory, motor or amnestic). The disorder can be combined with right-sided hemiparesis. Speech motor excitation is observed in severe TBI with intracranial hemorrhage. Periods of general and speech arousal may be followed by depression of consciousness (up to coma), which indicates an increase in the volume of hemorrhage.

Syndromes of stupefaction are relatively rare and mostly occur in mature patients. They are not observed in old people and children in the first years of life. Mention is made of oneiroid, depersonalization and derealization, “flashes of past experiences” (meaning life in the past, i.e. ecmnesia), twilight state and delirium. Psychotic disorders usually occur in the first two months after emerging from a coma.

Transient global amnesia is temporary (up to 24 hours) and total amnesia, in which absolutely everything can be forgotten, including given name. Sometimes it happens immediately after a very short coma (seconds, minutes), it is noted with a concussion, mild to moderate bruises of the brain. It is important not to confuse this disorder with episodes of amentive confusion.

5.Syndromes of affective disorders

The absence and extreme impoverishment of emotionality and expressiveness in post-comatose states is later replaced by euphoria, anger, aggressiveness, and then mania, depression, and bipolar mood disorders may occur. The most serious violations emotional sphere observed with bruises and hematomas of the frontal regions of the cerebral hemispheres. Bipolar affect disorders in TBI are observed with damage to the right hemisphere.

Emotional paralysis (in aspontaneity syndrome) is observed in severe TBI with hemorrhage in the left frontal region of the brain. The phenomena of aspontaneity can last for months. As the patients' activity increases, against the background of indifference, initially rare smiles, irritation, anger, and gradually and more often other emotional manifestations appear.

Euphoria with disinhibition is more often observed with contusions of the fronto-basal parts of the brain, and lasts most long after a prolonged coma. This condition is usually defined as pseudoparalytic syndrome.

Angry mania usually occurs in patients with bilateral damage (contusion) to the frontotemporal regions of the brain. Combined with euphoria. It is more pronounced in mature patients in the acute period of TBI, lasting up to several weeks.

Dysphoria occurs in the long-term period of TBI and occurs in short (up to several days) and repeatedly repeated episodes. Possible evening worsening of mood.

Hypomania in TBI is rare and occurs both in the acute period of concussion and in the long-term period with bruises and hematomas of the posterior parts of the right hemisphere. According to EEG data, it indicates activation of brainstem structures.

Melancholy depression is more characteristic of remote and intermediate periods of the course of a traumatic disease with damage to the temporal parts of the right hemisphere. It is usually combined, like other affective disorders, with a psychoorganic disorder.

Anxious depression is more often observed with bruises of the temporal part of the dominant hemisphere (i.e., left - lateralization is indicated from the position of a right-handed person).

Apathetic depression is observed with damage (bruise) mainly to the anterior parts of the hemispheres.

6. Borderline syndromes

Asthenic syndrome. The phenomena of asthenia are observed at different stages of the course of a traumatic disease. Often this is the only disorder in the residual period of TBI.

Obsessive-phobic syndrome. It occurs quite rarely in TBI.

Hysteria-like syndromes. Sometimes there are phenomena of pseudodementia, as well as rental behavior.

Phenomena of pseudology. According to some reports, they were often encountered after head injury (especially with brain contusions) during the Great Patriotic War.

Paranoid syndrome. Rarely encountered; its connection with TBI is quite complex.

Hypochondriacal syndrome. Shows somewhat exaggerated attention to the state of one's own health. Much more often, perhaps, patients underestimate the severity of their disorders.

7.Syndromes of decreased mental activity

Traumatic dementia. It is a consequence of severe TBI or a series of TBIs of lesser severity. According to A.S. Shmaryan (1948), one should not rush to make this diagnosis. There are known facts of significant improvement in cognitive functions in seemingly hopeless cases.

Memory disorders. Meaning different variants amnesia of organic type.

Abulia. Rarely reaches the degree of complete spontaneity. Significant improvement is possible, however, even in severe cases.

8. Epileptic syndrome

A common consequence of TBI. Seizures are observed, for example, in 12% of children who have suffered a TBI. Seizures may occur different types, but in a patient with traumatic epilepsy they are usually of the same type. If these are grand mal seizures, then, as a rule, they are secondary generalized. With left-sided brain damage, twilight states of consciousness, absence seizures, psychomotor seizures, speech and ideation seizures, and seizures with psychotic phenomena may occur. More often (72%) seizures occur 6–12 months after TBI. It is believed that with traumatic epilepsy, personality changes are less pronounced than with genuine epilepsy. The exception is children and adolescents who were injured at an early age.

Some authors believe that TBI in early and old age has more severe consequences. Treatment for patients with TBI is individualized and determined by the current condition. Of primary importance is therapy aimed at eliminating liquorodynamic, metabolic, hemodynamic disorders, inflammatory processes, resorption of adhesions and scars. The prognosis is determined by the severity of the TBI and subsequent complications.

Based on the mechanism of injury and the fact of the integrity of the cutaneous aponeurosis, the following types of traumatic brain injury (abbreviated as TBI) are distinguished:

Open traumatic brain injury

It is characterized by damage to the bones of the skull, meninges (hard and soft), and brain tissue. Wounds can be either non-penetrating (the bone plate remains intact, the wound cavity does not communicate with the external environment) or penetrating.

Closed head injury

This category includes injuries in which the skin remains completely intact or its defect does not reach the level of the aponeurosis: concussion, barotrauma, bruises, compression. They are often combined with internal hemorrhages.

As a result of trauma, damage to brain tissue occurs due to disturbances in the dynamics of blood circulation and cerebrospinal fluid. During concussions (shakes), pinpoint hemorrhages and ruptures of small vessels occur. Also, during trauma, the brain hits the base of the skull, causing a cerebrospinal fluid concussion, which damages the walls of the ventricles of the brain. The pathogenesis of mental disorders in the first stages is due to increased permeability of small vessels, oxygen starvation and edema.

Clinical picture of traumatic brain injury

There are three stages in the development of consequences after a traumatic brain injury:

Initial period. It is manifested by deficit disorders that appear precisely during the period of trauma. Their severity and duration depend on the strength of the traumatic factor and the presence of associated complications (hemorrhage, compression of the brain). Therefore, there may be states of stunned, obliterated, stupor, as well as coma.

Acute period. After the restoration of consciousness, asthenia occurs - exhaustion, lack of vitality. Patients complain of eye pain, tinnitus, and high sensitivity to external stimuli. There is retrograde memory loss at the time of injury, as well as for time periods before it. With severe trauma, memory for subsequent events is impaired (retroanterograde amnesia). In parallel with this, autonomic disorders are observed: increased sweating (hyperhidrosis), instability of blood pressure and pulse, blue discoloration of the fingertips, ears, and nose (acrocyanosis).

Period of residual changes. Manifests itself in the form of headaches, sleep disturbances, memory impairment, and asthenia.

Psychoses associated with the acute period of traumatic brain injury

Psychoses can appear in the first days after a traumatic brain injury, sometimes after 3-4 weeks. Characterizing the mechanism of their development, these disorders are also called “edema psychoses” or “exhaustion psychoses.”

Traumatic twilight state

In the twilight state, a narrowing of consciousness occurs, that is, a person perceives the external world in fragments, seeing only a narrow circle of its elements. Adequacy of thinking and orientation are lost. Outpatient automatisms may be observed (a person performs ordinary everyday activities with a narrowed consciousness), trance episodes, and a disorder of orientation in one’s personality and locality.

Delirium

The state of delirium develops with severe traumatic brain injuries, accompanied by intracerebral hemorrhages and swelling of the brain. A person with delirium experiences multiple, scene-like visual hallucinations. At the same time, he feels fear, anxiety, which can quickly change to anger, complete complacency and euphoria. A severe variant is occupational delirium, when the patient begins to automatically perform actions that he performs in his work life.

Amentia

For it to occur, there must be a combination of two factors: severe traumatic brain injury and exhaustion due to massive blood loss, intoxication or infection. With this disorder, the patient completely loses coherence of thinking, attention, there is no consciousness and orientation. The motor sphere is characterized by confusion and lack of coordination. The prognosis is unfavorable, since traumatic amentia can be fatal.

Korsakov's syndrome

It can be observed either in the acute period or as part of long-term consequences. It is characterized by pseudoreminescence - a shift in the memory of events from the past to the present. This is a distinctive feature from Korsakoff syndrome in alcoholism, when vivid confabulations - false memories - come first.

Traumatic deafness

Basically, this type of injury occurs after a person is thrown back by a shock wave and further injured. In its mild form, deafness lasts 2-3 weeks. In a more severe version, it is combined with severe adynamia (lack of motor activity), dyssomnia (insomnia), and depressed mood. Hearing and speech are restored to normal gradually, over about a month.

Cerebrostenia

This is the most common disorder in which there is increased exhaustion, mental intolerance, physical activity and external stimuli (temperature, sound, auditory). The patient's ability to concentrate is impaired, emotional lability is present (mood instability, incontinence of affect - the patient's elation and euphoria quickly change to depression, tearfulness). It is difficult for a person to concentrate and remember new material, due to which the ability to work and social adaptation are lost.

Psychopathic-like syndrome

Occurs against the background of traumatic brain injury, moderate in severity. The patient’s environment, social support and family circumstances also play a role here. There are two main variants of psychopathic syndrome: explosive and hysterical. In the case of hysterical syndrome, a person always tries to be the center of attention (egocentrism), greatly exaggerate the severity of the disease, and hysterical reactions such as paralysis, paresis, and hysterical seizures occur. In the event that an explosive variant develops, the patient is prone to aggressive, rash actions, he is quick-tempered and cannot contain his affect, which creates problems for interpersonal communication, as well as work activity.

Organic brain damage due to traumatic brain injury is a serious pathology that requires long-term observation and treatment by neurologists and psychiatrists.

Among possible injuries to areas of the human body, traumatic brain injuries occupy a leading position and account for almost 50% of recorded cases. In Russia, almost 4 such injuries are registered per 1000 people every year. Quite often, TBI is combined with trauma to other organs, as well as parts: thoracic, abdominal, upper and lower extremities. Such combined injuries are much more dangerous and can lead to more serious complications. What are the dangers of a traumatic brain injury, the consequences of which depend on various circumstances?

The consequences of traumatic brain injury are largely influenced by the injuries received and their severity. The degree of TBI is as follows:

• light;
• average;
• heavy.

By type, open and closed injuries are distinguished. In the first case, the aponeurosis and skin are damaged, and bones or tissues located deeper are visible from the wound. When a penetrating wound occurs, the dura mater is damaged. In the case of a closed TBI, partial damage to the skin is possible (not necessary), but the aponeurosis remains intact.

Brain injuries are classified according to possible consequences:

• compression of the brain;
• head bruises;
• axonal damage;
• brain concussion;
• intracerebral and intracranial hemorrhage.

Squeezing

This pathological condition is the result of volumetric accumulations of air or cerebrospinal fluid, liquid or coagulated hemorrhage under the membranes. As a result, compression of the midline structures of the brain occurs, deformation of the cerebral ventricles, and trunk infringement. The problem can be recognized by obvious inhibition, but with preserved orientation and consciousness. Increasing compression entails loss of consciousness. This condition threatens not only the health, but also the life of the patient, so immediate help and treatment is required.

Concussion

One of the common complications of TBI is concussion, accompanied by the development of a triad of symptoms:

• nausea and vomiting;
• loss of consciousness;
• memory loss.

A severe concussion can cause prolonged loss of consciousness. Adequate treatment and the absence of complicating factors results in absolute recovery and the return of the ability to work. After the acute period, many patients may experience disturbances in attention, memory concentration, dizziness, irritability, increased light and sound sensitivity, etc. for some time.

Brain contusion

Focal macrostructural damage in the medulla is observed. Depending on the severity of the traumatic brain injury, brain contusion is classified into the following types:

1. Mild degree. Loss of consciousness can last from several minutes to 1 hour. The person, upon regaining consciousness, complains of severe headaches, as well as vomiting or nausea. Brief blackouts lasting up to several minutes are possible. Functions important for life are preserved or changes are unexpressed. Moderate tachycardia or hypertension may occur. Neurological symptoms are present for up to 2–3 weeks.
2. Average degree. The patient remains unconscious for up to several hours (possibly several minutes). Amnesia concerning the moment of injury and those events that preceded or already occurred after the injury. The patient complains of pain in the head and repeated vomiting. Upon examination, respiratory distress, heart rate and pressure are detected. The pupils are unevenly enlarged, weakness is felt in the limbs, and there are problems with speech. Menigial symptoms are often observed, probably mental disorder. There may be temporary disturbances in the functioning of vital organs. Smoothing of organic symptoms occurs within 2–5 weeks, then some signs may still appear for a long time.
3. Severe degree. In this case, blackout can last for several weeks. Severe malfunctions in the functioning of vital organs are detected. The neurological status is complemented by the clinical severity of brain injury. In severe cases of injury, weakness in the limbs develops to the point of paralysis. There is deterioration in muscle tone, epileptic seizures. Also, such damage is often accompanied by massive subarachnoid bleeding due to a fracture of the vault or base of the skull.

Axonal damage and hemorrhage

Such an injury entails axonal ruptures, combined with hemorrhagic small focal hemorrhages. In this case, quite often the “field of view” includes the corpus callosum, brain stem, paraventicular zones and white matter in the cerebral hemispheres. The clinical picture changes rapidly, for example, coma turns into a transistor and vegetative state.

Clinical picture: how are the consequences of TBI classified?

All consequences of TBI can be classified into early (acute) and long-term. Early ones are those that occur immediately after receiving damage, while late ones appear after some time, perhaps even years later. Absolute signs Head injuries include nausea, pain and dizziness, as well as loss of consciousness. It occurs immediately after injury and can last for a variable period of time. Early symptoms also include:

• facial redness;
• hematomas;
• seizure;
• visible bone and tissue damage;
• liquor leakage from the ears and nose, etc.

Depending on how much time has passed since the injury, the severity of the injuries, as well as their location, various types of long-term consequences of traumatic brain injury are distinguished.

Location of damage	Possible consequences
Temporal lobe	convulsive attacks throughout the body; speech and vision disorder.
Frontal lobe	tremor (shaking) of the upper and lower extremities; slurred speech; unsteady gait, weakness in the legs and possible falls on the back.
Parietal lobe	sharp deterioration of vision up to the formation of blindness; lack of manifestation of sensitive reactions on one half of the body.
Cranial nerve injuries	hearing impairment; pronounced asymmetry of the oval of the face; the appearance of strabismus.
Cerebellar region	nystagmus (involuntary eye movements from side to side); disturbances in coordination of movements; hypotonia of muscle mass; “shaky” gait and possible falls.

Glasgow scale - what to expect from TBI

Doctors usually classify the consequences of traumatic brain injury according to special system- This is the Glasgow scale. So, the result of the damage received is as follows:

1. The patient experiences absolute recovery and, as a result, recovery, after which he returns to his usual life and work.
2. Moderate disability. The patient has mental and neurological disorders that prevent him from returning to work, but his self-care skills are preserved.
3. The disability is severe. The patient is not capable of self-care.
4. Vegetative states. Inability to perform certain movements, sleep disturbances and other autonomic symptoms.
5. Death. Termination of activity of vital organs.

The outcome of the injury can be judged as early as a year after it was received. All this time, rehabilitation therapy must be present, including physical therapy, medication, physiotherapeutic procedures, a vitamin and mineral complex, work with neurologists and psychiatrists, etc.

What determines the severity of TBI and its types?

All, including long-term types of consequences of traumatic brain injury, are subject to many factors:

1. Nature of injury. The stronger and deeper it is, the greater the likelihood of complications and, as a result, long-term treatment.
2. Patient's age. The younger the body, the easier it is for it to cope with the injuries received.
3. Delivery speed medical care. The sooner the victim is shown to a doctor and the stage of treatment begins, the easier it will be for him to recover.

As already mentioned, there are mild, moderate and severe forms of damage. According to statistics, there are almost no complications with minor injuries in young people aged 20–25 years.

Consequences in mild form

A mild form of head trauma is the most favorable option of all existing ones. Treatment usually does not take much time, and patients recover quickly. All complications are reversible, and symptoms are either early (acute) or last a short time. The following signs can be noted here:

• dizziness and headaches;
• profuse sweating;
• nausea and vomiting;
• irritability and sleep disturbance;
• weakness and fatigue.

Typically therapy after which the patient returns to ordinary life, takes 2 – 4 weeks.

Consequences in moderate form

Moderate severity is a more serious reason for concern about the patient’s health. Most often, such conditions are recorded with partial brain damage, severe bruise or fracture of the base of the skull. The clinical picture can last for quite a long time and includes symptoms:

• speech impairment or partial loss of vision;
• problems with the cardiovascular system, or more precisely with heart rhythm;
• mental disorders;
• paralysis of the cervical muscles;
• seizures;
• amnesia.

Rehabilitation after a traumatic brain injury can take from 1 month to six months.

Consequences in severe form

Severe injuries are the most dangerous and are the most likely to cause death. Most often, this type of injury is recorded after open skull fractures, severe brain contusions or compression, hemorrhages, etc. The most common type of complication after severe TBI is coma.

According to statistics, every second person in severe cases will experience the following types of consequences:

1. Partial or complete disability. In case of partial disability, the ability to work is lost, but self-care skills are retained, mental and neurological disorders are present (incomplete paralysis, psychosis, movement disorders). With complete disability, the patient requires constant care.
2. Coma of varying degrees of manifestation and depth. Coma due to traumatic brain injury can last from several hours to several months or years. At this time, the patient is on artificial life support devices or his organs are working independently.
3. Death.

Also even the most effective treatment and a favorable outcome of the measures taken necessarily entail the appearance of the following signs:

• problems with vision, speech or hearing;
• abnormal heart rhythm or breathing;
• epilepsy;
• seizures;
• partial amnesia;
• personality and mental disorder.

They can be combined and appear immediately after a head injury or years later.

It is impossible to give an accurate assessment of the patient’s recovery, because each organism is individual, and there are multiple examples of this. If in one case, even with severe injuries, patients endured rehabilitation with resilience and returned to normal life, then in other situations, even a mild head injury did not have the best effect on the neurological status and health in general. In any case, rehabilitation and psychological support play an important role in cases of traumatic brain injury.