Traumatic brain injury (TBI) is defined as trauma resulting in an injury or damage to the brain caused by an external physical force such as from a blow to the head, striking the head on a hard surface, a fall, car accident, or a gunshot wound to the head. A TBI is not caused by something internal such as a stroke or tumor, and does not include Acquired Brain Injuries (ABIs) or damage to the brain due to prolonged lack of oxygen (anoxic brain injuries). A Traumatic brain injury includes any injury to the brain resulting from a direct blow to the head that is caused by trauma where the force is large enough to break through the skull and damage the soft brain, or to cause the brain to move within the skull including:

• Concussions
• Contusions
• Coup-contrecoup Injuries
• Second Impact Syndrome (Recurrent TBI); and
• Penetration Injuries.

Traumatic Brain injuries are classified as closed or open. A closed traumatic brain injury is the result of trauma in which the brain is injured as a result of a blow to the head, or a sudden, violent motion that causes the brain to knock against the skull. Closed traumatic brain injuries can be diffuse, meaning that they affect cells and tissues throughout the brain; or focal, meaning that the damage occurs in one area. Closed traumatic brain injuries can range from mild to severe. These traumatic brain injuries can cause issues in many places like the occipital lobe or the parietal lobe.

About 50 to 70 percent of all traumatic brain injuries are the result of motorized vehicle accidents. Other causes include:

• Slips and falls,
• Violence, and
• Sports-related accidents.

TBIs are included as part of the broader category of acquired brain injuries (ABIs).

Acquired brain injury (ABI) is an injury to the brain that is not hereditary, congenital, degenerative, or induced by birth trauma. Essentially, this type of brain injury is one that has occurred after birth. The injury results in a change to the brain's neuronal activity, which affects the physical integrity, metabolic activity, or functional ability of nerve cells in the brain.

ABI is a broader category that includes two types of acquired brain injury: traumatic (such as those caused by accidents) and non-traumatic injuries caused by certain medical conditions. A non-traumatic brain injury is an alteration in brain function or pathology caused by an internal force (such as strokes).

Traumatic Brain Injury

Concussion

Even a concussion can cause substantial difficulties or impairments that can last a lifetime. Whiplash can result in the same difficulties as head injury. Such impairments can be helped by rehabilitation, however many individuals are released from treatment without referrals to brain injury rehabilitation, or guidance of any sort.

• A concussion can be caused by direct blows to the head, gunshot wounds, violent shaking of the head, or force from a whiplash type injury.
• Both closed and open head injuries can produce a concussion. A concussion is the most common type of traumatic brain injury.
• A concussion is caused when the brain receives trauma from an impact or a sudden momentum or movement change. The blood vessels in the brain may stretch and cranial nerves may be damaged.
• A person may or may not experience a brief loss of consciousness.
• A person may remain conscious, but feel dazed.
• A concussion may or may not show up on a diagnostic imaging test, such as a CAT Scan.
• Skull fracture, brain bleeding, or swelling may or may not be present. Therefore, concussion is sometimes defined by exclusion and is considered a complex neurobehavioral syndrome.
• A concussion can cause diffuse axonal type injury resulting in temporary or permanent damage.
• A blood clot in the brain can occur occasionally and be fatal.
• It may take a few months to a few years for a concussion to heal.

Contusion

• A contusion can be the result of a direct impact to the head.
• A contusion is a bruise (bleeding) on the brain.
• Large contusions may need to be surgically removed.

Coup-Contrecoup

• Coup-Contrecoup Injury describes contusions that are both at the site of the impact and on the complete opposite side of the brain.
• This occurs when the force impacting the head is not only great enough to cause a contusion at the site of impact, but also is able to move the brain and cause it to slam into the opposite side of the skull, which causes the additional contusion.

Diffuse Axonal

• A Diffuse Axonal Injury can be caused by shaking or strong rotation of the head, as with Shaken Baby Syndrome, or by rotational forces, such as with a car accident.
• Injury occurs because the unmoving brain lags behind the movement of the skull, causing brain structures to tear.
• There is extensive tearing of nerve tissue throughout the brain. This can cause brain chemicals to be released, causing additional injury.
• The tearing of the nerve tissue disrupts the brain’s regular communication and chemical processes.
• This disturbance in the brain can produce temporary or permanent widespread brain damage, coma, or death.
• A person with a diffuse axonal injury could present a variety of functional impairments depending on where the shearing (tears) occurred in the brain.

Penetration

Penetrating injury to the brain occurs from the impact of a bullet, knife or other sharp object that forces hair, skin, bones and fragments from the object into the brain.

• Objects traveling at a low rate of speed through the skull and brain can ricochet within the skull, which widens the area of damage.
• A “through-and-through” injury occurs if an object enters the skull, goes through the brain, and exits the skull. Through-and-through traumatic brain injuries include the effects of penetration injuries, plus additional shearing, stretching and rupture of brain tissue. (Brumback R. (1996). Oklahoma Notes: Neurology and Clinical Neuroscience. (2nd Ed.). New York: Springer.)
• The devastating traumatic brain injuries caused by bullet wounds result in a 91% firearm-related death rate overall. (Center for Disease Control. [Online August 22, 2002: http://www.cdc.gov/ncipc/didop/tbi.htm#rate,]).
• Firearms are the single largest cause of death from traumatic brain injury.
• (Center for Disease Control. [Online August 22, 2002: http://www.cdc.gov/ncipc/didop/tbi.htm#rate,]).

Acquired Brain Injury, (ABI), results from damage to the brain caused by strokes, tumors, anoxia, hypoxia, toxins, degenerative diseases, near drowning and/or other conditions not necessarily caused by an external force.

Anoxia

Anoxic Brain Injury occurs when the brain does not receive any oxygen. Cells in the brain need oxygen to survive and function.

Types of Anoxic Brain Injury:

• Anoxic Anoxia- Brain injury from no oxygen supplied to the brain
• Anemic Anoxia- Brain injury from blood that does not carry enough oxygen
• Toxic Anoxia- Brain injury from toxins or metabolites that block oxygen in the blood from being used Zasler, N. Brain Injury Source, Volume 3, Issue 3, Ask the Doctor

Hypoxic

A Hypoxic Brain Injury results when the brain receives some, but not enough oxygen.

Types of Hypoxic Brain Injury:

• Hypoxic Ischemic Brain Injury, also called Stagnant Hypoxia or Ischemic Insult- Brain injury occurs because of a lack of blood flow to the brain because of a critical reduction in blood flow or blood pressure.

Resources:

Mild Traumatic Brain Injury (Glasgow Coma Scale score 13-15)

Mild traumatic brain injury occurs when:

• Loss of consciousness is very brief, usually a few seconds or minutes
• Loss of consciousness does not have to occur—the person may be dazed or confused
• Testing or scans of the brain may appear normal
• A mild traumatic brain injury is diagnosed only when there is a change in the mental status at the time of injury—the person is dazed, confused, or loses consciousness. The change in mental status indicates that the person’s brain functioning has been altered, this is called a concussion

Moderate Traumatic Brain Injury (Glasgow Coma Scale core 9-12)

Most brain injuries result from moderate and minor head injuries. Such injuries usually result from a non-penetrating blow to the head, and/or a violent shaking of the head. As luck would have it many individuals sustain such head injuries without any apparent consequences. However, for many others, such injuries result in lifelong disabling impairments.

A moderate traumatic brain injury occurs when:

• A loss of consciousness lasts from a few minutes to a few hours
• Confusion lasts from days to weeks
• Physical, cognitive, and/or behavioral impairments last for months or are permanent.
• Persons with moderate traumatic brain injury generally can make a good recovery with treatment or successfully learn to compensate for their deficits.

Severe Brain Injury

Severe head injuries usually result from crushing blows or penetrating wounds to the head. Such injuries crush, rip and shear delicate brain tissue. This is the most life threatening, and the most intractable type of brain injury.

Typically, heroic measures are required in treatment of such injuries. Frequently, severe head trauma results in an open head injury, one in which the skull has been crushed or seriously fractured. Treatment of open head injuries usually requires prolonged hospitalization and extensive rehabilitation. Typically, rehabilitation is incomplete and for most part there is no return to pre-injury status. Closed head injuries can also result in severe brain injury.

TBI can cause a wide range of functional short- or long-term changes affecting thinking, sensation, language, or emotions.

TBI can also cause epilepsy and increase the risk for conditions such as Alzheimer’s disease, Parkinson’s disease, and other brain disorders that become more prevalent with age.1

Repeated mild TBIs occurring over an extended period of time (i.e., months, years) can result in cumulative neurological and cognitive deficits. Repeated mild TBIs occurring within a short period of time (i.e., hours, days, or weeks) can be catastrophic or fatal.

There is a kind of brain damage that results from genetics or birth trauma. It's called congenital brain damage. It is not included, though, within the standard definition of brain damage or traumatic brain injury.

Resources:

• Vehicle-related collisions
• Blows to the head
• Sports injuries -- Collisions, blows and falls during sports
• Falls, especially in and around the home
• Bicycle Accidents
• Motorcycle Accidents
• Nursing Home Abuse
• Construction Accidents
• Work Accidents
• Physical violence
• Gunshots
• Military combat, including explosive blasts and shrapnel injuries
• Other penetrating wounds to the head

• Poisoning or exposure to toxic substances
• Infection
• Strangulation, choking, or drowning
• Stroke
• Heart attacks
• Tumors
• Aneurysms
• Neurological illnesses
• Abuse of illegal drugs

• In the U.S., every year, about 2.6 million people have some type of brain injury -- whether as a result of trauma, stroke, tumor, or other illnesses, according to the Brain Injury Association of America.
• A quarter of a million people are hospitalized for traumatic brain injuries every year.
• Half of a million ER visits for traumatic brain injuries are for children under 14.
• People over the age of 75 have the highest rate of traumatic brain injuries.
• Approximately 52,000 people die every year as a result of traumatic brain injury.
• More than 5 million Americans who've suffered traumatic brain injury require assistance in performing daily activities.
• Approximately 3 in 4 traumatic brain injuries are also classified as concussions.
• Those most likely to receive a traumatic brain injury fall in the following age ranges: 0-4; 15-19; 65 and up.

Before you can start rehab, you must get care and treatment for the early effects of TBI. This might include:

• Emergency treatment for head and any other injuries
• Intensive care treatment
• Surgery to repair brain or skull injuries
• Recovery in the hospital
• Transfer to a rehabilitation hospital

If you have had a TBI, rehabilitation (or rehab) is an important part of your recovery. Rehab takes many forms depending on your individual needs, and may include physical, occupational, and speech therapy, as well as psychiatric care and social support. All of these are designed to help you recover from the effects of your injury as much as possible.

Rehab can take place in various settings. You, your case coordinator, and your family should pick the setting that works best for you. How long your rehab lasts and how much follow-up care you will need afterwards depends on how severe your brain damage was and how well you respond to therapy. Some people may be able to return to the same level of ability they had before TBI. Others need lifetime care.

The Rancho Los Amigos Levels of Cognitive Functioning Scale is a renowned clinical tool used to rate how people with brain injury are recovering. The ten levels of recovery noted in the scale also help to decide when a patient is ready for rehabilitation. As patients "wake up" after a head injury, they go through different levels of recovery on the Rancho Scale. Each level describes a general pattern of recovery, with a focus on cognition and behavior. Check out the Levels of Cognitive Functioning on the CNS Centre for Neuro Skills education and resources webpage.

Nearly 23% of traumatic brain injury patients require additional treatment following discharge from the hospital. Your individual program may include any or all of these treatments:

• Physical therapy
• Physical medicine
• Occupational therapy
• Psychiatric care
• Psychological care
• Speech and language therapy
• Social support

You have many options for rehabilitation therapy, and the type of therapy that you need is determined by your care team. For a list of the rehabilitation facilities in Delaware and surrounding areas visit the Brain Injury Rehabilitation page of this site.

Brain injuries can be a major challenge for survivors, family members and caregivers.

• Visit the Traumatic Brain Injury Information page for helpful Abstracts, Fast Facts, InfoSheets, Problem Sheets and Reports
• Visit the Brain Injury Resources page for a list of helpful contacts and phone numbers for TBI Survivors in Delaware.
• Visit the Financial Assistance for Persons with Brain Injury page for information on financial support.
• To obtain additional information or assistance for brain injury survivors contact the Delaware Aging and Disability Resource Center (ADRC).