Stroke

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  • What is a Stroke?A stroke occurs if the flow of oxygen-rich blood to a portion of the brain is blocked. Without oxygen, brain cells start to die after a few minutes. Sudden bleeding in the brain also can cause a stroke if it damages brain cells.If brain cells die or are damaged because of a stroke, symptoms occur in the parts of the body that these brain cells control. Examples of stroke symptoms include sudden weakness; paralysis or numbness of the face, arms, or legs (paralysis is an inability to move); trouble speaking or understanding speech; and trouble seeing.

     

     

     

     

     

     

     

     

     

    A stroke is a serious medical condition that requires emergency care. A stroke can cause lasting brain damage, long-term disability, or even death.

    If you think you or someone else is having a stroke, call 9–1–1 right away. Do not drive to the hospital or let someone else drive you. Call an ambulance so that medical personnel can begin life-saving treatment on the way to the emergency room. During a stroke, every minute counts.

    Overview

    The two main types of stroke are ischemic (is-KE-mik) and hemorrhagic (hem-ah-RAJ-ik). Ischemic is the more common type of stroke.

    An ischemic stroke occurs if an artery that supplies oxygen-rich blood to the brain becomes blocked. Blood clots often cause the blockages that lead to ischemic strokes.

    A hemorrhagic stroke occurs if an artery in the brain leaks blood or ruptures (breaks open). The pressure from the leaked blood damages brain cells. High blood pressure and aneurysms (AN-u-risms) are examples of conditions that can cause hemorrhagic strokes. (Aneurysms are balloon-like bulges in an artery that can stretch and burst.)

    Another condition that’s similar to a stroke is a transient ischemic attack, also called a TIA or “mini-stroke.” A TIA occurs if blood flow to a portion of the brain is blocked only for a short time. Thus, damage to the brain cells isn’t permanent (lasting).

    Like ischemic strokes, TIAs often are caused by blood clots. Although TIAs are not full-blown strokes, they greatly increase the risk of having a stroke. If you have a TIA, it’s important for your doctor to find the cause so you can take steps to prevent a stroke.

    Both strokes and TIAs require emergency care.

    Outlook

    Stroke is a leading cause of death in the United States. Many factors can raise your risk of having a stroke. Talk with your doctor about how you can control these risk factors and help prevent a stroke.

    If you have a stroke, prompt treatment can reduce damage to your brain and help you avoid lasting disabilities. Prompt treatment also may help prevent another stroke.

    Researchers continue to study the causes and risk factors for stroke. They’re also finding new and better treatments and new ways to help the brain repair itself after a stroke.

    Source: National Institutes of Health

    Types of Stroke

    Ischemic Stroke

    An ischemic stroke occurs if an artery that supplies oxygen-rich blood to the brain becomes blocked. Blood clots often cause the blockages that lead to ischemic strokes.

    The two types of ischemic stroke are thrombotic (throm-BOT-ik) and embolic (em-BOL-ik). In a thrombotic stroke, a blood clot (thrombus) forms in an artery that supplies blood to the brain.

    In an embolic stroke, a blood clot or other substance (such as plaque, a fatty material) travels through the bloodstream to an artery in the brain. (A blood clot or piece of plaque that travels through the bloodstream is called an embolus.)

    With both types of ischemic stroke, the blood clot or plaque blocks the flow of oxygen-rich blood to a portion of the brain.

    Hemorrhagic Stroke

    A hemorrhagic stroke occurs if an artery in the brain leaks blood or ruptures (breaks open). The pressure from the leaked blood damages brain cells.

    The two types of hemorrhagic stroke are intracerebral (in-trah-SER-e-bral) and subarachnoid (sub-ah-RAK-noyd). In an intracerebral hemorrhage, a blood vessel inside the brain leaks blood or ruptures.

    In a subarachnoid hemorrhage, a blood vessel on the surface of the brain leaks blood or ruptures. When this happens, bleeding occurs between the inner and middle layers of the membranes that cover the brain.

    In both types of hemorrhagic stroke, the leaked blood causes swelling of the brain and increased pressure in the skull. The swelling and pressure damage cells and tissues in the brain.

    Other Names for a Stroke

    • Brain attack
    • Cerebrovascular accident (CVA)
    • Hemorrhagic stroke (includes intracerebral hemorrhage and subarachnoid hemorrhage)
    • Ischemic stroke (includes thrombotic stroke and embolic stroke)

    A transient ischemic attack sometimes is called a TIA or mini-stroke. A TIA has the same symptoms as a stroke, and it increases your risk of having a stroke.

    What Causes a Stroke?

    Ischemic Stroke and Transient Ischemic Attack

    An ischemic stroke or transient ischemic attack (TIA) occurs if an artery that supplies oxygen-rich blood to the brain becomes blocked. Many medical conditions can increase the risk of ischemic stroke or TIA.

    For example, atherosclerosis (ath-er-o-skler-O-sis) is a disease in which a fatty substance called plaque builds up on the inner walls of the arteries. Plaque hardens and narrows the arteries, which limits the flow of blood to tissues and organs (such as the heart and brain).

    Plaque in an artery can crack or rupture (break open). Blood platelets (PLATE-lets), which are disc-shaped cell fragments, stick to the site of the plaque injury and clump together to form blood clots. These clots can partly or fully block an artery.

    Plaque can build up in any artery in the body, including arteries in the heart, brain, and neck. The two main arteries on each side of the neck are called the carotid (ka-ROT-id) arteries. These arteries supply oxygen-rich blood to the brain, face, scalp, and neck.

    When plaque builds up in the carotid arteries, the condition is called carotid artery disease. Carotid artery disease causes many of the ischemic strokes and TIAs that occur in the United States.

    An embolic stroke (a type of ischemic stroke) or TIA also can occur if a blood clot or piece of plaque breaks away from the wall of an artery. The clot or plaque can travel through the bloodstream and get stuck in one of the brain’s arteries. This stops blood flow through the artery and damages brain cells.

    Heart conditions and blood disorders also can cause blood clots that can lead to a stroke or TIA. For example, atrial fibrillation (A-tre-al fi-bri-LA-shun), or AF, is a common cause of embolic stroke.

    In AF, the upper chambers of the heart contract in a very fast and irregular way. As a result, some blood pools in the heart. The pooling increases the risk of blood clots forming in the heart chambers.

    An ischemic stroke or TIA also can occur because of lesions caused by atherosclerosis. These lesions may form in the small arteries of the brain, and they can block blood flow to the brain.

    Hemorrhagic Stroke

    Sudden bleeding in the brain can cause a hemorrhagic stroke. The bleeding causes swelling of the brain and increased pressure in the skull. The swelling and pressure damage brain cells and tissues.

    Examples of conditions that can cause a hemorrhagic stroke include high blood pressure, aneurysms, and arteriovenous (ar-TEER-e-o-VE-nus) malformations (AVMs).

    “Blood pressure” is the force of blood pushing against the walls of the arteries as the heart pumps blood. If blood pressure rises and stays high over time, it can damage the body in many ways.

    Aneurysms are balloon-like bulges in an artery that can stretch and burst. AVMs are tangles of faulty arteries and veins that can rupture within the brain. High blood pressure can increase the risk of hemorrhagic stroke in people who have aneurysms or AVMs.

    Who Is at Risk for a Stroke?

    Certain traits, conditions, and habits can raise your risk of having a stroke or transient ischemic attack (TIA). These traits, conditions, and habits are known as risk factors.

    The more risk factors you have, the more likely you are to have a stroke. You can treat or control some risk factors, such as high blood pressure and smoking. Other risk factors, such as age and gender, you can’t control.

    The major risk factors for stroke include:

    • High blood pressure. High blood pressure is the main risk factor for stroke. Blood pressure is considered high if it stays at or above 140/90 mmHg over time. If you have diabetes or chronic kidney diseaseexternal link icon, high blood pressure is defined as 130/80 mmHg or higher. (The mmHg is millimeters of mercury—the units used to measure blood pressure.)
    • Smoking. Smoking can damage blood vessels and raise blood pressure. Smoking also may reduce the amount of oxygen that reaches your body’s tissues. Exposure to secondhand smoke also can damage the blood vessels.
    • Diabetes. Diabetes is a disease in which the blood sugar level is high because the body doesn’t make enough insulin or doesn’t use its insulin properly. Insulin is a hormone that helps move blood sugar into cells where it’s used for energy.
    • Heart diseases. Coronary heart disease (also called coronary artery disease), cardiomyopathy (KAR-de-o-mi-OP-a-the), heart failure, and atrial fibrillation can cause blood clots that can lead to a stroke.
    • Brain aneurysms or arteriovenous malformations (AVMs). Aneurysms are balloon-like bulges in an artery that can stretch and burst. AVMs are tangles of faulty arteries and veins that can rupture (break open) within the brain. AVMs may be present at birth, but often aren’t diagnosed until they rupture.
    • Age and gender. Your risk of stroke increases as you get older. At younger ages, men are more likely than women to have strokes. However, women are more likely to die from strokes. Women who take birth control pills also are at slightly higher risk of stroke.
    • Race and ethnicity. Strokes occur more often in African American, Alaska Native, and American Indian adults than in Caucasian, Hispanic, or Asian American adults.
    • Personal or family history of stroke or TIA. If you’ve had a stroke, you’re at higher risk for another one. Your risk of having a repeat stroke is the highest right after a stroke. A TIA also increases your risk of having a stroke, as does having a family history of stroke.
    • Other risk factors for stroke, many of which of you can control, include:
      • Alcohol and illegal drug use, including cocaine, amphetamines, and other drugs
      • Unhealthy cholesterol levels
      • Lack of physical activity
      • Unhealthy diet
      • Obesity
      • Stress and depression
      • Certain medical conditions, such as sickle cell anemia, vasculitis (vas-kyu-LI-tis; inflammation of the blood vessels), and bleeding disorders

      Following a healthy lifestyle can lower the risk of stroke. Some people also may need to take medicines to lower their risk.

      Sometimes strokes can occur in people who don’t have any known risk factors.

      What are the Signs and Symptoms of a Stroke?

      The signs and symptoms of a stroke often develop quickly. However, they can develop over hours or even days.

      The type of symptoms depends on the type of stroke and the area of the brain that’s affected. How long symptoms last and how severe they are vary among different people.

      Signs and symptoms of a stroke may include:

      • Sudden weakness
      • Paralysis (an inability to move) or numbness of the face, arms, or legs, especially on one side of the body
      • Confusion
      • Trouble speaking or understanding speech
      • Trouble seeing in one or both eyes
      • Problems breathing
      • Dizziness, trouble walking, loss of balance or coordination, and unexplained falls
      • Loss of consciousness
      • Sudden and severe headache

      signs of a stroke

      A transient ischemic attack (TIA) has the same signs and symptoms as a stroke. However, TIA symptoms usually last less than 1–2 hours (although they may last up to 24 hours). A TIA may occur only once in a person’s lifetime or more often.

      At first, it may not be possible to tell whether someone is having a TIA or stroke. All stroke-like symptoms require medical care.

      If you think you or someone else is having a TIA or stroke, call 9–1–1 right away. Do not drive to the hospital or let someone else drive you. Call an ambulance so that medical personnel can begin life-saving treatment on the way to the emergency room. During a stroke, every minute counts.

      Stroke Complications

      After you’ve had a stroke, you may develop other complications, such as:

      • Blood clots and muscle weakness. Being immobile (unable to move around) for a long time can raise your risk of developing blood clots in the deep veins of the legs. Being immobile also can lead to muscle weakness and decreased muscle flexibility.
      • Problems swallowing and pneumonia. If a stroke affects the muscles used for swallowing, you may have a hard time eating or drinking. You also may be at risk of inhaling food or drink into your lungs. If this happens, you may develop pneumonia.
      • Loss of bladder control. Some strokes affect the muscles used to urinate. You may need a urinary catheter (a tube placed into the bladder) until you can urinate on your own. Use of these catheters can lead to urinary tract infections. Loss of bowel control or constipation also may occur after a stroke.

      How is a Stroke Diagnosed?

      Your doctor will diagnose a stroke based on your signs and symptoms, your medical history, a physical exam, and test results.

      Your doctor will want to find out the type of stroke you’ve had, its cause, the part of the brain that’s affected, and whether you have bleeding in the brain.

      If your doctor thinks you’ve had a transient ischemic attack (TIA), he or she will look for its cause to help prevent a future stroke.

      Medical History and Physical Exam

      Your doctor will ask you or a family member about your risk factors for stroke. Examples of risk factors include high blood pressure, smoking, heart disease, and a personal or family history of stroke. Your doctor also will ask about your signs and symptoms and when they began.

      During the physical exam, your doctor will check your mental alertness and your coordination and balance. He or she will check for numbness or weakness in your face, arms, and legs; confusion; and trouble speaking and seeing clearly.

      Your doctor will look for signs of carotid artery disease, a common cause of ischemic stroke. He or she will listen to your carotid arteries with a stethoscope. A whooshing sound called a bruit (broo-E) may suggest changed or reduced blood flow due to plaque buildup in the carotid arteries.

      Diagnostic Tests and Procedures

      Your doctor may recommend one or more of the following tests to diagnose a stroke or TIA.

      Brain Computed Tomography

      A brain computed tomography (to-MOG-rah-fee) scan, or brain CT scan, is a painless test that uses x rays to take clear, detailed pictures of your brain. This test often is done right after a stroke is suspected.

      A brain CT scan can show bleeding in the brain or damage to the brain cells from a stroke. The test also can show other brain conditions that may be causing your symptoms.

      Magnetic Resonance Imaging

      Magnetic resonance imaging (MRI) uses magnets and radio waves to create pictures of the organs and structures in your body. This test can detect changes in brain tissue and damage to brain cells from a stroke.

      An MRI may be used instead of, or in addition to, a CT scan to diagnose a stroke.

      Computed Tomography Arteriogram and Magnetic Resonance Arteriogram

      A CT arteriogram (CTA) and magnetic resonance arteriogram (MRA) can show the large blood vessels in the brain. These tests may give your doctor more information about the site of a blood clot and the flow of blood through your brain.

      Carotid Ultrasound

      Carotid ultrasound is a painless and harmless test that uses sound waves to create pictures of the insides of your carotid arteries. These arteries supply oxygen-rich blood to your brain.

      Carotid ultrasound shows whether plaque has narrowed or blocked your carotid arteries.

      Your carotid ultrasound test may include a Doppler ultrasound. Doppler ultrasound is a special test that shows the speed and direction of blood moving through your blood vessels.

      Carotid Angiography

      Carotid angiography (an-jee-OG-ra-fee) is a test that uses dye and special x rays to show the insides of your carotid arteries.

      For this test, a small tube called a catheter is put into an artery, usually in the groin (upper thigh). The tube is then moved up into one of your carotid arteries.

      Your doctor will inject a substance (called contrast dye) into the carotid artery. The dye helps make the artery visible on x-ray pictures.

      Heart Tests

      EKG (Electrocardiogram)

      An EKG is a simple, painless test that records the heart’s electrical activity. The test shows how fast the heart is beating and its rhythm (steady or irregular). An EKG also records the strength and timing of electrical signals as they pass through each part of the heart.

      An EKG can help detect heart problems that may have led to a stroke. For example, the test can help diagnose atrial fibrillation or a previous heart attack.

      Echocardiography

      Echocardiography (EK-o-kar-de-OG-ra-fee), or echo, is a painless test that uses sound waves to create pictures of your heart.

      The test gives information about the size and shape of your heart and how well your heart’s chambers and valves are working.

      Echo can detect possible blood clots inside the heart and problems with the aorta. The aorta is the main artery that carries oxygen-rich blood from your heart to all parts of your body.

      Blood Tests

      Your doctor also may use blood tests to help diagnose a stroke.

      A blood glucose test measures the amount of glucose (sugar) in your blood. Low blood glucose levels may cause symptoms similar to those of a stroke.

      A platelet count measures the number of platelets in your blood. Blood platelets are cell fragments that help your blood clot. Abnormal platelet levels may be a sign of a bleeding disorder (not enough clotting) or a thrombotic disorder (too much clotting).

      Your doctor also may recommend blood tests to measure how long it takes for your blood to clot. Two tests that may be used are called PT and PTT tests. These tests show whether your blood is clotting normally.

    How is a Stroke Treated?

    Treatment for a stroke depends on whether it is ischemic or hemorrhagic. Treatment for a transient ischemic attack (TIA) depends on its cause, how much time has passed since symptoms began, and whether you have other medical conditions.

    Strokes and TIAs are medical emergencies. If you have stroke symptoms, call 9–1–1 right away. Do not drive to the hospital or let someone else drive you. Call an ambulance so that medical personnel can begin life-saving treatment on the way to the emergency room. During a stroke, every minute counts.

    Once you receive initial treatment, your doctor will try to treat your stroke risk factors and prevent complications.

    Treating Ischemic Stroke and Transient Ischemic Attack

    An ischemic stroke or TIA occurs if an artery that supplies oxygen-rich blood to the brain becomes blocked. Often, blood clots cause the blockages that lead to ischemic strokes and TIAs.

    Treatment for an ischemic stroke or TIA may include medicines and medical procedures.
    Medicines

    A medicine called tissue plasminogen activator (tPA) can break up blood clots in the arteries of the brain. A doctor will inject tPA into a vein in your arm. This medicine must be given within 4 hours of the start of symptoms to work. Ideally, it should be given as soon as possible.

    If, for medical reasons, your doctor can’t give you tPA, you may get an antiplatelet medicine. For example, aspirin may be given within 48 hours of a stroke. Antiplatelet medicines help stop platelets from clumping together to form blood clots.

    Your doctor also may prescribe anticoagulants, or “blood thinners.” These medicines can keep blood clots from getting larger and prevent new blood clots from forming.

    Medical Procedures

    If you have carotid artery disease, your doctor may recommend a carotid endarterectomy (END-ar-ter-EK-to-me) or carotid artery percutaneous (per-ku-TA-ne-us) coronary intervention, sometimes referred to as angioplasty (AN-jee-oh-plas-tee). Both procedures open blocked carotid arteries.

    Researchers are testing other treatments for ischemic stroke, such as intra-arterial thrombolysis (throm-BOL-ih-sis) and mechanical clot (embolus) removal in cerebral ischemia (MERCI).

    In intra-arterial thrombolysis, a long flexible tube called a catheter is put into your groin (upper thigh) and threaded to the tiny arteries of the brain. Your doctor can deliver medicine through this catheter to break up a blood clot in the brain.

    MERCI is a device that can remove blood clots from an artery. During the procedure, a catheter is threaded through a carotid artery to the affected artery in the brain. The device is then used to pull the blood clot out through the catheter.

    Treating Hemorrhagic Stroke

    A hemorrhagic stroke occurs if an artery in the brain leaks blood or ruptures (breaks open). The first steps in treating a hemorrhagic stroke are to find the cause of bleeding in the brain and then control it.

    Unlike ischemic strokes, hemorrhagic strokes aren’t treated with antiplatelet medicines and blood thinners. This is because these medicines can make bleeding worse.

    If you’re taking antiplatelet medicines or blood thinners and have a hemorrhagic stroke, you’ll be taken off the medicine.

    If high blood pressure is the cause of bleeding in the brain, your doctor may prescribe medicines to lower your blood pressure. This can help prevent further bleeding.

    Surgery also may be needed to treat a hemorrhagic stroke. The types of surgery used include aneurysm clipping, coil embolization (EM-bol-ih-ZA-shun), and arteriovenous malformation (AVM) repair.

    Aneurysm Clipping and Coil Embolization

    If an aneurysm (a balloon-like bulge in an artery) is the cause of a stroke, your doctor may recommend aneurysm clipping or coil embolization.

    Aneurysm clipping is done to block off the aneurysm from the blood vessels in the brain. This surgery helps prevent further leaking of blood from the aneurysm. It also can help prevent the aneurysm from bursting again.

    During the procedure, a surgeon will make an incision (cut) in the brain and place a tiny clamp at the base of the aneurysm. You’ll be given medicine to make you sleep during the surgery. After the surgery, you’ll need to stay in the hospital’s intensive care unit for a few days.

    Coil embolization is a less complex procedure for treating an aneurysm. The surgeon will insert a tube called a catheter into an artery in the groin. He or she will thread the tube to the site of the aneurysm.

    Then, a tiny coil will be pushed through the tube and into the aneurysm. The coil will cause a blood clot to form, which will block blood flow through the aneurysm and prevent it from bursting again.

    Coil embolization is done in a hospital. You’ll be given medicine to make you sleep during the surgery.

    Arteriovenous Malformation Repair

    If an AVM is the cause of a stroke, your doctor may recommend an AVM repair. (An AVM is a tangle of faulty arteries and veins that can rupture within the brain.) AVM repair helps prevent further bleeding in the brain.

    Doctors use several methods to repair AVMs. These methods include:

    Surgery to remove the AVM

    Injecting a substance into the blood vessels of the AVM to block blood flow
    Using radiation to shrink the blood vessels of the AVM

    Treating Stroke Risk Factors

    After initial treatment for a stroke or TIA, your doctor will treat your risk factors. He or she may recommend lifestyle changes to help control your risk factors.

    Lifestyle changes may include quitting smoking, following a healthy diet, maintaining a healthy weight, and being physically active.

    If lifestyle changes aren’t enough, you may need medicine to control your risk factors.
    Quitting Smoking

    If you smoke or use tobacco, quit. Smoking can damage your blood vessels and raise your risk of stroke and other health problems. Talk with your doctor about programs and products that can help you quit. Also, try to avoid secondhand smoke. Secondhand smoke also can damage the blood vessels.

    For more information about how to quit smoking, go to the Health Topics Smoking and Your Heart article and the National Heart, Lung, and Blood Institute’s (NHLBI’s) “Your Guide to a Healthy Heart.” Although these resources focus on heart health, they include general information about how to quit smoking.

    The U.S. Department of Health and Human Services (HHS) also has information about how to quit smoking.

    Following a Healthy Diet

    A healthy diet is an important part of a healthy lifestyle. Choose a variety of fruits, vegetables, and grains; half of your grains should come from whole-grain products.

    Choose foods that are low in saturated fat, trans fat, and cholesterol. Healthy choices include lean meats, poultry without skin, fish, beans, and fat-free or low-fat milk and milk products.

    Choose and prepare foods with little sodium (salt). Too much salt can raise your risk of high blood pressure. Studies show that following the Dietary Approaches to Stop Hypertension (DASH) eating plan can lower blood pressure.

    Choose foods and beverages that are low in added sugar. If you drink alcoholic beverages, do so in moderation.

    For more information about following a healthy diet, go to the NHLBI’s Aim for a Healthy Weight Web site, “Your Guide to a Healthy Heart,” and “Your Guide to Lowering Your Blood Pressure With DASH.” All of these resources provide general information about healthy eating.

    Maintaining a Healthy Weight

    Maintaining a healthy weight can lower your risk of stroke. A general goal to aim for is a body mass index (BMI) of less than 25.

    BMI measures your weight in relation to your height and gives an estimate of your total body fat. You can measure your BMI using the NHLBI’s online calculatorexternal link icon, or your health care provider can measure your BMI.

    A BMI between 25 and 29.9 is considered overweight. A BMI of 30 or more is considered obese. A BMI of less than 25 is the goal for preventing a stroke.

    For more information about losing weight and maintaining your weight, go to the HEALTH TOPICS Overweight and Obesity article.
    Being Physically Active

    Regular physical activity can help control many stroke risk factors, such as high blood pressure, unhealthy cholesterol levels, and excess weight.

    Talk with your doctor before you start a new exercise plan. Ask him or her how much and what kinds of physical activity are safe for you.

    People gain health benefits from as little as 60 minutes of moderate-intensity aerobic activity per week. The more active you are, the more you will benefit.

    For more information about physical activity, go to the HHS’ “2008 Physical Activity Guidelines for Americans,”external link icon the HEALTH TOPICS Physical Activity and Your Heart article, and the NHLBI’s “Your Guide to Physical Activity and Your Heart.”

    Although the HEALTH TOPICS article and “Your Guide” booklet focus on heart health, they include information that applies to general health and well-being.

    How Can a Stroke be Prevented?

    Taking action to control your risk factors can help prevent or delay a stroke. If you’ve already had a stroke, these actions can help prevent another one.

    • Don’t smoke. If you smoke or use tobacco, quit. Smoking can damage and tighten blood vessels and raise your risk of stroke. Talk with your doctor about programs and products that can help you quit. Also, try to avoid secondhand smoke. Secondhand smoke also can damage the blood vessels.
    • Make healthy eating choices. A healthy diet includes a variety of fruits, vegetables, and whole grains. It also includes lean meats, poultry, fish, beans, and fat-free or low-fat milk or milk products. A healthy diet is low in saturated fat, trans fat, cholesterol, sodium (salt), and added sugars.
    • Maintain a healthy weight. If you’re overweight or obese, work with your doctor to create a reasonable weight-loss plan. Controlling your weight helps you control stroke risk factors.
    • Be as physically active as you can. Physical activity can improve your fitness level and your health. Talk with your doctor about what types and amounts of activity are safe for you.
    • Know your family history of stroke. If you or someone in your family has had a stroke, be sure to tell your doctor.

    For more information about healthy lifestyle changes, go to “How Is a Stroke Treated?” If lifestyle changes are not enough, you also may need medicines to control your stroke risk factors. Take all of your medicines as your doctor prescribes.

    If you’ve had a transient ischemic attack (TIA), don’t ignore it. It’s important for your doctor to find the cause of the TIA so you can take steps to prevent a stroke.

    Life After a Stroke

    The time it takes to recover from a stroke varies—it can take weeks, months, or even years. Some people recover fully, while others have long-term or lifelong disabilities.

    Ongoing care, rehabilitation, and emotional support can help you recover and may even help prevent another stroke.

    If you’ve had a stroke, you’re at risk of having another one. Know the warning signs of a stroke and transient ischemic attack (TIA) and what to do if they occur. Call 9–1–1 as soon as symptoms start.

    Do not drive to the hospital or let someone else drive you. Call an ambulance so that medical personnel can begin life-saving treatment on the way to the emergency room. During a stroke, every minute counts.

    Ongoing Care

    Lifestyle changes can help you recover from a stroke and may help prevent another one. Examples of these changes include quitting smoking, following a healthy diet, maintaining a healthy weight, and being physically active. Talk with your doctor about the types and amounts of physical activity that are safe for you.

    Your doctor also may prescribe medicines to help you recover from a stroke or control your stroke risk factors. Take all of your medicines as your doctor prescribes.

    If you had an ischemic stroke, you may need to take anticoagulants, also called blood thinners. These medicines prevent blood clots from getting larger and keep new clots from forming. You’ll likely need routine blood tests to check how well these medicines are working.

    The most common side effect of blood thinners is bleeding. This happens if the medicine thins your blood too much. This side effect can be life threatening. Bleeding can occur inside your body cavities (internal bleeding) or from the surface of your skin (external bleeding).

    Know the warning signs of bleeding so you can get help right away. They include:

    • Unexplained bruising and/or tiny red or purple dots on the skin
    • Unexplained bleeding from the gums and nose
    • Increased menstrual flow
    • Bright red vomit or vomit that looks like coffee grounds
    • Blood in your urine, bright red blood in your stools, or black tarry stools
    • Pain in your abdomen or severe pain in your head

    A lot of bleeding after a fall or injury or easy bruising or bleeding also may mean that your blood is too thin. Call your doctor right away if you have any of these signs. If you have severe bleeding, call 9–1–1.

    Talk with your doctor about how often you should schedule followup visits or tests. These visits and tests can help your doctor monitor your stroke risk factors and adjust your treatment as needed.

    Rehabilitation

    After a stroke, you may need rehabilitation (rehab) to help you recover. Rehab may include working with speech, physical, and occupational therapists.

    Language, Speech, and Memory

    You may have trouble communicating after a stroke. You may not be able to find the right words, put complete sentences together, or put words together in a way that makes sense. You also may have problems with your memory and thinking clearly. These problems can be very frustrating.

    Speech and language therapists can help you learn ways to communicate again and improve your memory.

    Muscle and Nerve Problems

    A stroke may affect only one side of the body or part of one side. It can cause paralysis (an inability to move) or muscle weakness, which can put you at risk for falling.

    Physical and occupational therapists can help you strengthen and stretch your muscles. They also can help you relearn how to do daily activities, such as dressing, eating, and bathing.

    Bladder and Bowel Problems

    A stroke can affect the muscles and nerves that control the bladder and bowels. You may feel like you have to urinate often, even if your bladder isn’t full. You may not be able to get to the bathroom in time. Medicines and a bladder or bowel specialist can help with these problems.

    Swallowing and Eating Problems

    You may have trouble swallowing after a stroke. Signs of this problem are coughing or choking during eating or coughing up food after eating.

    A speech therapist can help you with these issues. He or she may suggest changes to your diet, such as eating puréed (finely chopped) foods or drinking thick liquids.

    Emotional Issues and Support

    After a stroke, you may have changes in your behavior or judgment. For example, your mood may change quickly. Because of these and other changes, you may feel scared, anxious, and depressed. Recovering from a stroke can be slow and frustrating.

    Talk about how you feel with your health care team. Talking to a professional counselor also can help. If you’re very depressed, your doctor may recommend medicines or other treatments that can improve your quality of life.

    Joining a patient support group may help you adjust to life after a stroke. You can see how other people have coped with having strokes. Talk with your doctor about local support groups or check with an area medical center.

    Support from family and friends also can help relieve fear and anxiety. Let your loved ones know how you feel and what they can do to help you.

    Source: National Institutes of Health

    The Division for Heart Disease and Stroke Prevention has put together a set of educational materials. One set is geared to be given to patients and another set is geared for the professional.

    Patients

  • Professionals

 

Resources:

 

Sexual Dysfunction Following Brain Injury

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Although we live in a society where people freely discuss toilet paper, hemorrhoids, and all sorts of quite personal issues, without bashfulness or hesitation, the problem of sexual dysfunction following lightning strike, electric shock, or traumatic brain injury is so “hush hush” that not even the treating physicians inquire about possible sexual dysfunction in their usual history-taking from the patient. It is well known and well recognized, in all of the literature and research, that sexual dysfunction can be the result of chronic pain, medications, injury to the brain, psychological injury, depression, and a whole host of common problems that those surviving electric shock, lightning strike, or traumatic brain injury may have, yet it seems to be a well-kept secret and people are left to deal with problems related to sexual dysfunction on their own.

In a society where sexuality seems so important in our humor, television commercials, politics, and sometimes the very core of our culture, it is a shame that people are left to suffer on their own, without knowing why, and without knowing that there may be some kind of care, treatment, or therapy that could be of help. This article is an attempt to pull back the curtain of darkness in an effort to give comfort to those in that it is not “their fault,” and maybe to educate so that people can get real and available help.

Let me be clear that it was not my idea to write an article about sexual dysfunction following injury. I must confess that when I was first asked to write an article about sexual dysfunction following injury, my first thought was “whoa, sex is a very sensitive subject,” and then I thought, “whoa, whoa, talking about sex is a very, very sensitive subject,” and then I thought “whoa, whoa, whoa, writing about sexual dysfunction is going to be a really sensitive subject and there is no way that I am going to do that.”

As I thought about responding to the request to write this article about sexual dysfunction following injury, I realized that in my over 25 years of representing persons and families surviving various types of injury, including traumatic brain injury, lightning strike, or electric shock injury, that one of the very real consequences of those injuries, directly or indirectly, has been sexual dysfunction. But I still thought, no way am I going to write about this, and there is no way that I want to be introduced at seminars, or be known, as an expert in sexual dysfunction.

Suffice it to say that those who know me best would not consider me as the poster child for openness in discussion of sexual issues. Then, I thought it was perhaps the type of attitude that I had in terms of reluctance to discuss sexual issues or sexual dysfunction issues, that formed part of the weave of the cloak of darkness and silence that surrounds the very real issue and problem of sexual dysfunction following injury.

It just so happened that right about this time, I came across a booklet put out by Pfizer, Inc., U.S. Pharmaceuticals entitled “Putting Sexual Health Into Practice”, that was published in August, 1999 for physicians. As I read through the booklet, I began to think that maybe an article of this type could be help to some people.

At page one of the booklet, under the heading of “Breaking the Silence Around Sexual Health”, it says:

Having a healthy sex life is one factor that may contribute directly to the quality and longevity of an individual’s life, according to the Duke First Longitudinal Study of Aging. In a World Health Organization (WHO) Report, sexual health is defined as the integration of the somatic, emotional, intellectual, and social aspects of sexual being, in ways that are positively enriching and that enhance personality, communication, and love. The international group of experts convened by WHO take the position that the notion of sexual health implies a positive approach to human sexuality, and the purpose of sexual healthcare should be the enhancement of life and personal relationships and not merely counseling and care related to procreation or sexually transmitted diseases. But sexual health, primarily in men, is frequently overlooked as an integral part of overall health. ? For various reasons, millions of men are not discussing the sexual health problems with their physicians. By keeping these issues to themselves, they suffer silently.

In a survey of 500 adults, 94 percent of those polled said that sexual satisfaction added to the quality of life at any age. Marianne J. Legato, M.D., commented, “As human beings our sexuality is inextricably linked to our overall health, happiness, and sense of wellness.” Furthermore, the American Medical Association lists “participating in desired sexual activity” as one of many important activities of daily living.”

At page three of this booklet and remembering that it is a booklet written for doctors, it says:

One of the most rewarding aspects of treating sexual health is that you can impact two lives. Often, a sexual problem can make partners feel that they are no longer attractive or that the problem is a reflection on them.

The fact is that the world health organization and the American Medical Association consider sexual function to be in the category of an important daily activity. There are many studies that relate a number of health benefits to a healthy sexual life. There may be millions of people in the United States and around the world who are suffering from some aspect of sexual dysfunction as a result of injury and maybe at least one of those people could benefit from receiving at least the knowledge that they are not alone.

For those persons who may be shy, reserved, or reluctant to bring up sexual issues with their doctor, at the end of this article is a form that can be filled out in advance of the doctor’s appointment, and simply handed to the doctor to sort of help break the ice about any discussions with regard to sexual issues.

This has been the most difficult article that I have ever written, and I have tried to be as careful as I could so as not to offend anyone. While some aspects of this article may focus on male issues, that is simply because much of the available literature and research deals with male sexual dysfunction as opposed to female. Every word in this article is intended to help women as much as men.

Sexual Dysfunction: Purpose

As basic as is the human sexual desire and function, we all know, from research, medical literature and, most of all, life and experience, that the sexual function is a highly complicated process. It depends upon emotion, feelings, timing, mood, words, and so many other factors, and when injury and consequences are added to the mix, the process can become impossible.

The purpose of this article is not only to discuss these issues, but more importantly, to accomplish one or more of the following:

1. To let people know that they are not alone in their situation;

2. To empower people to have the knowledge, ability, and courage to bring this type of information to the attention of their treating physician;

3. To provide help as to what type of information to have available, even written out, in advance, to provide to the physician to be the most helpful in understanding the problem;

4. To let people know that there are various types of treatment and therapy available; and

5. To provide a starting place for discussion.

Since the beginning of time, and at whatever stage of the civilization humanity was, and whether people lived outside, in a cave, in a hut, in a barn, or in a mansion, the common historical thread of a man was that he could always do what had to be done in order to get food for himself and his family, to do what was needed to be done to have shelter for himself and his family, and at the same time, to have the energy and imagination to dream and plan for better days for himself and his family. Women and men are taught and raised to be self-reliant, and if fortunate, are able to go through their entire lives taking care of themselves, raising their children, paying their bills, and persevering regardless of their lot in life.

When injury strikes, all of this changes because all of a sudden, instead of being self-reliant, the family may now have to rely on an insurance clerk to mail a check on time to pay their bills, or rely on a doctor to send a certain report to an insurance carrier to get bills paid and the focus of the family’s financial security may literally shift from the wage earner to the mailbox. This alone may have an impact on a person’s sexual function. While this is going on, and just as suddenly, the entire focus of the family’s social life may change, or disappear, and now the time that was spent working, enjoying social and leisure activities, enjoying children, is replaced with time in therapy, sitting in doctors’ offices, worrying and wondering about when things will get back to normal.

With all of this going on, it is no wonder that the delicate balance of life that leads to human sexuality is upset and disturbed, but the suffering in silence, in terms of any sexual dysfunction issues, only adds to the cycle of frustration, problems, and everything else that is going on.

In the United States, men seem to have, on one level or another, the image of themselves as the “Marlboro Man,” with a very macho image of themselves. Women may equate their own sexuality with attractiveness, beauty, and personality, all of which may suffer when there is sexual dysfunction following injury. Men and women may be reluctant to even discuss issues related to sexual dysfunction with their treating physicians, and they are left to suffer in silence.

Sometimes, regardless of what our problem may be, we think we suffer alone. There is comfort, as well as knowledge, knowing that many other people are in the same situation, and it is the purpose of this article not only to distribute that information about the possible causes of sexual dysfunction, but to let people know that there may be help in the form of medical treatment, care, or therapy that can alleviate some of these problems. In this situation of sexual dysfunction, in order for the person to be able to get help, there must be a bridge between the person’s knowledge of their own sexual dysfunction, and the doctor’s knowledge of the patient’s sexual dysfunction. That bridge is sometimes not built because of shyness or reservation, on the part of either the doctor or the patient, or both, and part of the purpose of this article is to help build that bridge, and one of the recommendations, at the end of this article, is a written form that can be filled out in advance and given to the doctor.

Sexual Dysfunction: The Problem

Several years ago, Dr. George Zitnay, then president of the National Head Injury Foundation, testified before congress, and started his prepared remarks with the following statement:

Ladies and gentlemen, I am here today to talk about the largest and most important sex organ in the human body – the brain.

As Dr. Zitnay spoke those words, everyone in the hearing stopped talking and paid strict attention to what he had to say.

Amazingly enough, all of the following have one thing in common:

1. Depression;
2. Brain injury;
3. Post traumatic stress disorder;
4. Amputation;
5. Chronic pain;
6. Disability from work;
7. Sleep difficulties;
8. Frustration;
9. Changed perception of self;
10. Medication;
11. Changed personality;
12. Change in sense of humor;
13. Physical injury;
14. Scarring;
15. Fatigue;
16. Increased stress;
17. Getting behind in bills;
18. Reduced recreational activities;
19. Elimination or reduction of social life;
20. Elimination or reduction of recreational activities;
21. Loss of job.

What all of these have in common is that any or all of these can have an impact upon a person’s sexual functioning. For example, many medications have, as a side effect, a potential impact on a person’s libido which may not be known to the patient or their family.

Following the injury, it may be weeks or months before the person experiences the romance of a sexual encounter, which may not be the same as it was before the injury. This may lead to embarrassment, and depending upon how the situation is dealt with, may lead to humiliation, particularly on the part of the man. This humiliation may, in and of itself, lead to stress, and in and of itself, lead to an avoidance of the next romantic sexual encounter, which may then engender some feelings of guilt on the part of the uninjured spouse. This may snowball and become a vicious cycle of frustration for both parties.

Where the woman experiences a lack of libido, for any number of reasons related to the injury, the man may feel unloved and unwanted, which leads to stress, arguing, and again, can snowball and become a vicious cycle of frustration for both parties.

The uninjured spouse may then begin to think that the injured spouse no longer cares about them, or no longer has romantic feelings, and is unable to provide an explanation for the cause of the problem. It may very well be that as of that point in time, no one in the health care system has taken the time to explain to either of the parties that any aspect of the injuries may have an impact upon sexual function.

In the book Neuropsychological Assessment, Third Edition, by Dr. Muriel D. Lezak, at page 42, she writes:

One significant personality change that is rarely discussed but is a relatively common concomitant of brain injury is a changed sexual drive level. A married man or woman who has settled into a comfortable sexual activity pattern of intercourse two or three times a week may begin demanding sex two and three times a day from the bewildered spouse. More frequently, the patient loses sexual interest or capability. This leaves the partner feeling unsatisfied and unloved, adding to other tensions and worries associated with cognitive and personality changes in the patient. For example, some brain damaged men are unable to achieve or sustain an erection, or they may have ejaculatory problems secondary to nervous tissue damage. Patients who become crude, boorish, or childlike as a result of brain damage no longer are welcomed bed partners and may be bewildered and upset when rejected by their once affectionate mates. Younger persons brain damaged before experiencing an adult sexual relationship may not be able to acquire acceptable behavior and appropriate attitudes. Adults who were normally functioning when single often have difficulty finding and keeping partners because of cognitive limitations or social incompetence resulting from their neurological impairments. For all of these reasons, the sexual functioning of many brain damaged persons will be thwarted. Although some sexual problems diminish in time, for many patients they seriously complicate the problems of readjusting to new limitations and handicaps, by adding another stage of frustrations, impulses, and reactions.

There may be an escalating cascade of problems which can be, for example:

1. The first problem is that it happens, and then, through embarrassment, reluctance, or other feelings, how is it dealt with? As we all know, while some people may joke and talk about sexuality, when it comes to the individual, there may be reluctance to talk about personal sexual issues, and it may be that this is especially true in term of one’s own partner. It may be that the entire relationship has flourished before injury without there having been a discussion about sexual issues, and now, any discussion must revolve around sexual dysfunction about which both may be ignorant.

2. The second problem may be that no one will admit it, not even one partner to another.

3. That where it is the woman who has had a loss or decrease of libido, following injury, the man may assume that her lack of interest means that she no longer cares for him, and this leads to another whole set of problems.

4. People may not even suspect that the injury or medication or consequence of the injury is causing the problem, and they may not have received any such advice or information from the treating health care providers.

5. The relationship begins to deteriorate.

6. The doctor may not know about it because people may not initiate discussion about sexual issues, let alone sexual dysfunction issues, and doctors do not routinely ask about sexual function as part of their history, or as a part of a routine examination.

7. The next problem is that the doctors may not know what to do, or just say something like “it will be all right,” and leave the patient without any recommendations.

8. The next problem is that if the person is in a managed care situation, there may be a financial incentive for the primary care physician not to make referrals for an extensive sexual dysfunction work-up that may be appropriate, or, in some cases, the doctor may not care.

9. The next problem is that there are doctors who have the attitude that so long as the person is alive, they should be grateful.

10. Another problem is that if the person initiates discussion, and the doctor does not handle it appropriately, the patient may be embarrassed, humiliated, and the cycle could repeat itself.

One of the concepts in psychology is the concept of what is called a stroke as being a unit of recognition, or a form of stimulation. This is far different from the medical concept of a stroke, and this discussion is related solely to the psychological concept of stroke. In psychology, strokes can be physical, verbal, or non-verbal, and as a person grows older, new ways are discovered to receive and exchange strokes. For example, some may enjoy making presentations at church, or at local groups, because they enjoy the recognition, and the recognition would, in psychology, be called a stroke. The need for stimulation becomes at least, in part, a need for recognition, and this is a very basic human need and, as stated in the book entitled Transactional Analysis by Woollams, Brown & Huige, at page 16:

Since the need for strokes is inherent in each person, exchanging strokes is one of the most important of all human activities.

Further, at page 16:

Since strokes are necessary for survival, a person will do whatever she thinks necessary in order to receive the strokes she needs. A person will develop a style of giving and receiving strokes based on her life position.

Again, remember that the concept of strokes in this context is a psychological term. Now think about the psychological concept of strokes in the context of a relationship between a loving couple, having sexual relations prior to injury. Human sexuality certainly encompasses far more than just the act of sex between two people. When we think of the delicate balance necessary for human sexuality, in terms of mood, physical, mental, emotional, and timing, and then remember that all of this must exist in a multiple of two, the psychological concept of what are called strokes is very applicable.

With the intimacy of the couple’s knowledge of each other, they have developed a concept of strokes for each other, and how they receive strokes in the world, through their work, recreational activities, and things. Now, with injury, all of this has changed not only for the injured person, but then in consequence, also for the uninjured person. Just looking at this psychological concept of strokes alone, one could think that there must be a proper balance of strokes, from an emotional point of view, in order for there to be a loving sexual relationship, and if that emotional framework becomes unbalanced and distorted, as it does, that alone can impact on the sexual function.

Consider, for example, a young couple who would typically enjoy going out to dinner, a little dancing, and each other’s personality, filled with a sense of humor, as a prelude to sexual relations. Now, following injury, a partner is in pain, has very little sense of humor, does not enjoy eating in the noisy atmosphere of a restaurant, and it is easy to see that the emotional framework of this couple has become unbalanced and distorted, and without help, the relationship may become further unbalanced and distorted through the silence of sexual dysfunction.

Sexual Dysfunction: Medical Literature

As I researched and thought about what to say and include in this article, I was amazed to discover that just about every medical textbook that I reviewed had at least some information about sexual dysfunction, whether neurology, psychiatry, orthopedics, neuropsychology, or other areas, somewhere in each book there was some discussion about relationships between trauma, medications, emotions, injury, or something to sexual dysfunction.

I decided to include this section with just quotes from the medical literature not, in any way, to try and teach the medical substance of the quotes, but rather, for the purpose of making the reader aware of how extensively this topic is discussed in some of the very same medical books that may well be on your doctors’ shelves. This knowledge may help people feel a little more comfortable about discussing issues of sexual dysfunction with a doctor.

It is also important to remember that there are physicians, specialists, and health care providers who specialize in working with people with sexual dysfunction and people have the right to request such referrals.

Rehabilitation of the Adult and Child with Traumatic Brain Injury, Second Edition, by Rosenthal, Griffith, Bond, and Miller, 1990. At page 206, the chapter is entitled “Sexuality and Sexual Dysfunction.”

Human sexuality conceptually embraces the composite of those factors that result in our capacity to love and procreate. A related aspect of sexuality is the individual’s perception and expression of “womanliness” or “manliness.” By these terms, it is predictable that a catastrophic event such as brain injury will almost ineluctably affect the sexuality of the survivor. Sexual disabilities may include disturbances of any of the component functions of sexuality: sexual drive, interests, beliefs, attitudes, behaviors, identity, activities, responses, and fertility.

In this chapter, they refer to:

Disabilities resulting from physical or organic factors as primary dysfunction, and secondary sexual dysfunctions resulting from brain trauma are those disturbances of psychosocial abilities or sexual responses due to the mental deficits in psychologic reactions consequent to the injury. Secondary sexual dysfunctions may arise in the partner, if one exists, as the consequences of reactions to the disabled person and the altered life situation.

Current evidence indicates that secondary factors account for the great majority of sexual dysfunctions in brain injured subjects. However, more recent data suggest that primary factors may be less rare than previously surmised . . . In contrast to the growing body of general information on psychosocial aspects of brain trauma, very little has been written about sexuality.

Page 207:

Sexual responses – erection, vaginal lubrication, ejaculation, orgasm, and fertility – are not altered as a direct consequence of brain injury unless the hypothalamic-pituitary function has been disturbed or disrupted. The resulting endocrinopathies have received increasing attention, with recognition that testicular and ovarian hypofunction can occur. Some women with mesial temporal lobe foci of seizures have recently been reported to have hypogonadotropic hypogonadism. Women often become temporarily amenorrheic following severe trauma, but menses should ordinarily resume within 4 to 6 months. Persistent amenorrhea should alert the clinician to the possibility of pituitary dysfunction. Similarly, men frequently have transient impotence, but the ability to achieve an erection should reappear after several months.

Page 207:

Trauma to the craniofacial area, primary or secondary sexual organs, and orthopedic injuries resulting in amputation, contractures, deformities, and chronic pain are potential sources of dysfunction . . . Abdominal or pelvic vascular injuries can compromise circulation to the genitalia, producing impotence or other alterations in sexual responses.

Recurrent medical complications, sustained bed rest, and inactivity with its many consequences cause deconditioning and other effects that impinge upon sexual activity. A multitude of drugs produce side effects that influence sexual acts and responses . . .

Finally, pre-existing disorders may become additive factors contributing to the primary sexual dysfunction. Cardiac, vascular, pulmonary, or other types of diseases may already have compromised sexual function of the elderly before injury.

In the book Principals of Neurology by Adams, Victor, and Ropper, Sixth Edition, at page 517, under the heading of “Altered Sexuality” it states:

The normal pattern of sexual behavior in both male and female may be altered by cerebral disease quite apart from impairment due to obvious physical disability or to diseases that destroy or isolate the segmental reflex mechanisms.

Hypersexuality in men or women is a rare but well-documented complication of neurologic disease. Kleist pointed out that lesions of the orbital parts of the frontal lobes may remove moral-ethical restraints and lead to indiscriminate sexual behavior, and that superior frontal lesions may be associated with a general loss of initiative which reduces all impulsivity, including sexual.

At page 518:

In our clinical work we find that hyposexuality, meaning loss of libido, is most often due to a depressive illness. Certain chemical agents – notably antihypertensive, anticonvulsant, serotoninergic antidepressant and neuroleptic drugs – may cause a loss of libido. A variety of cerebral diseases may also have this effect.

At page 545, under the heading of “Disturbances of Sexual Function,” it says:

Sexual function in the male, which is not infrequently affected in neurologic disease, may be divided into several parts: (1) sexual impulse, drive, or desire, often referred to as libido; (2) penile erection, enabling the act of sexual intercourse (potency); and (3) ejaculation of semen by the prostate through the urethra, whereby impregnation of the female may be accomplished.

The arousal of libido in men and women may result from a variety of stimuli, some purely imaginary. Such neocortical influences are transmitted to the limbic system and thence to the hypothalamus and spinal centers.

The difference aspects of sexual function may be affected separately. Loss of libido may depend upon both psychic and somatic factors. It may be complete, as in old age or in medical and endocrine diseases, or it may occur only in certain circumstances or in relation to a certain situation or individual.

. . . sexual desire may be present but penile erection impossible to attain or sustain, a condition called impotence, in which nocturnal erections are usually preserved. The commonest cause of impotence is a depressive state.

1. Comprehensive Textbook of Psychiatry, Volume I, Sixth Edition, by Kaplan and Sadock, at page 1296:

Innervation of the organs of sexuality is mediated primarily through the autonomic nervous system. It is generally assumed that the parasympathetic system activates the process of erection via impulses that pass through the pelvic splanchnic nerves (S2, S3, S4) which caused the smooth muscles of the penile arteries to dilate.

Recent evidence implicates the sympathetic (adrenergic) system as being responsible for ejaculation . . . In women, the sympathic system facilitates smooth muscle contraction of the vagina, urethra, and uterus that occurs during orgasm.

The autonomic nervous system functions outside of voluntary control and is influenced by external events (for example, stress, drugs) and internal events (hypothalamic, limbic, and cortical stimuli). It is not surprising, therefore, that erection and orgasm are so vulnerable to dysfunction.

At page 1298:

Experimentation with animals has demonstrated that the limbic system is directly involved with elements of sexual functioning. In all mammals the limbic system is involved in behavior required for self-preservation and the preservation of the species.

Page 1298:

A vast array of neurotransmitters are produced by the brain. They include dopamine, epinephrine, norepinephrine, and serotonin. All have effects on sexual function. For example, an increase in dopamine is presumed to increase libido. Serotonin produced in the upper pons and mid-brain is presumed to have an inhibitory effect on sexual function.

At page 1300, it says:

Seven major categories of sexual dysfunction are listed in DSM-IV: (1) sexual desire disorders, (2) sexual arousal disorders, (3) orgasm disorders, (4) sexual pain disorders, (5) sexual dysfunction due to a general medical condition, (6) substance-induced sexual dysfunction, and (7) sexual dysfunction not otherwise specified.

At page 1300:

The sexual cycle is divided into four phases: desire, excitement, orgasm, and resolution. The essential feature of the sexual dysfunctions is inhibition in one or more of the phases, including disturbance in the subjective sense of pleasure or desire or disturbance in the objective performance. Either type of disturbance can occur alone or in combination. Sexual dysfunctions are so diagnosed only when such disturbances are a major part of the clinical feature. They can be lifelong or acquired, generalized or situational, and due to psychological factors or due to combined factors. If they are attributable entirely to a general medical condition, substance use, or adverse effects of medication, then sexual dysfunction due to a general medical condition or substance-induced sexual dysfunction is diagnosed.

With the possible exception of premature ejaculation, sexual dysfunctions rarely are found separate from other psychiatric syndromes. Sexual disorders may lead to or result from relational problems, and patients invariably develop an increasing fear of failure and self-consciousness about their sexual performance. Sexual dysfunctions are frequently associated with other mental disorders, such as depressive disorders, anxiety disorders, personality disorders, and schizophrenia. In many instances, sexual dysfunctions may be diagnosed in conjunction with the other psychiatric disorders. In some cases, however, it is but one of many signs or symptoms of the psychiatric disorder.

A sexual disorder can be symptomatic of biological problems, intrapsychic conflicts, interpersonal difficulties, or a combination of these factors. The sexual function can be affected by stress of any kind, by emotional disorders, and by a lack of sexual knowledge.

At page 1302:

Hypoactive sexual desire disorder is experienced by both men and women; however, they may not be hampered by any dysfunction once they are involved in the sex act. Conversely, hypoactive desire may be used to mask another sexual dysfunction. Lack of desire may be expressed by decreased frequency of coitus, perception of the partner as unattractive, or overt complaints of lack of desire. In some cases there are biochemical correlates associated with hypoactive desire. A recent study found markedly decreased levels of serum testosterone in men complaining of this dysfunction when they were compared with normal controls in a sleep-laboratory situation. Also, a central dopamine blockage is known to decrease desire.

Page 1303:

Patients with desire problems often have good ego strengths and use inhibition of desire in a defensive way to protect against unconscious fears about sex. Lack of desire can also be the result of chronic stress, anxiety, or depression. Abstinence from sex for a prolonged period sometimes results in suppression of the sexual impulse. It may also be an expression of hostility or the sign of a deteriorating relationship.

The presence of desire depends on several factors: biological drive, adequate self-esteem, previous good experiences with sex, the availability of an appropriate partner, and a good relationship in nonsexual areas with one’s partner. Damage to any of those factors may result in diminished desire.

Page 1304:

Male erectile disorder is also called erectile dysfunction and impotence . . . In acquired male erectile disorder the man has successfully achieved vaginal penetration at some time in his sexual life but is later unable to do so.

Page 1305:

The percentage of all men treated for sexual disorders who have impotence as the chief complaint ranges from 35 to 50 percent. The incidence of psychological as opposed to organic impotence has been the focus of many recent studies. Physiologically, impotence may be due to a variety of medical causes. In the United States it is estimated that two million men are impotent because they suffer from diabetes mellitus; an additional 300,000 are impotent because of other endocrine diseases; 1.5 million are impotent as a result of vascular disease; 180,000 because of multiple sclerosis; 400,000 because of traumas and fractures leading to pelvic fractures or spinal cord injuries; and another 650,000 as a result of radical surgery, including prostatectomies, colostomies, and cystectomies. In addition, the clinician should be aware of the possible pharmacological effects of medication on sexual functioning. The increased incidence of organic etiologies for this dysfunction in the past 15 years may, in part, reflect the increased use of psychotropic and antihypertensive medications. Statistics indicate that 20 to 50 percent of men with erectile dysfunction have a medical basis for their problem.

Page 1306:

Sexual dysfunction due to a general medical condition. The category covers sexual dysfunction that results in marked distress and interpersonal difficulty when there is evidence from the history, the physical examination, or the laboratory findings of a general medical condition judged to be causally related to the sexual dysfunction.

Male erectile disorder due to a general medical condition. The incidence of psychological as opposed to organic male erectile disorder has been the focus of many studies. Statistics indicate that 20 to 50 percent of men with erectile disorder have an organic basis for the disorder. The medical causes of male erectile disorder are listed in Table 21.1a-10 which include, as general categories, infectious and parasitic diseases, cardiovascular disease, renal and urological disorders, hepatic disorders, pulmonary disorders, genetics, nutritional disorders, endocrine disorders, neurological disorders, pharmacological contributants, poisoning, surgical procedures, and miscellaneous including “any severe systemic disease or debilitation condition.” Side effects of medication may impair male sexual functioning in a variety of ways. Castration does not always lead to sexual dysfunction, depending on the person. Erection may still occur after castration.

A number of procedures, benign and invasive, are used to help differentiate medically caused impotence from psychogenic impotence. The procedures include monitoring nocturnal penile tumescence (erections that occur during sleep), normally associated with rapid eye movement; monitoring tumescence with strain gauge; measuring blood pressure in the penis with a penile plethysmograph or an ultrasound (Doppler) flow meter, both of which assess blood flow in the internal pudendal artery; and measuring pudendal nerve latency time. Neurological impairment of penile function may be indicated if vibratory perception is increased in the penis. Other diagnostic tests that delineate organic bases for impotence include glucose tolerance tests, plasma hormone assays, liver and thyroid function tests, prolactin and follicle-stimulating hormone (FSH) determinations, and cystometric examinations. Invasive diagnostic studies include penile arteriography, infusion cavernosography, and radioactive xenon penography. Invasive procedures require expert interpretation and are used only for patients who are candidates for vascular reconstructive procedures.

Page 1306:

A good history is crucial in determining the etiology of the male erectile disorder. If a man reports having spontaneous erections at times when he does not plan to have intercourse, having morning erections or only sporadic erectile dysfunction, or having good erections with masturbation or with partners other than his usual one, then organic causes for his impotence can be considered negligible, and costly diagnostic procedures can be avoided. In those cases in which a medical basis for impotence is found, psychological factors often contribute to the dysfunction, and psychiatric treatment may be helpful. In some diabetics, for instance, erectile dysfunction may be psychogenic. In general, the psychological conflicts that cause impotence are related to an inability to express the sexual impulse because of fear, anxiety, anger, or moral prohibition.

Many developmental factors have been cited as contributing to erectile disorder. Any experience that hinders the ability to be intimate, that leads to a feeling of inadequacy or distrust, or that develops a sense of being unloving or unlovable may result in impotence. In an ongoing relationship, erectile dysfunction may reflect difficulties between the partners, particularly if the person cannot communicate his or her needs or angry feelings in a direct and constructive way. Successive episodes of impotence are reinforcing, with the man becoming increasingly anxious about his next sexual encounter. Regardless of the original etiology of the dysfunction, his anticipatory anxiety about achieving and maintaining an erection interferes with his pleasure and sexual contract and with his ability to respond to stimulation, thus perpetuating the problem.

Page 1307:

Hypoactive sexual desire disorder due to a general medical condition. Desire commonly decreases after major illness or surgery, particularly when the body image is affected after such procedures as mastectomy, ileostomy, hysterectomy, and prostatectomy. Illness that deplete a person’s energy, chronic conditions that require physical and psychological adaptation, and serious illnesses that may cause the person to become depressed can all result in a marked lessening of sexual desire in both men and women.

In some cases, biochemical correlates are associated with hypoactive sexual desire disorder.

Other male sexual dysfunction due to a general medical condition. The category is used when some other dysfunctional feature is predominant (for example, orgasmic disorder) or no feature predominates. Male orgasmic disorder may have physiological causes and can occur after surgery on the genitourinary tract, such as prostatectomy. It may also be associated with Parkinson’s disease and other neurological disorders involving the lumbar or sacral sections of the spinal cord. The antihyptensive drug guanethidine monosulfate (Ismelin), methyldopa (Aldomet), the phenothiazines, the tricyclic drugs, and fluoxetine (Prozac), among others have been implicated in retarded ejaculation. Male orgasmic disorder must also be differentiated from retrograde ejaculation, in which ejaculation occurs but the seminal fluid passes backward into the bladder. Retrograde ejaculation always has an organic cause.

Page 1308:

Acquired female orgasmic disorder is a common complaint in clinical populations. One clinical treatment facility described nonorgasmic women as about four times more common in its practice than patients with all other sexual disorders. In another study 46 percent of the women complained of difficulty in reaching orgasm, and 15 percent described an inability to have orgasm.

Page 1308:

Male orgasmic disorder. In male orgasmic disorder (previously inhibited male orgasm and called retarded ejaculation) the man achieves climax during coitus with great difficulty, if at all. A man suffers from lifelong orgasmic disorder if he has never been able to ejaculate during coitus. The disorder is diagnosed as acquired if it develops after previous normal functioning.

Page 1314:

Almost every pharmacological agent, particularly those used in psychiatry, has been associated with an effect on sexuality. In men those effects include decreased sex drive, erectile failure (impotence), decreased volume of ejaculate, and delayed or retrograde ejaculation. In women decreased sex drive, decreased vaginal lubrication, inhibited or delayed orgasm, and decreased or absent vaginal contractions may occur. Drugs may also enhance the sexual response and increase the sex drive, but that effect is less common than are adverse effects.

Talk about the male ego being associated with sex, and the male ego being associated with the ability to make a living, as 19th century as that may sound. When the man is all of a sudden transformed from the wage earner, and head of the family, to someone who is reliant upon the system for his living, or a workers compensation carrier for money, this does tremendous damage to the male ego.

Page 1316:

Under the heading of Treatment of Sexual Dysfunction:

Various corrective therapies are now used to treat sexual dysfunctions . . .

In addition to making the determination of which type of therapy to use, the clinician must evaluate whether or not the disorder has a physiological cause. It is assumed that prior to entering psychotherapy, a patient will have had a thorough medical evaluation, including a medical history, physical examination, and appropriate laboratory studies when necessary. If a medical cause for the disorder is found, treatment should be directed toward ameliorating the cause of the dysfunction.

Page 1319, under the heading of Biological Treatment Methods, it says:

Pharmacotherapy. Penile injections produce a transient increase in penile blood flow, which allows the patient to become tumescent or gain an erection. The physician usually administers a test dose of the drug, and if the patient responds favorably, he is then taught to inject himself. Hormone therapy is listed, antiandrogens and antiestrogens, male prosthesis (at page 1320): Surgical treatment is rarely advocated, but improved penile prosthetic devices are available for men with inadequate erectile response who are resistant to other treatment methods or who have medically caused deficiencies.

Page 751:

The course and prognosis of secondary sexual dysfunctions vary widely, depending on the etiology . . . Dysfunctions due to neurological disease may run protracted, even progressive, courses. The treatment approach similarly varies widely, depending on the etiology. When reversal of the underlying cause is not possible, supportive and behaviorally oriented psychotherapy with the patient (and perhaps the partner) may minimize distress and increase sexual satisfaction (for example, by developing sexual interactions that are not limited by the specific dysfunction). Support groups for people with specific types of dysfunction are available.

Organic Psychiatry, the Psychological Consequences of Cerebral Disorder by Dr. William A. Lishman, Third Edition, 1988. At page 271 under the heading of Sexual Disorder in Epilepsy:

Sexual disorder attracted little attention in epileptic patients until relatively recently. Several reports, however, now stress the frequency of sexual disturbance in patients with temporal lobe epilepsy. Hyposexuality has emerged as the commonest abnormality, with perversions of sexual interest and outlet occurring in a much smaller number.

Gastaut and Collomb (1954) were the first to draw attention to hyposexuality after specific inquiry in 36 patients with temporal lobe epilepsy. More than two-thirds showed marked diminution or absence of interest, appetite or sexual activity. Other forms of focal and generalized epilepsy appeared to be unassociated with such problems. There was often a remarkable lack of sexual curiosity, fantasies or erotic dreams, yet little to suggest inhibition since the patients talked easily and without reserve about such matters. Indeed they appeared to be quite indifferent about the subject.

By detailed interviews it was established that 41% of the male temporal lobe epileptics were hyposexual, compared to 8% of the males with generalized epilepsy. The corresponding figures for females were 38% and 5% respectively. On restricting attention to patients over the age of 15 and where adequate information was available these differences were accentuated, reaching statistically significant levels. Among the males the disorder was manifest as a global lack of interest, failure of erections and nocturnal emissions, and absence of fantasies or dreams of a sexual nature. The females remained totally passive in sexual relations and failed to reach orgasm . . . The lack of concern evidenced by the patients, and their failure to make complaints, probably accounted for the problem having attracted so little attention in the past. Toone et al (1989) found that temporal lobe epileptics and other focal epileptics recruited from general practice were equivalently impaired, both more often lacking sexual interest and activity than patients with primary generalized epilepsy.

From the Textbook of Clinical Neurology by Goetz and Pappert, at page 369, under the heading of “Sexual Dysfunction” it says:

Treatment of organic impotence includes treatment of secondary psychological problems and reducing or eliminating aggravating factors such as poor sleep, chronic pain, malnutrition, alcohol use, and some medications. Yohimbine can be used orally to increase penile arterial vasodilatation and enhance relaxation of the cavernous trabeculae. Direct injection of papaverine (direct smooth muscle relaxant), phentolamine, or prostaglandin E1 into the corpora cavernosa may be effective but poses the risks of priapism and scarring of the tunica albuginea. A vacuum device may also be used to enhance corporal filling.

In the book Head Injury and Post Concussive Syndrome by Rizzo and Tranel, at page 312, under the heading of “Sexual Disorders” it says:

Symptoms of sexual dysfunction can be noted after TBI. These symptoms can be grouped into changes in sexual interest or performance and the development of inappropriate or unusual sexual behaviors. A syndrome of apathy can extend to apathy in sexuality, with diminished desire and reduced frequency of sexual intercourse. Impotence can also develop after TBI. Finally, inappropriate sexual behavior and speech have been noted, especially in patients with significant frontal lobe dysfunction. This can include suggestive remarks or unwanted sexual advances toward health professionals. Increased interest in pornography has also been noted.

Under DSM-IV Classification, it says:

When sexual apathy is a target of evaluation and interest, the appropriate classification comes under the sexual dysfunction due to head trauma category. The subclassification would be 608.89 Male (or 625.80 Female) hypoactive sexual desire due to head trauma. Male impotency following TBI would be denoted by 607.84, male erectile disorder due to head trauma.

Inappropriate sexual behavior problems can be clinically important enough for diagnosis. Inappropriate sexual behaviors believed to be due to frontal lobe damage would be designated as personality change due to head trauma – disinhibited type.

Under the heading of “Differential Diagnosis” it says:

Disorders of sexual desire can be primary (i.e., present prior to head trauma or unrelated to the injury). Medications can have significant effect on sexual interest and performance. A variety of causes for impotence should be reviewed, including vascular disorders, diabetes, and psychological disorders impairing male sexual function.

Sexual Dysfunction: Suggestions

The only way that your doctor is going to have the information about your situation following injury is if it is provided by you, or someone on your behalf. Since the doctor may not inquire about it, as a part of the history, and since it is important to provide complete information, the following is suggested. It is suggested that you actually make a copy of this form, fill it out, and hand it to your doctor at your next appointment to start the conversation that may lead to a more fulfilling life for you and your partner.

Dear Dr. _________:

Since my injury, I have noticed a change in my sexual functioning, and I am providing you with this information, and any other information that you might need to evaluate my situation. Can you help me, or refer me to a doctor or health care provider who could help me with this change in my sexual functioning?

Then, provide in that same letter, the following information:

1. A brief description of your sexual pattern in the year before injury;

2. A description of your sexual pattern since the injury;

3. An honest appraisal as to your desire for sex since the injury;

4. How has the sexual situation been handled between you and your partner since the injury, in terms of any discussion;

5. List all of your medications that you have been on since the injury, and ask “could any of these be affecting my sexual function?”

6. Are there any specialists to whom you could refer me for evaluation of my sexual dysfunction, and treatment;

7. Is there any information that I can provide to you, at this appointment, or at the next appointment, to help you in evaluating, diagnosing, and treating my condition?

Any other information that you think would be helpful for the doctor should be written down and given to the doctor.

This should help break the ice about any discussion of sexual dysfunction.

Sexual Dysfunction: Dedication

This article is dedicated to my friend, Mr. Steve Marshburn, founder and president of Lightning Strike & Electric Shock Survivors International. If this article dealing with sexual dysfunction after injury is of any help or comfort to anyone, such persons owe a great debt of gratitude to Mr. Steve Marshburn. When God chose Steve Marshburn to be at the forefront of the fight for better understanding, medical care, and legal representation for persons and families surviving electric shock and lightning strike injury, obviously He chose wisely. The courage, persistence, determination, and wisdom of my friend, Mr. Steve Marshburn, can never be underestimated.

It has been a real privilege working with Steve and Joyce Marshburn over the years. When Steve told me that many members had requested an article and information on sexual dysfunction following injury, and asked me to write such an article, I was somewhat taken aback with shyness and awe at the complexity of the task. But, as anyone who knows Steve Marshburn knows, no one ever says no to Steve Marshburn.

Sexual Dysfunction: About the Author

CHARLES N. (NICK) SIMKINS, is a trial lawyer specializing exclusively in representing persons and families surviving traumatic brain injury, spinal cord injury, and brain dysfunction, and electric shock and lightning strike survivors. Mr. Simkins has served as a consultant to Lightning Strike and Electric Shock Survivors International, is an elected board member of the Brain Injury Association, editor of the National Head Injury Foundation book entitled “Analysis, Understanding, and Presentation of Cases Involving Traumatic Brain Injury,” author of “Can Long Term Cognitive and Emotional Problems be Caused by Electric Shock and Lightning Strike Accidents, or Is Anything That I Know About Brain Injury Applicable to Electric Shock and Lightning Strike Victims?,” Editor, Melvin Belli Society Newsletter, and he has represented injured persons and served as a consultant for trial lawyers throughout the United States on cases involving traumatic brain injury, brain dysfunction, and electric shock and lightning strike injuries. During his career, Mr. Simkins, whose office is in Northville, Michigan, has achieved numerous seven-figure plus verdicts and settlements in cases involving traumatic brain injury, brain dysfunction, and issues related to post traumatic stress disorder.

Charles N. (Nick) Simkins
Attorney at Law

Epidemiology of Traumatic Brain Injury

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Of all types of injury, those to the brain are among the most likely to result in death or permanent disability. Estimates of traumatic brain injury (TBI) incidence, severity, and cost reflect the enormous losses to individuals, their families, and society from these injuries. These data demonstrate a critical need for more effective ways to prevent brain injuries and care for those who are injured.

Highlights

Incidence of traumatic brain injury (TBI). Using national data for 1995-1996, the CDC estimates that TBIs have this impact in the United States each year:

  • 1 million people are treated and released from hospital emergency departments
  • 230,000 people are hospitalized and survive
  • 50,000 people die

TBI incidence rate, risk factors, and causes. Using preliminary hospitalization and mortality data collected from 12 states (Alaska, Arizona, Sacramento County [California], Colorado, Louisiana, Maryland, Missouri, New York, Oklahoma, Rhode Island, South Carolina, and Utah) during 1995-1996, CDC finds the following:

  • The average TBI incidence rate (combined hospitalization and mortality rate) is 95 per 100,000 population. Twenty-two percent of people who have a TBI die from their injuries. The risk of having a TBI is especially high among adolescents, young adults, and people older than 75 years of age.
  • For persons of all ages, the risk of TBI among males is twice the risk among females.
  • The leading causes of TBI are motor vehicle crashes, violence, and falls. Nearly two-thirds of firearm-related TBIs are classified as suicidal in intent.
  • The leading causes of TBI vary by age: falls are the leading cause of TBI among persons aged 65 years and older, whereas transportation leads among persons aged 5 to 64 years.
  • The outcome of these injuries varies greatly depending on the cause: 91% of firearm-related TBIs resulted in death, but only 11% of fall-related TBIs are fatal.

Incidence and prevalence of TBI-related disability. Based on national TBI incidence data and preliminary data from the Colorado Traumatic Brain Injury Registry that describe TBI-related disability in 1996-1997, CDC estimates the following:

  • Each year more than 80,000 Americans survive a hospitalization for traumatic brain injury but are discharged with TBI-related disabilities.
  • 5.3 million Americans are living today with a TBI-related disability.

Note: The preliminary estimates described above are derived from provisional data that are subject to change, pending receipt of additional data. Therefore, the information contained in this outline should not be published without approval from the Centers for Disease Control and Prevention.

Traumatic Brain Injury Incidence: Morbidity and Mortality

There are several published epidemiologic studies of TBI-related hospitalizations and deaths in the U.S. Kraus has reviewed some of these studies in detail.6 Recent data suggest a decline in rates of hospitalization for less severe TBI, possibly due to changes in hospital admission criteria.2 The lower TBI incidence rate seen today may be due in part to a real decline in brain injuries but also appear to be an artifact of counting methods which capture only hospitalized and fatal cases.

Location of Study Year(s) Annual Rate of TBI per 100,000 Population

Olmstead County, Minnesota 1934-74 [193]
U.S. 1974 [200]
San Diego, California 1978 [294]
North Central Virginia 1978 [175]
Rhode Island 1979-80 [249]
Chicago, Illinois 1980 [367]
Bronx, New York City, New York 1980 [249]
San Diego County, California1 1981 [180]
Maryland 1986 [132]
Utah 1990-92 [106]
Colorado, Missouri, Oklahoma, Utah 1990-93 [103]
Colorado18 1991-92 [101]
Seven states (AZ, CO, MN, MO, NY excluding NYC, OK, SC) 1994 [92]

Traumatic Brain Injury Mortality: Causes and Trends

There was a 22% decline in the TBI-related death rate from 24.6/100,000 U.S. residents in 1979 to 19.3/100,000 in 1992. Firearm-related rates increased 13% from 1984 through 1992, undermining a 25% decline in motor vehicle-related rates for the same period. Firearms surpassed motor vehicles as the largest single cause of death associated with traumatic brain injury in the United States in 1990. These data highlight the success of efforts to prevent traumatic brain injury due to motor vehicles and failure to prevent such injuries due to firearms. The increasing importance of penetrating injury has important implications for research, treatment, and prevention of traumatic brain injury in the United States.

Populations at Risk, Outcome and Cost

Populations at Risk

A number of studies have shown that males are about twice as likely to incur TBI as females. Most studies indicate that the highest rates of these injuries are found in persons 15-24 years of age. Persons under the age of 5 or over the age of 75 are also at high risk.

Outcome

Each year more than 50,000 Americans die following traumatic brain injuries.3 Each year an estimated 80,000 Americans survive a hospitalization for traumatic brain injury but are discharged with TBI-related disabilities. An estimated 5.3 million Americans are living today with a TBI-related disability.

There are many kinds of impairments that may occur as a result of TBI. These injuries may impair:

  • cognition — concentration, memory, judgment, and mood
  • movement abilities — strength, coordination, and balance
  • sensation — tactile sensation and special senses such as vision
  • TBI sometimes results in seizure disorders (epilepsy). About 1 percent of persons with severe TBI survive in a state of persisting unconsciousness.

Cost

There is no way to describe fully the human costs of traumatic brain injury: the burdens borne by those who are injured and their families.

Only a few analyses of the monetary costs of these injuries are available, including the following estimate (lifetime cost of all brain injuries occurring in the United States in 1985):

Direct annual expenditures: $4.5 billion
Indirect annual costs: $33.3 billion
Total costs: $37.8 billion

Traumatic Brain Injury as a Public Health Problem

A large number of people experience traumatic brain injury each year, often with severe consequences. This is a public health problem that requires:

Ongoing surveillance to follow trends in the incidence, risk factors, causes, and outcomes of these injuries. To promote TBI surveillance efforts, the National Center for Injury Prevention and Control (NCIPC): developed Guidelines for the Surveillance of Central Nervous System Injury, a publication that sets forth standards and recommendations to improve coordination of central nervous system injury surveillance.22 The surveillance standards provide case definitions for traumatic brain injury and spinal cord injury and a list of defined data elements to be collected for each case of injury. Provided funding to Alaska, Arkansas, Arizona, California, Colorado, Louisiana, Maryland, Minnesota, Missouri, Nebraska, New York, Oklahoma, Rhode Island, South Carolina, and Utah to enhance current traumatic brain injury surveillance by using the standards defined in the Guidelines for the Surveillance of Central Nervous System Injury. These states contribute data to a multi-state surveillance system maintained by the NCIPC.

The development of effective, science-based strategies to prevent the occurrence of these injuries. In collaboration with other federal and state agencies, the National Center for Injury Prevention and Control supports programs for the primary prevention of motor vehicle-related injuries, other unintentional injuries, and violence-related injuries.

The development of more effective strategies to improve the outcomes of these injuries and minimize disability among those injured. The National Center for Injury Prevention and Control: provides funding to the Colorado Department of Public Health and the Environment (in collaboration with Craig Hospital) and the South Carolina Department of Health and Environmental Control (in collaboration with the University of South Carolina School of Medicine) to develop population-based follow-up registries of persons who have sustained traumatic brain injury. This project will determine the burden of disabilities, monitor trends in disabilities, identify subgroups of people with traumatic brain injury at highest risk of disability, and determine service utilization and barriers to service access. Developed Facts about Concussion and Brain Injury to address the lack of information on the symptoms, sequelae and treatment of less severe TBI. This booklet explains what can happen after a concussion, how to get better, and where to go for more information and help when needed. Funds cooperative agreements for Statewide Traumatic Brain Injury Surveillance Programs created the document, Traumatic Brain Injury in the United States: A Report to Congress, summarizing current knowledge about the incidence, causes, severity, associated disabilities, and prevalence of TBI.

References

Guerrero J, Thurman DJ, Sniezek JE. Emergency department visits association with traumatic brain injury: United States, 1995-1996. Brain Injury, 2000; 14(2):181-6. Thurman DJ, Guerrero J. Trends in hospitalization associated with traumatic brain injury. JAMA, 1999; 282(10):954-7.

Unpublished data from Multiple Cause of Death Public Use Data from the National Center for Health Statistics, 1996. Methods are described in Sosin DM, Sniezek JE, Waxweiler RJ. Trends in death associated with traumatic brain injury, 1979-1992. JAMA 1995;273(22):1778-1780.

Analysis by the CDC National Center for Injury Prevention and Control, using data obtained from state health departments in Alaska, Arizona, California (reporting Sacramento County only), Colorado, Louisiana, Maryland, Missouri, New York, Oklahoma, Rhode Island, South Carolina, and Utah. Methods are described in: Centers for Disease Control and Prevention. Traumatic Brain Injury — Colorado, Missouri, Oklahoma, and Utah, 1990-1993. MMWR 1997;46(1):8-11.

Thurman DJ, Sniezek JE, Johnson D, Greenspan A, Smith SM. Guidelines for Surveillance of Central Nervous System Injury. Atlanta: Centers for Disease Control and Prevention, 1995.

Thurman DJ, Alverson CA, Dunn KA, Guerrero J, Sniezek JE. Traumatic brain injury in the United States: a public health perspective. J Head Trauma Rehab, 1999; 14(6):602-15.

Kraus JF. Epidemiology of head injury. In: Cooper, PR, ed. Head Injury, Third Edition. Baltimore: Williams and Wilkins, 1993; 1-25.

Annegers JF, Grabow HD, Kurland LT, et al. The incidence, cause and secular trends in head injury in Olmstead County, Minnesota, 1935-1974. Neurology 1980;30:912-919.

Kalsbeek WD, McLaurin RL, Harris BS, Miller JD. The national head and spinal cord injury survey: Major findings. Journal of Neurosurgery 1980;53:S19-S24.

Klauber MR, Barrett-Connor E, Marshall LF, Bowers SA. The epidemiology of head injury: A prospective study of an entire community–San Diego County, California, 1978. American Journal of Epidemiology 1981;113:500-509.

Jagger J, Levine JI, Jane JA, Rimel RW. Epidemiologic features of head injury in a predominantly rural population. Journal of Trauma 1984;24:40-44.

Fife D, Faich G, Hollinshead W, Wentworth B. Incidence and outcome of hospital-treated head injury in Rhode Island. American Journal of Public Health 1986;76:773-778.

Whitman S, Coonley-Hoganson R, Desai BT. Comparative head trauma experience in two socioeconomically different Chicago-area commmunities: A population study. American Journal of Epidemiology 1984; 4:560-580. Cooper KD, Tabaddor K, Hauser WA, et al. The epidemiology of head injury in the Bronx. Neuroepidemiology 1983;2:70-88.

Kraus JF, Black MA, Hessol N, et al. The incidence of acute brain injury and serious impairment in a defined population. American Journal of Epidemiology 1984;119:186-201.

MacKenzie EJ, Edelstein SL, Flynn JP. Hospitalized head-injured patients in Maryland: Incidence and severity of injuries. Maryland Medical Journal 1989:38:725-732.

Thurman DJ, Jeppson L, Burnett CL, et al. Surveillance of traumatic brain injuries in Utah. West J Med 1996;165:192-196.

Centers for Disease Control and Prevention. Traumatic brain injury — Colorado, Missouri, Oklahoma, and Utah, 1990-1993. MMWR 1997;46(1):8-11.

Gabella B, Hoffman RE, Marine WW, Stallones L. Urban and rural traumatic brain injuries in Colorado. AEP 1997;7(3):207-212.

Thurman DJ, et al. Traumatic brain injury in the United States: A report to Congress. Atlanta, Centers for Disease Control and Prevention, 1999.

Sosin DM, Sniezek JE, Waxweiler RJ. Trends in death associated with brain injury, 1979-1992. JAMA 1995;273:1778-80.

Max W, MacKenzie EJ, Rice DP. Head injuries: costs and consequences. Journal of Head Trauma Rehabilitation 1991;6(2):76-91.

Thurman DJ, Sniezek JE, Johnson D, Greenspan A, Smith SM. Guidelines for Surveillance of Central Nervous System Injury. Atlanta: Centers for Disease Control and Prevention, 1995.

National Committee for Injury Prevention and Control. Injury Prevention: Meeting the Challenge. New York: Oxford University Press, 1989.

Pope AM, Tarlov AR, editors. Disability in America: Toward a National Agenda for Prevention. Washington, DC: National Academy Press, 1991.

www.cdc.gov

Concussion

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About Concussion

A blow or jolt to the head can disrupt the normal function of the brain. Doctors often call this type of brain injury a “concussion” or a “closed head injury.” Doctors may describe these injuries as “mild” because concussions are usually not life threatening. Even so, the effects of a concussion can be serious.

After a concussion, some people lose consciousness or are “knocked out” for a short time, but not always – you can have a brain injury without losing consciousness. Some people are simply dazed or confused. Sometimes whiplash can cause a concussion.

Because the brain is very complex, every brain injury is different. Some symptoms may appear right away, while others may not show up for days or weeks after the concussion. Sometimes the injury makes it hard for people to recognize or to admit that they are having problems.

The signs of concussion can be subtle. Early on, problems may be missed by patients, family members, and doctors. People may look fine even though they’re acting or feeling differently.

Because all brain injuries are different, so is recovery. Most people with mild injuries recover fully, but it can take time. Some symptoms can last for days, weeks, or longer.

In general, recovery is slower in older persons. Also, persons who have had a concussion in the past may find that it takes longer to recover from their current injury.

This brochure explains what can happen after a concussion, how to get better, and where to go for more information and help when needed.

Medical Help

People with a concussion need to be seen by a doctor. Most people with concussions are treated in an emergency department or a doctor’s office. Some people must stay in the hospital overnight for further treatment.

Sometimes the doctors may do a CT scan of the brain or do other tests to help diagnose your injuries. Even if the brain injury doesn’t show up on these tests, you may still have a concussion.

Your doctor will send you home with important instructions to follow. For example, your doctor may ask someone to wake you up every few hours during the first night and day after your injury.

Be sure to carefully follow all your doctor’s instructions. If you are already taking any medicines – prescription, over-the-counter, or “natural remedies” – or if you are drinking alcohol or taking illicit drugs, tell your doctor. Also, talk with your doctor if you are taking “blood thinners” (anticoagulant drugs) or aspirin, because these drugs may increase your chances of complications. If it’s all right with your doctor, you may take acetaminophen (for example, Tylenol®* or Panadol®*) for headache or neck pain.

*Use of trade names is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.

Danger Signs – Adults

In rare cases, along with a concussion, a dangerous blood clot may form on the brain and crowd the brain against the skull. Contact your doctor or emergency department right away if, after a blow or jolt to the head, you have any of these danger signs:

1. Headaches that get worse
2. Weakness, numbness, or decreased coordination
3. Repeated vomiting

The people checking on you should take you to an emergency department right away if you:

1. Cannot be awakened
2. Have one pupil – the black part in the middle of the eye – larger than the other
3. Have convulsions or seizures
4. Have slurred speech
5. Are getting more and more confused, restless, or agitated

Danger Signs – Children

Take your child to the emergency department right away if the child has received a blow or jolt to the head and:

1. Has any of the danger signs for adults
2. Won’t stop crying
3. Can’t be consoled
4. Won’t nurse or eat

Although you should contact your child’s doctor if your child vomits more than once or twice, vomiting is more common in younger children and is less likely to be an urgent sign of danger than it is in an adult.

Symptoms of Concussion

“I just don’t feel like myself.”

The type of brain injury called a concussion has many symptoms. These symptoms are usually temporary, but may last for days, weeks, or even longer. Generally, if you feel that “something is not quite right,” or if you’re “feeling foggy,” you should talk with your doctor.

Here are some of the symptoms of a concussion:

1. Low-grade headaches that won’t go away
2. Having more trouble than usual:
a. Remembering things
b. Paying attention or concentrating
c. Organizing daily tasks
d. Making decisions and solving problems
3. Slowness in thinking, acting, speaking, or reading
4. Getting lost or easily confused
5. Neck pain
6. Feeling tired all the time, lack of energy
7. Change in sleeping pattern:
a. Sleeping for much longer periods of time than before
b. Trouble sleeping or insomnia
8. Loss of balance, feeling light-headed or dizzy
9. Increased sensitivity to:
a. Sounds
b. Lights
c. Distractions
10. Blurred vision or eyes that tire easily
11. Loss of sense of taste or smell
12. Ringing in the ears
13. Change in sexual drive
14. Mood changes:
a. Feeling sad, anxious, or listless
b. Becoming easily irritated or angry for little or no reason
c. Lack of motivation

Young Children

Although children can have the same symptoms of brain injury as adults, it is harder for young children to let others know how they are feeling. Call your child’s doctor if your child seems to be getting worse or if you notice any of the following:

1. Listlessness, tiring easily
2. Irritability, crankiness
3. Change in eating or sleeping patterns
4. Change in the way they play
5. Change in the way they perform or act at school
6. Lack of interest in favorite toys
7. Loss of new skills, such as toilet training
8. Loss of balance, unsteady walking

Older Adults

Older adults with a brain injury may have a higher risk of serious complications such as a blood clot on the brain. Headaches that get worse or an increase in confusion are signs of this complication. If these signs occur, see a doctor right away.

Getting Better After a Concussion

“Sometimes the best thing you can do is just rest and then try again later.”

How fast people recover from brain injury varies from person to person. Although most people have a good recovery, how quickly they improve depends on many factors. These factors include how severe their concussion was, what part of the brain was injured, their age, and how healthy they were before the concussion.

Rest is very important after a concussion because it helps the brain to heal. You’ll need to be patient because healing takes time. Return to your daily activities, such as work or school, at your own pace. As the days go by, you can expect to gradually feel better.

If you already had a medical problem at the time of your concussion, it may take longer for you to recover from your brain injury. Anxiety and depression may also make it harder to adjust to the symptoms of brain injury.

While you are healing, you should be very careful to avoid doing anything that could cause a blow or jolt to your head. On rare occasions, receiving another concussion before a brain injury has healed can be fatal.

Even after your brain injury has healed, you should protect yourself from having another concussion. People who have had repeated brain injuries, such as boxers or football players, may have serious problems later in life. These problems include difficulty with concentration and memory and sometimes with physical coordination.

Tips for Healing – Adults

Here are a few tips to help you get better:

01. Get plenty of sleep at night, and rest during the day.
02. Return to your normal activities gradually, not all at once.
03. Avoid activities that could lead to a second brain injury, such as contact or recreational sports, until your doctor says you are well enough to take part in these activities.
04. Ask your doctor when you can drive a car, ride a bike, or operate heavy equipment because your ability to react may be slower after a brain injury.
05. Talk with your doctor about when you can return to work or school. Ask your doctor about ways to help your employer or teacher understand what has happened to you.
06. Consider talking with your employer about returning to work gradually and changing your work activities until you recover.
07. Take only those drugs that your doctor has approved.
08. Don’t drink alcoholic beverages until your doctor says you are well enough to do so. Alcohol and certain other drugs may slow your recovery and can put you at risk of further injury.
09. If it’s harder than usual to remember things, write them down.
10. If you’re easily distracted, try to do one thing at a time. For example, don’t try to watch TV while fixing dinner.
11. Consult with family members or close friends when making important decisions.
12. Don’t neglect your basic needs such as eating well and getting enough rest.

Tips for Healing – Children

Parents and caretakers of children who have had a concussion can help them heal by:

1. Having the child get plenty of rest.
2. Making sure the child avoids activities that could result in a second blow or jolt to the head – such as riding a bicycle, playing sports, or climbing playground equipment – until the doctor says the child is well enough to take part in these activities.
3. Giving the child only those drugs that the doctor has approved.
4. Talking with the doctor about when the child should return to school and other activities and how to deal with the challenges the child may face.
5. Sharing information about concussion with teachers, counselors, babysitters, coaches, and others who interact with the child so they can understand what has happened and help meet the child’s needs.

Where to Get Help With a Concussion

“It was the first time in my life that I couldn’t depend on myself.”

There are many people who can help you and your family as you recover from your brain injury. You don’t have to do it alone.

Show this brochure to your doctor or health care provider and talk with them about your concerns. Ask your doctor whether you need specialized treatment and about the availability of rehabilitation programs.

Your doctor may be able to help you find a health care provider who has special training in the treatment of concussion. Early treatment of symptoms by professionals who specialize in brain injury may speed recovery. Your doctor may refer you to a neurologist, neuropsychologist, neurosurgeon, or specialist in rehabilitation.

Keep talking with your doctor, family members, and loved ones about how you are feeling, both physically and emotionally. If you do not think you are getting better, tell your doctor. For more information, see Resources for Getting Help.

Help for Families and Caregivers

“My husband used to be so calm. But after his injury, he started to explode over the littlest things. He didn’t even know that he had changed.”

When someone close to you has a brain injury, it can be hard to know how best to help. They may say that they are “fine” but you can tell from how they are acting that something has changed.

If you notice that your family member or friend has symptoms of brain injury that are getting worse or are not getting better, talk to them and their doctor about getting help. They may also need help if you can answer YES to any of the following questions:

1. Has their personality changed?
2. Do they get angry for no reason?
3. Do they get lost or easily confused?
4. Do they have more trouble than usual making decisions?

You might also want to talk with people who have experienced what you are going through. The Brain Injury Association can put you in contact with people who can help.

Resources for Getting Help

“I thought I was all alone, but I’m not. There are lots of people out there who understand what I’ve been through.”

Several groups help people with brain injury and their families. They provide information and put people in touch with local resources, such as support groups, rehabilitation services, and a variety of health care professionals.

Among these groups, the Brain Injury Association of America (BIAA) has a national office that gathers scientific and educational information and works on a national level to help people with brain injury. In addition, 44 affiliated state Brain Injury Associations provide help locally.

You can reach the BIAA office by calling the toll-free BIAA National Help Line at 1-800-444-6443. You can also get information through the national BIAA Web site at www.biausa.org. Both the Help Line and the Web site can provide you with information about your closest state Brain Injury Association.

More information about brain injury is available through the Centers for Disease Control and Prevention (CDC) Web site at www.cdc.gov/ncipc/tbi.

 

Centers for Disease Control and Prevention

 

 

Coma

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Description

A coma is a profound or deep state of unconsciousness. The affected individual is alive but is not able to react or respond to life around him/her. Coma may occur as an expected progression or complication of an underlying illness, or as a result of an event such as head trauma. A persistent vegetative state, which sometimes follows a coma, refers to a condition in which individuals have lost cognitive neurological function and awareness of the environment but retain noncognitive function and a perserved sleep-wake cycle. It is sometimes described as when a person is technically alive, but his/her brain is dead. However, that description is not completely accurate. In persistent vegetative state the individual loses the higher cerebral powers of the brain, but the functions of the brainstem, such as respiration (breathing) and circulation, remain relatively intact. Spontaneous movements may occur and the eyes may open in response to external stimuli, but the patient does not speak or obey commands. Patients in a vegetative state may appear somewhat normal. They may occasionally grimace, cry, or laugh.

Treatment

Once the patient is out of immediate danger, although still in coma or vegetative state, the medical care team will concentrate on preventing infections and maintaining the patient’s physical state as much as possible. Such maintenance includes preventing pneumonia and bed sores and providing balanced nutrition. Physical therapy may also be used to prevent contractures (permanent muscular contractions) and orthopedic deformities that would limit recovery for the patients who emerge from coma.

Prognosis

The outcome for coma and vegetative state depends on the cause and on the location, severity, and extent of neurological damage: outcomes range from recovery to death. People may emerge from a coma with a combination of physical, intellectual, and psychological difficulties that need special attention. Recovery usually occurs gradually, with patients acquiring more and more ability to respond. Some patients never progress beyond very basic responses, but many recover full awareness. Patients recovering from coma require close medical supervision. A coma rarely lasts more than 2 to 4 weeks. Some patients may regain a degree of awareness after vegetative state. Others may remain in a vegetative state for years or even decades. The most common cause of death for a person in a vegetative state is infection such as pneumonia.

Research

The NINDS supports research on neurological conditions such as coma and persistent vegetative state. This research is aimed at finding ways to prevent, treat, and cure these conditions.

These articles, available from a medical library, are sources of in-depth information on coma:

Plum, F. “Disturbances of Consciousness and Arousal.” In Cecil Textbook of Medicine, 19th edition, W.B. Saunders Co., Philadelphia, pp. 2048-2063 (1992).

Harris, J, and Berger, J. “Clinical Approach to Stupor and Coma.” Chapter 5 in Neurology in Clinical Practice, Vol. 1, Butterworth-Heinemann, Boston, pp. 43-63 (1991).

National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892

ninds.nih.gov

Cognitive and Communication Disorders

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What Are the Cognitive and Communication Problems That Result From Traumatic Brain Injury?

Cognitive and communication problems that result from traumatic brain injury vary from person to person. These problems depend on many factors which include an individual’s personality, preinjury abilities, and the severity of the brain damage.

The effects of the brain damage are generally greatest immediately following the injury. However, some effects from traumatic brain injury may be misleading. The newly injured brain often suffers temporary damage from swelling and a form of “bruising” called contusions. These types of damage are usually not permanent and the functions of those areas of the brain return once the swelling or bruising goes away. Therefore, it is difficult to predict accurately the extent of long-term problems in the first weeks following traumatic brain injury.

Focal damage, however, may result in long-term, permanent difficulties. Improvements can occur as other areas of the brain learn to take over the function of the damaged areas. Children’s brains are much more capable of this flexibility than are the brains of adults. For this reason, children who suffer brain trauma might progress better than adults with similar damage.

In moderate to severe injuries, the swelling may cause pressure on a lower part of the brain called the brainstem, which controls consciousness or wakefulness. Many individuals who suffer these types of injuries are in an unconscious state called a coma. A person in a coma may be completely unresponsive to any type of stimulation such as loud noises, pain, or smells. Others may move, make noise, or respond to pain but be unaware of their surroundings. These people are unable to communicate. Some people recover from a coma, becoming alert and able to communicate.

In conscious individuals, cognitive impairments often include having problems concentrating for varying periods of time, having trouble organizing thoughts, and becoming easily confused or forgetful. Some individuals will experience difficulty learning new information. Still others will be unable to interpret the actions of others and therefore have great problems in social situations. For these individuals, what they say or what they do is often inappropriate for the situation. Many will experience difficulty solving problems, making decisions, and planning. Judgment is often affected.

Language problems also vary. Problems often include word-finding difficulty, poor sentence formation, and lengthy and often faulty descriptions or explanations. These are to cover for a lack of understanding or inability to think of a word. For example, when asking for help finding a belt while dressing, an individual may ask for “the circular cow thing that I used yesterday and before.” Many have difficulty understanding multiple meanings in jokes, sarcasm, and adages or figurative expressions such as, “A rolling stone gathers no moss” or “Take a flying leap.” Individuals with traumatic brain injuries are often unaware of their errors and can become frustrated or angry and place the blame for communication difficulties on the person to whom they are speaking. Reading and writing abilities are often worse than those for speaking and understanding spoken words. Simple and complex mathematical abilities are often affected.

The speech produced by a person who has traumatic brain injury may be slow, slurred, and difficult or impossible to understand if the areas of the brain that control the muscles of the speech mechanism are damaged. This type of speech problem is called dysarthria. These individuals may also experience problems swallowing. This is called dysphagia. Others may have what is called apraxia of speech, a condition in which strength and coordination of the speech muscles are unimpaired but the individual experiences difficulty saying words correctly in a consistent way. For example, someone may repeatedly stumble on the word “tomorrow” when asked to repeat it, but then be able to say it in a statement such as, “I’ll try to say it again tomorrow.”

How Are Cognitive and Communication Problems Assessed?

The assessment of cognitive and communication problems is a continual, ongoing process that involves a number of professionals. Immediately following the injury, a neurologist (a physician who specializes in nervous system disorders) or another physician may conduct an informal, bedside evaluation of attention, memory, and the ability to understand and speak. Once the person’s physical condition has stabilized, a speech-language pathologist may evaluate cognitive and communication skills, and a neuropsychologist may evaluate other cognitive and behavioral abilities. Occupational therapists also assess cognitive skills related to the individual’s ability to perform “activities of daily living” (ADL) such as dressing or preparing meals. An audiologist should assess hearing. All assessments continue at frequent intervals during the rehabilitative process so that progress can be documented and treatment plans updated. The rehabilitative process may last for several months to a year.

How Are Cognitive and Communication Problems Treated?

The cognitive and communication problems of traumatic brain injury are best treated early, often beginning while the individual is still in the hospital. This early therapy will frequently center on increasing skills of alertness and attention. They will focus on improving orientation to person, place, time, and situation, and stimulating speech understanding. The therapist will provide oral-motor exercises in cases where the individual has speech and swallowing problems.

Longer term rehabilitation may be performed individually, in groups, or both, depending upon the needs of the individual. This therapy often occurs in a rehabilitation facility designed specifically for the treatment of individuals with traumatic brain injury. This type of setting allows for intensive therapy by speech-language pathologists, physical therapists, occupational therapists, and neuropsychologists at a time when the individual can best benefit from such intensive therapy. Other individuals may receive therapy at home by visiting therapists or on an outpatient basis at a hospital, medical center, or rehabilitation facility.

The goal of rehabilitation is to help the individual progress to the most independent level of functioning possible. For some, ability to express needs verbally in simple terms may be a goal. For others, the goal may be to express needs by pointing to pictures. For still others, the goal of therapy may be to improve the ability to define words or describe consequences of actions or events.

Therapy will focus on regaining lost skills as well as learning ways to compensate for abilities that have been permanently changed because of the brain injury. Most individuals respond best to programs tailored to their backgrounds and interests. The most effective therapy programs involve family members who can best provide this information. Computer-assisted programs have been successful with some individuals.

What Research Is Being Done for Cognitive and Communication Problems Caused by Traumatic Brain Injury?

Researchers are studying many issues related to the special cognitive and communication problems experienced by individuals who have traumatic brain injuries. Scientists are designing new evaluation tools to assess the special problems that children who have suffered traumatic brain injuries encounter. Because the brain of a child is vastly different from the brain of an adult, scientists are also examining the effects of various treatment methods that have been developed specifically for children. These new strategies include the use of computer programs. In addition, research is examining the effects of some medications on the recovery of speech, language, and cognitive abilities following traumatic brain injury.

National Institute on Deafness and Other Communication Disorders
National Institutes of Health
31 Center Drive, MSC 2320
Bethesda, MD USA 20892-2320
nih.gov/nidcd

Biomechanics of Brain Injury

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Traumatic brain injury (TBI) is the main cause of death for patients less than 45 (1). TBI biomechanics explores the mechanical phenomena that cause the initial cranio-cerebral lesions and thus represents the starting point for the overall understanding of the TBI pathophysiology. TBI is the consequence of the spatiotemporal pressure variations occuring inside the brain during head traumas. The spatial distribution of the pressure gradient (PG) is responsible for the tissue strains (compression, tensile, shear), the cerebral lesions’ localisation and the consequent neurological signs (2). Beside skull’s deformation caused by the contact loading and determining skull vibrations and/or fractures, current biomechanical theories concern two inertial phenomena: the linear acceleration and the rotational head movements. The first theory explains the superficial brain lesions. The second theory seems better explain the deep cerebral lesions and the concussion mechanism but is still controversed (3). Here is exposed a new biomechanical approach that can explain the deep cerebral lesions and the common neurological signs observed after human head traumas.

Traumatic brain lesions

Focal and diffuse cerebral lesions are currently described. The focal lesions, also called cerebral contusions, are haemorrhagical and are visible on frequently performed radiological exams as the X-ray computed tomography. The focal lesions are often located in the superficial brain structures, close from the skull, but sometimes deep cerebral hematomas occur. The focal lesions always coexist with different degrees of diffuse cerebral lesions, also called “diffuse axonal injury” (DAI). The DAI is concentrated in the deep cerebral regions and is not visible on the radiological exams. Meanwhile, in accordance with its severity, the DAI is mainly responsible of various degrees of consciousness disturbances and further clinical outcome (2). The clinical entity corresponding to the rather pathological sense of the DAI term is the brain concussion.

Current Biomechanical Theories

The linear acceleration theory was first evoked about one century ago. Relative movements and secondary impacts occur between the skull and the brain during a head impact. The pressure increases in the superficial cerebral structures below the impact zone, proportionally to the head linear acceleration (4). This theory explains the superficial cerebral lesions’ occurrence. It cannot explain the preferential DAI localisation in the deep cerebral structures (8), neither the traumatic deep cerebral hematoma. It cannot axplain neither why the loss of consciousnes and the memory troubles are the most frequent clinic signs occuring after head trauma – despite the fact that the resposible cerebral structures are deeply located.

According to the rotational movements’ theory evoked in 1943 by Holbourn (5), DAI and deep cerebral hematoma are caused by the tensile strains occuring between superficial and deep cerebral structures during the head circular movements. In a large series of experiments on primates, Thibault and Gennarelli particularly supported the role of the rotational movements in the DAI occurrence (6).

The consequences of the skull’s vibrations are poorly understood. It is probable that the low-frequency skull vibrations (below 200 Hz) mainly cause deep cerebral lesions, while high-frequency vibrations have more consequences on the superficial cerebral structures (7).

In real life head trauma all these phenomena coexist. In the mean time, DAI and brain concussion also occured in pure linear accelerated experimental head trauma (5) even if under the current approach, the linear acceleration theory cannot explain how deep cerebral structures can be injured while superficial cerebral structures are respected.

Stereotactical Theory

The stereotactical approach considers the geometrical shape of the interface skull-brain, the close interactions between the two structures during their relative movements and the resultant pressure waves propagation.

The shape of the interface skull-brain is approximately spherical. The skull-brain relative movements, caused by the acceleration phenomena – linear or rotational – and by the skull vibrations, generate secondary pressure waves with an approximately spherical wave front. Because the brain tissue is isotrop on concentric plans, the wave propagation velocity toward the deep cerebral structures is spatially homogenous.

C = (E/r)0,5
C = wave propagation velocity; E = resilience; r = density

The spherical shape of the wave front is thus conserved. Its spoke and its surface progressively decrease. Despite attenuation phenomenon and according to the energy conservation law, the amplitude of the pressure waves, and thus the pressure gradient, progressively increases toward the deep cerebral structures. It will be maximal in the geometrical centre of the implied skull vault segment (figure 1), particularly if no significant energy consumption process occurs in the superficial cerebral structures before. If such a superficial cerebral contusion occur, a pressure wave “shadow cone” is delimited towards the deep cerebral structures and thus the stereotactical summation phenomena are partly perturbed.

In low or medium-energy impacts, the skull vibrations have a significant role by generating successive wave fronts. Cumulative effects related to the temporal summation phenomena thus add to the spatial (stereotactical) ones.

In high-energy impacts, the acceleration phenomena are predominant. Because of the skull fractures that often occur, the skull vibrations are perturbed and their stereotactical consequences reduced. In the mean time, the high acceleration effects diminish the relative importance of the skull vibrations’ consequences.

Discussion and Conclusion

The stereotactical phenomena explain common neurological signs

The stereotactical phenomena explain why the initial and reversible loss of consciousness (IRLC) is the most common posttraumatic neurological sign, even if the involved structure – the ascendant reticulate matter (ARM) – is placed in the deep cerebral regions. It can also explain why, after the IRLC, most patients don’t have any focal neurological deficit (motor, sensitive or visual) related to the superficial cerebral structures’ lesions or functional impairement. The functional recovery is faster for the neuronal circuits with less infrastructure lesions and if the superficial lesions were more important than the deep ones, the recovery of the focal deficits would be longer than the recovery of the consciousness.

The stereotactical phenomena also explain the high incidence of the memory disturbances after a head trauma as the result of the periventricular neuronal circuits’ functional impairment or lesions. At our best knowledge, this is the first theory to explain these clinical phenomena. The isolated functional impairment of the ARM could also be explained by the fact that the consisting neuronal fibres are less resistant because nonmyelinated. This argument is not applicable to the myelinated neuronal fibres whose functional impairment or lesions generate the frequent posttraumatic memory disturbances.

The stereotactical phenomena explain the deep cerebral lesions

The stereotactical approach can also explain the preferential localisation of the DAI in corona radiata, corpus callosum, fornix and upper brainstem (8). These anatomical regions correspond to geometrical centres of different skull vault segments. Deep traumatic cerebral hematomas can also be better understood as they occur close to the geometrical centre of the skull vault.

The stereotactical phenomena explain the importance of the contrecoup cerebral lesions

The stereotactical phenomena explain why the cerebral contrecoup lesions (CCL) are often more important than the direct lesions (DL). The bend spoke of the lateral skull segment is approximately equal to the bi-parietal skull diameter. According to the stereotactical theory the CCL are the consequence of the pressure waves’ stereotactical summation toward the geometrical centre of the implied skull vault segment. Thus, up to a critical energy lateral impact, the CCL occur before the DL.

The stereotactical phenomena explain why the cerebral contusions (direct or contrecoup) are often located in the temporal and the frontal lobes. These cerebral regions correspond to small bend spoke segments of the skull and contain their geometrical centre – where maximal stereotactical summation occurs.

The stereotactical phenomena are supported by prviously reported experimental data

In older experiments Gurdjian noted significant differences between the DAI localisation after head impacts on primates and dogs. The primates’ brains had predominant DAI in the upper brainstem while the dogs’ DAI was concentrated in the lower brainstem regions (9). These differences are unexplained by the current biomechanical theories, but they can be easily understood according to the stereotactical approach by the difference between the shape of the animals’ skull vaults and their geometrical centre localisation. According to the stereotactical approach, the DAI is concentrated in the geometrical centre of the skull vault and, as the primates’ skull vault is more incurved, their geometrical centre is placed higher than the dogs’ one.

Other stereotactical phenomena

The radiosurgery uses the stereotactical principle in order to avoid massive irradiation of the superficial structures when a deep cerebral lesion (tumour, malformation) has to be irradiated. The total irradiation doze, aimed to destroy the deep lesion, is spatially fractionated in many convergent beams. Thus, the superficial structures receive only small fractions of the total irradiation doze and are preserved.

Sounds are also pressure waves. Microphones with parabolic reflective surfaces and the concert halls’ architecture use the stereotactical principle in acoustic applications.

Conclusion

The stereotactical phenomena can explain common posttraumatic neurological signs and cerebral lesions. Its complementarity with the other biomechanical theories could allow us to integrate the TBI biomechanics in a common concept in order to better understand the TBI pathophysiology and also related pathological entities like boxers’ chronic encephalopathy or even Alzheimer’s disease (10). Further experimental and especially human observational research in TBI biomechanics is needed.

References

1. McIntosh TK, Smith DH, Meaney DF, Kotapka MJ, Gennarelli TA, Graham DI. Neuropathological sequelae of traumatic brain injury: relationship to neurochemical and biomechanical mechanisms. Lab Invest 74: 315-42, 1996

2. Teasdale, G, Mathew, P. Mechanisms of cerebral concussion, contusion and other effects of head injury. In: Julian R. Youmans editor, Neurological surgery. 4th ed. New York: W B Saunders Co, p 1533-46, 1996.

3. McLean, AJ Brain injury without head impact? In: Bandak, A.F., Eppinger, R.H., Ommaya, A.K. editors, Traumatic brain injury: bioscience and mechanics. Larchmont, NY, Mary Ann Liebert Inc, p 45-9, 1996.

4. Nahum, AM, Smith, RW, Ward, CC. Intracranial pressure dynamics during head impact. Proc. 21st Stapp Car Crash Conference, SAE No. 770922 p 339-66, 1977.

5. Holbourn, AS. Mechanics of head injuries. Lancet 2: 438-41, 1943

6. Thibault, LE, Gennarelli, TA. Brain injury: an analysis of neural and neurovascular trauma in the nonhuman primate. 34th Annual proceedings of the Association for the Advancement of Automotive Medicine, Des Plaines, IL, p 337-51, 1990.

7. Willinger, R, Taleb, L, Kopp, C. Modal and temporal analysis of head mathematical models. In: Bandak, A.F., Eppinger, R.H., Ommaya, A.K. editors, Traumatic brain injury: bioscience and mechanics. Larchmont, NY, Mary Ann Liebert Inc. p. 265-76, 1996.

8. Blumbergs, PC, Scott, G, Manavis, J, Wainwright, H, Simpson, DA, McLean, AJ. Staining of amyloid precursor to study axonal damage in mild head injury. Lancet 344: 1055-6, 1994.

9. Gurdjian, ES. Recent advances in the study of the mechanism of impact injury of the head – a summary. Clin Neurosurg 19: 1-42, 1972.

10. van Duijn, CM, Tanja, TA, Haaxma R Head trauma and the risk of Alzheimer desease Am J Epidemiol 135: 775-782, 1992.

Anoxia and Hypoxia

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Description

Specifically, anoxia is a condition in which there is an absence of oxygen supply to an organ’s tissues although there is adequate blood flow to the tissue. Hypoxia is a condition in which there is a decrease of oxygen to the tissue in spite of adequate blood flow to the tissue. Anoxia and hypoxia, however, are often used interchangeably–without regard to their specific meanings–to describe a condition that occurs in an organ when there is a diminished supply of oxygen to the organ’s tissues.

Anoxia and hypoxia may be caused by a number of events, such as smoke or carbon monoxide inhalation, high altitude exposure, strangulation, anesthetic accidents, or poisoning. In severe cases of anoxia and hypoxia, from any cause, the patient is often stuperous or comatose (in a state of unconsciousness) for periods ranging from hours to days, weeks, or months. Seizures, myoclonic jerks (muscle spasms or twitches), and neck stiffness may occur.

Treatment

Treatment of anoxia and hypoxia consists of establishing an adequate airway as soon as possible, using enough oxygen to saturate the blood, supporting the cardiovascular system as needed, and preventing or treating pneumonia. Respiratory assistance may be necessary.

Prognosis

If the patient’s respiratory and cardiovascular systems can be supported properly, recovery may occur, but depends upon the severity of injury. As recovery proceeds, a variety of psychological and neurological abnormalities may appear, persist for a time, and then disappear. Mental changes such as dementia or a psychosis may occur. Mental confusion, personality regression, parietal lobe syndromes, amnesia, hallucinations, and memory loss may also occur.

Research

The NINDS supports and conducts studies aimed at understanding neurological conditions that can damage the brain such as anoxia and hypoxia. The goals of these studies are to find ways to prevent and treat these conditions.

These articles, available from a medical library, are sources of in-depth information on anoxia and hypoxia:

Bradley, W, et al (eds). Neurology in Clinical Practice: Principles of Diagnosis and Management, vol. II, Butterworth-Heinemann, Boston, pp. 1343-1349 (1991).

Joynt, R (ed). Clinical Neurology, vol. 2, Chapter 17, J.B. Lippincott Co., Philadelphia, pp. 1-18 (1990).

Nyakas, C, Buwalda, B, and Luiten, P. “Hypoxia and Brain Development.” Progress in Neurobiology, 49:1; 1-51 (May 1996).

National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892

ninds.nih.gov