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Treatment and Diagnosis of Brain Injury - Fact Sheet

When a brain injury occurs and medical attention is required, the initial place of treatment is likely to be the emergency department of a hospital. The priority of care is to make an initial diagnosis, stabilise the patient’s condition and arrange for appropriate treatment.

Stabilisation includes providing respiration (breathing assistance which may require the use of ventilators) and maintaining blood circulation. Medical staff will also attend to secondary problems that arise from the injury, such as blood clotting, bleeding and brain swelling, and they will ensure that the oxygen supply to the brain is maintained. The treatment team caring for the patient at this point can be expected to involve emergency medical and nursing staff including the neurosurgical registrar and neurosurgical consultant.

Tests

X-rays, Computerised Axial Tomography (CT), Magnetic Resonance Imaging (MRI), and other tests may be performed to establish the nature and extent of the patient’s injuries. The CT brain scan provides a series of X-rays at different levels of the brain and can be used to determine whether surgery is needed. Depending on the results of the scan the patient may be transferred to an operating room for surgery, intensive care unit (ICU) or a general surgical/medical ward. An MRI provides a detailed picture of the brain without using X-rays, but is more expensive.

Surgery

Approximately half of severely head-injured patients will need surgery to remove or repair haematomas or contusions. These are often emergency procedures. In other cases such as some brain tumours more time is available to prepare the patient for surgery.

Pre-surgery

Prior to surgery your doctor will, when possible, seek informed consent from you. Informed consent means that you understand the costs, benefits and possible adverse outcomes of surgery. In an effort to fulfil their legal obligations some doctors will describe a long list of all the potential disasters that might occur during and after surgery. This can be frightening to say the least so be aware that you can tell your doctor how much or how little information you want.

There are a myriad of tests to be done prior to surgery and not all of them are specific to your brain. Your doctor needs to be sure that your other organs are capable of surviving surgery so an examination of your heart and lungs as well as blood tests is common.

The night before your surgery you may be feeling anxious or frightened, possibly experiencing some difficulty sleeping. If you are feeling anxious or feel you will need medication to help you sleep, tell the nursing staff.

Surgery

On the day of your surgery you will be wheeled in your bed from the ward to the operating theatre where the nurses will double or even triple check everything from your name to any allergies you may have.

You may also notice that operating theatres are quite cold. If you feel cold say so and a nurse can get you a heated blanket.

Next comes your meeting with the anaesthetist who will give you some intravenous medication that will send you to sleep.

Post-surgery

The next thing you know the operation is over and you are either in the recovery room or in the intensive care unit.

It is common for people to experience headache immediately after brain surgery and you should notify the recovery nurses immediately if you are in pain.

The recovery room is attached to the operating theatre and you will be kept there until you are awake enough to be transferred back to the ward

Intensive Care

It may be necessary for the patient to go to an intensive care unit (ICU) if special drugs or assistance with breathing are required. Here the patient is attached to a range of tubes and machines. This may be disturbing for visitors to view.

The patient is often heavily sedated and may be unconscious. Pads may cover the eyes to keep them closed and to prevent them from drying out. If an operation was required, the patient’s hair may have been partly shaved. The patient’s breathing may be assisted by a Ventilator and the patient will be unable to speak. Visitors are often unsure of how to behave but it is generally accepted that you should talk to the person and behave as if the person is conscious. It is not known if the patient can hear or understand what is going on.

Typically patients do not remember anything of their stay in the intensive care unit.

Brain Swelling

After any surgery, it is not unusual, at first, to feel worse than you did before. This can be depressing if you are not prepared for it. You have just had brain surgery. That is a lot for your body to cope with. The post-op swelling means it will be a while before you feel the benefit from your surgery.

Sometimes when the brain is injured swelling occurs and fluids accumulate within the brain space. It is normal for bodily injuries to cause swelling and disruptions in fluid balance. But when an injury occurs inside the skull-encased brain, there is no place for swollen tissues to expand and no adjoining tissues to absorb excess fluid. This leads to increased intracranial pressure (ICP). High ICP can cause delicate brain tissue to be crushed, or parts of the brain to herniate across structures within the skull, causing severe damage.

Spinal Injuries

In cases where spinal injury is even suspected the patient may be placed in a hard collar and receive special nursing care to prevent further injury to the spine. It is important to remember that hard collars are used if there is any possibility of spinal injury. Hard collars are used as a precaution and do not mean that the patient has a spinal injury.

Coma

Coma is a loss of consciousness in which patients typically do not open their eyes, do not speak and cannot follow instructions. In the case of a mild brain injury, the loss of consciousness, or coma, may last for one or two minutes, while coma after a severe injury can continue for days and, in some cases, even longer.

Glasgow Coma Scale

A measure called the Glasgow Coma Scale (GCS) is used to monitor the level of coma and the patient’s emergence from coma. It rates the patient according to response to stimulation, eye opening and ability to speak. A fully conscious person has a score of 15, a person in profound coma has a score of 3. Usually a shorter duration of coma and lower depth of coma (i.e. higher GCS score) is associated with a greater degree of recovery from the injury. However, patients who have been in a coma for a long time tend to experience varying levels of recovery with some patients improving beyond the level that was initially expected.

Post Traumatic Amnesia (PTA)

An individual coming out of a coma doesn’t just wake up, but will go through a gradual process of regaining consciousness. This stage of recovery is called Post Traumatic Amnesia (PTA) and may last for hours, days or weeks. In this stage, an individual will not be able to store continuous or recent memory, such as what happened just a few hours or even minutes ago. Individuals in PTA are partially or fully awake, but are confused about the day and time, where they are, what is happening and sometimes who they are. They may be afraid, physically and verbally aggressive, disinhibited, agitated and restless. If physically able, they may wander. They may have hallucinations and delusional beliefs such as an adult believing he or she is a child. It is important to remember that this behaviour is due to the brain injury and that too much stimulation during this time can compound the person’s confusion and distress.

In conjunction with the Glasgow Coma Scale, length of PTA is frequently used as a guide to the severity of brain injury. A commonly used interpretation of the scale involves the following: