Post Concussion and Post-TBI Traumatic Brain Injury Care

 

It may be easy to conceive of neuropsychiatric effects following obvious head injury when a person needs the attention of a Neurosurgeon or becomes comatose. It seems to surprise our patients when we are able to link seemingly “mild TBI” or even “concussion” to long-term neuropsychiatric dysfunction. In our multi-specialty clinic, we receive referrals for intractable psychiatric illness and also for ongoing consequences of nervous system injury.

The patients are often described as presenting a “diagnostic dilemma” and appear to have high comorbidity for emotional distress along with a coincident history of concussion or even more severe head injury. Because of the high comorbidity we have utilized objective testing of nervous system health & function. Common situations include treatment resistant depression, late onset attention or learning troubles, emotional instability, personality change, and head pain/headache with mood disorder.

In a comprehensive review of the Nationwide (Health) Registry in Denmark, Orlovska found a higher risk of mood disorder, psychosis, and cognitive disorders in patients who suffered head injury of any type. Peak risk for eventual psychiatric illness occurs when head injury is suffered in the late latency/early puberty years when children are learning to externalize and sublimate affiliative and aggressive urges: “Head injury between ages 11 and 15 years was the strongest predictor for subsequent development of schizophrenia, depression, and bipolar disorder.

The added risk of mental illness following head injury did not differ between individuals with and without a psychiatric family history.” The overall importance of the nature of the injury (mild, moderate, or severe) did not seem to matter for depression, bipolar disorder or schizophrenia. (in their report, Organic Mental Disorder is a synonym for cognitive disorder)

The interview and previous records will often give a hint of comorbidity. Objective brain testing such as brain SPECT, or EEG/QEEG, neuropsychology, or even more intensive scanning such as fMRI, MEG, or PET scanning. Often, we look for pathologic indications of ongoing inflammation – for instance with blood testing. fMRI is a very delicate technique and should be obtained at a facility that employs its own physicist or mathematician. MEG is available in a few locales – and will employ a team of physicians AND scientists. PET exposes a patient to comparatively higher doses of radiation than SPECT, and is best performed by highly trained teams when used in neuropsychiatry. Once a diagnostic “picture” is available, treatment planning can occur.

If an ongoing post-concussion syndrome or TBI condition occurs, it should be vigorously treated. Aside from the obvious concern for current suffering, there is an important piece of trivia hidden in the data; fully treating a condition allows the person to recover their strength and fight off other unforeseen stressors such as idiopathic depression, or a new concussion.

We offer a number of modalities of treatment. Sometimes, a person is on too much or mis-directed pharmacologic treatment. Often, neurobiofeedback is applied. Generally, an ongoing immune based “activated microglial” response is involved in non-recovery, or recovery is slowed by overall frailty. Treatments might include perispinal etanercept injections or hyperbaric oxygen therapy.