First Study: Early Brain Scan Results after Trauma are Linked with Future Abilities

Past Studies

Past Studies reveal that dangerous conditions can occur in the brain after injury– bleeding in the brain, blood clots, swelling, and compression of brain tissue. For instance, bleeding and the presence of clotted blood between the brain and the brain’s covering characterize life-threatening “subdural hematomas”. A subdural hematoma can accumulate as a mass and actually displace the brain. Displacement of the brain can cause a “midline shift” when the middle of the brain is moved from its normal position. “Cortical and subcortical contusions” refer to bruised tissue within the brain. It consists of blood and tissue swelling in specific locations. Bleeding in the brain, blood clots, and swelling are of great concern because they can cause further brain injury, stroke, and even death. If detected, they can be monitored or medical intervention can take place to prevent further injury.The size and location of subdural hematomas, cortical and subcortical contusions can be detected on x-rays taken of the brain taken with Computerized Tomography (CT Scan), an imaging technique that detects structural damage to the brain. A CT Scan takes pictures of very thin layers of the brain tissue. Layering these pictures produces an image of the brain, like the slices of bread that make up a loaf. CT Scans have been used to guide treatment and medical interventions, but the results of CT Scans have not been used to predict an individual’s long-term abilities and need for assistance from others. Physicians are very limited in ways to determine what a person’s exact abilities will be like after recovery, although they are frequently asked this question. This is the first large study to evaluate the relationship between CT Scan results and an individual’s eventual need for assistance with walking, self-care tasks (i.e. dressing, bathing, toileting), and supervision from others for safety.

This Study 

This Study included 1,839 individuals with traumatic brain injury from 17 Traumatic Brain Injury Model Systems centers. All participants received at least one CT Scan during the first week after their brain injuries. All were admitted to an acute inpatient rehabilitation program. The individuals were evaluated at discharge from rehabilitation for independence with self-care tasks, walking, continence, and need for supervision. At one year post-injury, 849 of the participants were again evaluated. At discharge from rehabilitation, individuals whose CT Scans showed a subdural hematoma with a midline shift of greater than 5 millimeters were more likely to require the assistance of another person for walking, bladder control, toileting tasks, dressing below the waist, and overall supervision. At one year from the brain injury, 57% of individuals with a midline shift of greater than 5 millimeters needed supervision in the home, as compared to 30% to 39% of individuals with less than a 5-millimeter midline shift. Both groups had comparable needs for assistance with self-care tasks and walking. The presence of a subdural hematoma itself was not associated with outcomes, but the degree to which the subdural hematoma caused a midline shift was associated with the need for assistance and supervision.Overall, individuals whose CT Scans showed subcortical contusions were 1 ½ to 2 times more likely to require more assistance at rehabilitation discharge for walking (32% vs. 18%), dressing below the waist (61% vs 44%), bladder control (34% vs 22%), toileting tasks (52% vs 35%), and overall supervision (61% vs 44%) than those participants without subcortical contusions. After one year, participants who had subcortical contusions more frequently required assistance with walking ( 15% vs 8%) and stair climbing (15% vs. 9%). Individuals with cortical contusions located on both sides of the brain in the front (frontal lobes) and the lateral surfaces (temporal lobes) needed more assistance with overall supervision at rehabilitation discharge than participants with no cortical contusions or cortical contusions on just one side of the brain.  

Who May Be Affected By These Findings

Health care providers and administrators; researchers; caregivers; individuals with brain injuries

Caveats

In contrast to earlier studies, individuals whose CT Scans indicated less than 5 millimeters of a midline shift, general brain swelling, and compression of the small pockets surrounding the brainstem that contain spinal fluid (“cisternal compression”) did not demonstrate poorer outcomes at one year after their brain injury.

Bottom Line

In this study, individuals whose early CT Scans indicated a midline shift of greater than 5 millimeters or a subcortical contusion demonstrated a greater need for assistance with walking, self-care tasks, and supervision at discharge from rehabilitation and a greater need for overall supervision one year after the injury. Individuals with subcortical contusions required the most assistance and supervision overall. Participants whose early CT Scans showed cortical contusions on both sides of the brain in the front (frontal lobes) or the lateral surfaces (temporal lobes) required more overall supervision at rehabilitation discharge, but did not have an increased need for assistance with walking and self-care tasks. The researchers state that these results are generalizable and should be considered when planning rehabilitation and discharge needs, as well as managing healthcare dollars.

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