Grading TBI

According to the United States Center for Disease Control and Prevention (CDC) 5.3 million individuals have suffered disabilities as a direct result from a traumatic brain injury. Direct costs for hospital care, extended care and other services were estimated at $4.5 billion annually in 1985. These figures in no way include the physical, emotional and social costs to the injured person or their family. In 2001 there were over 1300 veterans who had received VA inpatient hospital care as a result of a traumatic brain injury and those figures did not include any veterans who may have received care but did not require hospitalization. (1)

As a result of traumatic injury to the brain the families of individuals who suffer are often faced with challenges and follow-up care and rehabilitation. When faced with a traumatic brain injury the future is often uncertain. Families often seek answers all about the likelihood that their loved one will be functional and able to live on their own.

Physicians and rehabilitation specialists use a variety of methods in order to gauge the severity of injury which an individual receives. A combination of those methods will often lead to the ability to grade the injury from mild to moderate to severe. By looking carefully at the statistics of individuals who recover from specific types of injuries they are better able to offer families and estimation of the ability of the individual.

While these grading systems may work with some degree of accuracy in the adult population, research published in early 2009 have concluded that although these grading systems may guide initial treatments and can be used to classify initial severity, they appear to have a limited value in predicting who is at risk for secondary cerebral insults and final outcome. (2)

Some of the methods used to determine the severity of a traumatic brain injury include the Glasgow coma scale, trauma scores, head CT classifications, the age of the patient and specific physiological monitoring done in the intensive care unit or at the scene of the accident.

The Glasgow coma scale is often used in pediatric population and has motor components as well as monitoring of pupil reactivity, deep pain stimulation and level of consciousness. Trauma scores often include variables which include systolic blood pressure, mental status, ability to maintain airway, skeletal injury and any open wounds.

Another commonly used grading system in individuals who have traumatic brain injury, especially in the rehabilitation process, is the Modified Rancho Los Amigos level. Levels range between one and 13 and help to distinguish the ability of the individual as well as predict future functioning depending upon the level evaluated and the amount of time following the traumatic brain injury.

Individuals who suffer from a traumatic brain injury will often experience posttraumatic amnesia which is generally defined as the period following the injury during which the person is not fully conscious or aware of the events that occurred after the trauma. Although it usually refers to the memory after the event, it is sometimes used to refer to memory prior to the trauma.

A patient who is suffered a mild traumatic brain injury has had physiological disruption of brain function manifested by either a period of loss of consciousness, a loss of memory, an alteration in mental state or focal neurological deficits that can or cannot be transient. However, individuals who have a mild traumatic brain injury will not lose consciousness for more than 30 minutes and will not have posttraumatic amnesia for greater than 24 hours.

Individuals who have a moderate brain injury will have a Glasgow coma scale of between nine and 12, where the duration of loss of consciousness was 30 minutes to one week and the posttraumatic amnesia was greater than 24 hours but not more than one week. Individuals who suffer from moderate injuries will often have contusions or bleeding on their CT or MRI imaging studies.

Patients who suffer from a severe traumatic brain injury will have a Glassgow score of eight or less with the duration of loss of consciousness greater than one week and on this post amnesia exceeding one week. In the majority of instances individuals who have severe brain injuries will have positive findings on their imaging studies which can also include herniation of brain tissue or shifts in the brain matter.

Over the past 20 years physicians and researchers have become adept at grading the severity of the injury of individuals who have suffered from a traumatic brain injury. This has led to better advancements in initial care and follow-up rehabilitation. Through trial and error these grading systems has become objective and yielded better results because research and information can be shared from country to country and hospital to hospital when the same system for evaluation is used.

(1) Center for Disease Control and Prevention: Traumatic Brain Injury

(2) Lancet Neurology: Early Prognosis in Traumatic Brain Injury

RESOURCES

Centers for Disease Control and Prevention: Glasgow Coma Scale

Rancho Los Amigos National Rehabilitation Center: Family Guide to the Rancho Los Amigos Cognitive Functioning

Northeast Center for Special Care: Rancho Los Amigo Cognitive Scale Revised