Review article
Contemporary issues in mild traumatic brain injury1

https://doi.org/10.1016/j.apmr.2003.03.001Get rights and content

Abstract

Rees PM. Contemporary issues in mild traumatic brain injury. Arch Phys Med Rehabil 2003;84:1885–94.

Objectives

To determine (1) minimum criteria in adults for clinical diagnosis of mild traumatic brain injury (TBI) and (2) whether persistent postconcussive syndrome exists as a nosologic entity.

Data sources

PubMed search by MEDLINE of head injuries from January 1977 to July 2002.

Study selection

All reviews and studies of mild TBI with special reference to those on persistent postconcussive syndrome having a general trauma cohort as a control comparison.

Data extraction

Review of design and other methodologic issues. Studies dependent on superior strength of evidence (as defined by the American Academy of Neurology) concerning the biologic nature of persistent postconcussive syndrome.

Data synthesis

A period of altered awareness with amnesia brought on by a direct craniofacial blow is the starting point in determining whether diffuse mild TBI has occurred. An amnestic scale is more helpful than Glasgow Coma Scale score in grading mild injury and in formulating minimum inclusion criteria for mild TBI. Neuropsychologic test results coupled with self-reported symptoms should not be taken as the primary source of evidence for mild TBI. Prolonged cognitive impairment after injury is not unique to brain trauma.

Conclusions

Persistent postconcussive syndrome after mild brain trauma, uncomplicated by focal injury, is biologically inseparable from other examples of the posttraumatic syndrome. To account for the persistent cognitive and behavioral sequelae of posttraumatic states, including persistent postconcussive syndrome, we need further studies on the emerging concept of limbic neuronal attrition occurring as a maladaptive response to pain and stress.

Section snippets

Methods

A computer-aided English-language search of head injuries by PubMed, indexed for MEDLINE, was undertaken for the 25-year period January 1977–July 2002. The study was supplemented by cross-indexing of searched bibliographies without date restriction and reviewing of monographs and standard texts on head injuries. Requested search intersections were between mild TBI set against the postconcussive syndrome, clinical diagnostic criteria, pathophysiology, biomechanics, neuropsychologic assessment,

Biomechanics and pathophysiology

Mild brain injury or concussion can be defined as a trauma-induced, pathophysiologic alteration in mental status that may or may not invoke loss of consciousness (LOC). A force applied to the skull sufficient to cause altered mentation is the usual starting point in determining that brain injury has occurred. Deceleration brain injury without head contact has been shown experimentally in comatosed nonhuman primates1 and in harnessed pilots crashing in military aircraft in which the rapidly

Discussion

Published evidence makes it clear that the diagnosis of mild TBI is founded on the acute injury characteristics. Diagnosis is manifestly more difficult when an injury is unwitnessed. A remembered head blow and continuous memory for all events will strongly suggest that there was no concussion to the brain. Dazing or a stunned sensation may be wrongly attributed to brain trauma when brought about by fear and being startled at the scene of an accident. Panic (“going into shock”) augmented by

Conclusion

Further studies are invited on the role of HPA axis dysfunction in the specific context of mild TBI by longitudinal evaluation of neuroendocrine function and hippocampal volume into the late postconcussional phase compared with head injury without symptoms of persistent postconcussive syndrome.

Acknowledgements

I thank Dr. Rosemary Basson for her suggestions in preparing the manuscript.

References (105)

  • J. Bullock

    Injury and cell function

  • G.P. Siegmund et al.
  • A.J. McLean et al.

    Biomechanics of closed head injury

  • D.C. Viano et al.

    Response of the head, neck and torso to pendulum impacts on the back

    J Crash Prev Inj Control

    (2001)
  • A.K. Ommaya et al.

    Subdural hematoma after whiplash injury

    Lancet

    (1969)
  • A.J. McLean

    Brain injury without head impact

    J Neurotrauma

    (1995)
  • B. Jennett

    Assessment of the severity of head injury

    J Neurol Neurosurg Psychiatry

    (1976)
  • D.R. Oppenheimer

    Microscopic lesions in the brain following head injury

    J Neurol Neurosurg Psychiatry

    (1968)
  • P.C. Blumbergs et al.

    Staining of amyloid precursor protein to study axonal damage in mild head injury

    Lancet

    (1994)
  • T.A. Gennarelli et al.

    Diffuse axonal injury and traumatic coma in the primate

    Ann Neurol

    (1982)
  • E.H. Pettus et al.

    Traumatically induced altered membrane permeabilityits relationship to traumatically induced reactive axonal change

    J Neurotrauma

    (1994)
  • R.L. Mittl et al.

    Prevalence of MR evidence of diffuse axonal injury in patients with mild head injury and normal head CT findings

    AJNR Am J Neuroradiol

    (1994)
  • M.P. Alexander

    Mild traumatic brain injury

    Neurology

    (1995)
  • J.B. Selhorst

    Neurological examination of head-injured patients

  • T. Kay et al.

    Definition of mild traumatic brain injury

    J Head Trauma Rehabil

    (1993)
  • S.S. Dikmen et al.

    Methodological issues in the study of mild head injury

    J Head Trauma Rehabil

    (1993)
  • J. van der Naalt et al.

    Computed tomography and magnetic resonance imaging in mild to moderate head injuryearly and late imaging related to outcome

    Ann Neurol

    (1999)
  • J. van der Naalt et al.

    One year outcome in mild to moderate head injurythe predictive value of acute injury characteristics related to complaints and return to work

    J Neurol Neurosurg Psychiatry

    (1999)
  • B. Jennett

    An introduction to neurosurgery

    (1977)
  • J.P. Kelly et al.

    Practice parameterthe management of concussion in sports (summary statement)

    Neurology

    (1997)
  • V.P. Culotta et al.

    Clinicopathological heterogeneity in the classification of mild head injury

    Neurosurgery

    (1996)
  • J.M. Furman et al.

    Benign paroxysmal positional vertigo

    N Engl J Med

    (1999)
  • R.M. Costanzo et al.

    Epidemiology and pathophysiology of olfactory and gustatory dysfunction in head trauma

    J Head Trauma Rehabil

    (1992)
  • J.S. Jeret et al.

    Clinical predictors of abnormality disclosed by computed tomography after mild head trauma

    Neurosurgery

    (1993)
  • H.S. Levin et al.

    Mild head injury

    (1989)
  • E. Teasdale et al.

    Imaging the injury

  • I. McDonald

    Diagnostic methods and investigation

  • R. Ashikaga et al.

    MRI of head injury using FLAIR

    Neuroradiology

    (1997)
  • J.C. McGowan et al.

    Magnetization transfer imaging in the detection of injury associated with mild head trauma

    AJNR Am J Neuroradiol

    (2000)
  • J.D. Lewine et al.

    Neuromagnetic assessment of pathophysiologic brain activity induced by minor head trauma

    AJNR Am J Neuroradiol

    (1999)
  • K.M. Cecil et al.

    Proton magnetic resonance spectroscopy for detection of axonal injury in the splenium of the corpus callosum of brain-injured patients

    J Neurosurg

    (1998)
  • T.W. McAllister et al.

    Brain activation during working memory 1 month after mild traumatic brain injury

    Neurology

    (1999)
  • M. Bergsneider et al.

    Dissociation of cerebral glucose metabolism and level of consciousness during the period of metabolic depression following human traumatic brain injury

    J Neurotrauma

    (2000)
  • R.M. Ruff et al.

    Selected cases of poor outcome following a minor brain traumacomparing neuropsychological and positron emission tomography assessment

    Brain Inj

    (1994)
  • R.J. Dolan et al.

    Neuropsychological dysfunction in depression; the relationship to regional cerebral blood flow

    Psychol Med

    (1994)
  • P.H. Altrocchi et al.

    Assessment of brain SPECT. Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology

    Neurology

    (1996)
  • A. Mitchener et al.

    SPECT, CT, and MRI in head injuryacute abnormalities followed up at six months

    J Neurol Neurosurg Psychiatry

    (1997)
  • A.C. Papanicolaou et al.

    Evoked potential correlates of posttraumatic amnesia after closed head injury

    Neurosurgery

    (1984)
  • R.J. McLelland et al.

    The postconcussional syndrome revisited

    J R Soc Med

    (1994)
  • Cited by (101)

    • The role of the stress system in recovery after traumatic brain injury: A tribute to Bruce S. McEwen

      2022, Neurobiology of Stress
      Citation Excerpt :

      Moreover, multiple studies have reported that psychometric assessments of postconcussion symptoms fail to differentiate individuals that have suffered mild TBI from those that have not (Dean et al., 2012; Meares et al., 2011; Ponsford et al., 2012). Diagnostic issues aside, assigning causality to the lasting cognitive and neuropsychiatric symptomology is also a challenge (Rees, 2003; Wojcik, 2014). There is considerable evidence that the psychosocial and cognitive aspects of postconcussive symptoms play a role in symptom duration, in a way that is additive to the initial physical injury (Hanna-Pladdy et al., 2001; Meares et al., 2011; Taylor, 2010).

    • Postconcussion syndrome

      2018, Handbook of Clinical Neurology
    • Functional (dissociative) retrograde amnesia

      2016, Handbook of Clinical Neurology
    View all citing articles on Scopus
    1

    No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated.

    View full text