Traumatic Brain Injury Assessment, Diagnosis and Management

Abstract

Traumatic brain injuries are caused by external forces that affect many areas of cognition. These types of brain injuries lead to impairments in many different areas within the brain. Such areas include attention, reasoning, judgment, language, memory, problem-solving, psychosocial and perceptual and motor abilities. In this paper we will discuss the different assessment techniques and methods needed to treat individuals with traumatic brain injuries. We will investigate a pre-morbid measure of functioning using the Weschler test (WTAR) to determine the pre-morbid level of intellectual functioning. Other assessments we will cover include the WAIS-IV Assessment, Trails A & B, Digit Symbol and the PASAT test. The level of the TBI will be discussed while recognizing the cognitive deficits the intellectual has been experiencing. Assessment deficits will also be observed when studying both pre-injury and post-injury performance. The diagnosis, assessment and management of a traumatic brain injury is critical in achieving a successful outcome.

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Mary is a 17-year-old girl. She had recently jumped off of a balcony that was over two stories high in an attempt to land in a swimming pool. Mary had lost her footing and slipped causing her to hit her head before falling into the pool. After being pulled out of the pool she was already unconscious and there was blood present on the side of her head where she had hit it. After a trip to the emergency room and a PET scan, Mary was found to have bruising and hemorrhaging within the tissues of her frontal lobe.

When looking at the Diagnostic and Statistical Manual (DSM) to medically diagnosis Mary’s injuries and acute symptoms I found that her lack of concentration, tiredness and trouble keeping up are all relevant and coincide with her traumatic brain injury. I would diagnosis Mary with a moderate traumatic brain injury. When determining the level of a TBI for a patient you must look at the symptoms. Mary has a moderate traumatic brain injury because she is showing many of the symptoms that come along with a moderate brain injury. Mary is showing signs of persistent headaches, mental fatigue, lack of concentration and she’s emotional. I chose this level of a TBI for Mary based on several factors. Mary had a loss of consciousness for over three hours and was in a coma. When first waking up she had trouble speaking but as time passed, she gradually improved. Mary was awake and able to respond to doctor’s verbally. Although doctor’s thought other problems may be present, a week later she was cleared by the neurologist to return to school when she felt ready. When trying to determine the level of a TBI, professionals may run a battery of tests to assess an individual’s brain, nerve functioning, and level of consciousness. A mild traumatic brain injury would consist of a patient being unconscious for less than 30 minutes and experiencing memory loss in less than a 24-hour period. They would score anywhere from a 13-15 on the Glasgow coma scale. Symptoms of a mild traumatic brain injury include headaches, fatigue, depression, confusion, blurry vision and temporary memory loss. A moderate traumatic brain injury happens when patients are unconscious anywhere from 30 minutes to 24 hours and will score between a 9-12 on the GCS.  Patients with a moderate traumatic brain injury can suffer from an inability to communicate, diminished cognitive skills, and even partial paralysis. Serious effects can accompany this type of injury. A traumatic brain injury is considered severe if the patient is unconscious for more than 24 hours, has memory loss for over seven days and scores an 8 or lower on the GCS. Symptoms of a severe brain injury include possibly death, permanent vegetative condition and/or state, and locked-in syndrome.

The Glasgow coma scale can be used immediately following a trauma by emergency medical professionals. It can also be used continuously throughout a patient’s treatment in the hospital and in rehabilitation to track progress. The Glasgow Coma Scale is however a great predictor for individuals who have more severe brain injuries. When assessing the presence and initial severity of a traumatic brain injury, the Glasgow Coma Scale is the most commonly used. The Glasgow Coma Scale is a neurological evaluation tool that was designed to assess and evaluate the level of consciousness in people who have brain damage. There are three different parameters that that can be observed, and they include motor response, eye response, and verbal response (Lezak, Howieson, Bigler & Tranel, 2012). Using the Glasgow coma scale to measure Mary’s initial level of unconsciousness will include medical professionals using this tool to initial determine the severity of her TBI. The Glasgow Coma Scale will determine Mary’s current level of consciousness (LOC) based on her responses to various stimuli that include motor, verbal and eye-opening responses. Mary’s score will give doctor’s an idea on how bad her injury is. When Mary awoke three hours later in the ICU, medical professionals can retest her using the GCS. Mary will be rescored using a criterion based on her eye-opening responses, verbal responses, and her motor responses. If Mary’s score went up, that means there are signs of significant improvement. A decreased GCS score is associated with worsening level of consciousness (Ramazani & Hosseini, 2019).

To determine Mary’s pre-morbid level of intellectual functioning using the National Adult Reading Test (NART) we can estimate Mary’s level of intellectual functioning and her levels of cognitive competence. The NART test is pretty reliable when estimating the comparison standard such as the premorbid ability level of a patient. NART is correlated with episodic and working memory and can estimate premorbid memory functioning. If Mary is cognitively impaired, then her current cognitive functions would need to be compared with her premorbid function. Reading tests such as the NART, have been found to provide more accurate estimations. This test depends on cognitive function at time of acquiring correct pronunciation. As stated in the journal article by Frick, Wahlin, Pachana, & Byrne (2011), This makes reading ability relatively resistant to brain injury and other disorders affecting cognitive function, and a good estimator of premorbid cognitive function (Franzen et al., 1997).  Mary’s performance on the NART will correlate to an elevated degree with both cognitive ability and premorbid intelligence. The NART will also give medical professionals an indication of Mary’s previous cognitive functions regarding her visual perception, speed/attention, memory, learning, phonemic fluency, and executive functions when looking at her existing school records and comparing them to how she processes information after the accident.

Assessing Mary’s post-injury intellectual ability using the Wechsler Adult Intelligence Scale/assessment –Fourth Edition will allow us to examine cognitive functioning following a TBI. This test is composed of 10 core subtests and five supplemental subtests, with the 10 core subtests comprising the Full-Scale IQ. I.Q. scores have been the subject of validity because the declines in verbal I. Q. scores, indicate the suppression of good performance. After testing Mary’s perceptual reasoning, working memory, processing speed, general intellectual ability, and verbal comprehension, post-injury, we would then see what abilities are better developed and her overall cognitive ability. As far as any deficits when comparing her pre-injury and post-injury performance TBI patients with mild to severe injuries showed a greater magnitude of discrepancies.

The Paced auditory serial addition test (PASAT) is a sensitive auditory test that requires a patient to add 60 pairs of digits that are randomized together by adding each digit to the digit that immediately precedes it (Lezak, et al., 2012). The digits are presented using four different rates of speed. Performance will then be scored based on the number of correct responses. This test is known to be hard even for individuals who are normal (i.e. no brain damage). This can be quite stressful for people such as Mary who may be cognitively impaired or intact. Attentional deficits can be elicited by the use of others tests so the PASAT test might not be necessary for Mary to take. This test could help determine why Mary has trouble focusing in class.

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The Trails A & B Digit Symbol test will provide professionals with a wide variety of information in regard to the cognitive skills of the patient. This test will also measure processing speed, visual screening ability, and attention. Because Mary is having trouble focusing, this test could help in finding why she is struggling to keep up. This test will assess Mary’s cognition along with her ability to think, reason, and remember. The professional will administer different cognitive tasks that are related to the speed of processing and executive functioning. If Mary shows signs of cognitive impairment during this test that means she could have suffered some type of brain damage from her accident.

Some recommendations for her rehabilitation is to start with an effective treatment plan. Rehabilitation specialists will provide Mary with support in the functional management of her brain injury. Mental healthcare professionals may also be necessary in helping Mary in terms of dealing with her mood swings and learning how to function normally at school again. Mary’s neuro-functional strengths and weaknesses should also be taken into consideration when designing a program of brain rehabilitation. 

After assessing, diagnosing, and managing Mary’s traumatic brain injury, we can see that she has faced intellectual incapacitation, lack of concentration and emotional distress. Managing and treating traumatic brain injuries comes with a variety of requirements. Such requirements include the assessment factors that accompany a TBI. Language, speech production and cognition. When effective treatment procedures are followed, Mary can learn how to continue and manage the symptoms of her injury. Assistive strategies can also be implemented with symptoms such as amnesia and some memory loss.

References

• Czubaj, C. A. (1996). Traumatic Brain Injury-An Intellectual’s Need for Cognitive Rehabilitation. Education, 117(1), 51. Retrieved from https://search-ebscohost-com.libauth.purdueglobal.edu/login.aspx?direct=true&db=f5h&AN=9611212649&site=eds-live
• Frick, A., Wahlin, T.-B. R., Pachana, N. A., & Byrne, G. J. (2011). Relationships between the National Adult Reading Test and memory. Neuropsychology, 25(3), 397–403. https://doi.org/10.1037/a0021988
• Lezak, M., Howieson, D., Bigler, E. & Tranel, D. (2012). Neuropsychological Assessment. (5th ed.). Oxford, NY: Oxford University Press.
• Ramazani, J., & Hosseini, M. (2019). Comparison of full outline of unresponsiveness score and Glasgow Coma Scale in Medical Intensive Care Unit. Annals of Cardiac Anaesthesia, 22(2), 143–148. https://doi.org/10.4103/aca.ACA_25_18