Talk:Traumatic brain injury/Archive 1

Major Issues in This Treatment of Head Trauma

Whoever wrote this frankly did not have a scientific or even clinical background in this area. First of all, the definition of concussion, a source of endless confusion for both patients and even clinicians, is something out of the 18th century ("shaking of the brain?"). He never clarifies that concussion references an altered mental status following a blow to the head or a violent acceleration or deceleration of the head, that there are grades or severities of concussion, and that not all concussions involve loss of consciousness. Any piece on head trauma that does not even adequately clarify the basis for the term concussion cannot be considered scientifically adequate. The author states "Diffused trauma to the brain is frequently associated with concussion (a shaking of the brain in response to sudden motion of the head), diffused axonal injury, or coma." This is just plain embarrassingly bad, and makes category errors (between syndromal descriptions like the term concussion and the notion of diffuse axonal injury ( a presumed substrate for both coma and other effects of concussion). The author repeatedly generates what is in all honesty a paraphasia ('diffused' for diffuse), and mangles the term 'diffuse axonal injury' which is the substrate for most of the symptoms in mild to moderate head trauma. The whole thing needs a major rewrite. The evidence that large sections of it may indeed be plagiarized is even more embarrassing. Why does Wikipedia tolerate this kind of stuff? DFW Harvard Medical School —Preceding unsigned comment added by 207.180.129.233 (talk) 19:36, 31 July 2008 (UTC)

Why don't you rewrite it then? (I didn't write it, but if you are a medical authority, why don't you rewrite it?) My issue is with this one sentence: "TBI is one of two subsets of acquired brain injury (brain damage that is not congenital); the other subset is non-traumatic brain injury, which does not involve external mechanical force (examples include stroke, meningitis and insufficient oxygen)." I rather think that TBI doesn't stand as the major subsection with all of the others falling under an equal level non-TBI section. I like the authorities that site the major types of ABI as being on equal footing such as is this manner, "TBI, Stroke, Brain Tumor, Brain Illness, etc." (There are a couple of others.) I am not a doctor. I think this way would be easier to follow. This is how I list it in Brain Injury Directory, a resource directory affiliated with the Brain Injury Network. Also, in a related matter, I am sad to say, several imminent authorities in the USA in the field of brain injury (ex: NIH, Brain Injury Association, etc.) have completely different definitions of ABI. Some say another name for TBI is ABI. Some say ABI is strokes, etc. Oh, I would like everybody to get on a consistent defintion for the benefit of the community of acquired brain injury survivors, of which I am a part. --Sabisue (talk) 18:55, 9 November 2008 (UTC)

This page was cut and pasted

You know this entire page is lifted verbatim from the NINDS? It's even got verbatim copies of the captions for pictures that are in that article but aren't in this one. Why not have a shorter article and just link to the NINDS article? Even if it's a public domain page, there's no need to have an identical copy of it here. plus, some of the stuff is extraneous to TBI. Like the 'What kind of research is the NINDS doing' section. Maybe that should be its own page. Or hey, we could just link to the NINDS page that says the same thing. Delldot 13:09, 21 October 2005 (UTC)

Unsourced

Most of the information in the article is unsourced, however correct. Shouldn't there be footnote sources specific to the piece of information? (i.e. Every couple sentences or so.) I'm not very familiar with Wikipedia sourcing standards. Joanna.Licata (talk) 13:31, 7 April 2008 (UTC)

Role in Neuroanatomy

The many cases of brain-injured patients, those who have suffered a trauma, lesion, or some other defect in their brain, have been very useful in providing a better understanding of the internal functions of the human brain. By studying the behavioral shortcomings and perceptual changes which result from these location-specific brain-injuries shed light on the neural anatomy of the brain.

The individual role of large regions of the brain, such as the primary lobes, can be better understood when considering what mental deficit the brain-injured patient is suffering from. For example, patients with occipital lobe damage who appear to bee suffering from a visual perception impairment can lead to the localization of the visual cortex in the occipital lobe. Patients with frontal lobe damage have demonstrated impairments in areas such as planning, motivation, and higher-level reasoning. Patients with left-hemisphere damage may have language impairments. In this way, many distinct brain functions can be linked to their point of physical origin in the brain – that is, the location of the brain injury.

Concern

A concern about this article being incomprehensive has been raised at Wikipedia:Village_pump_(policy)/Archive AB#Traumatic_brain_injury.--Piotr Konieczny aka Prokonsul Piotrus ^Talk 02:32, 6 June 2006 (UTC)

Links

I've removed some of the links in the external links section. I felt that they were excessive and unnecessary, and some of them were commercial links, e.g. for law offices. I think it's best to have fewer links and only links that provide information that's not given here. No need to link to multiple pages that duplicate the same info. If there's any problem with the removals, let me know here. delldot | talk 20:27, 21 January 2007 (UTC)

Major edit

I've just finished a major edit of this page. I noticed that there were a lot of unreferenced facts in the page that I thought needed references, e.g. facts that mentioned percentages or lists of symptoms. A lot of the material in this article is still directly from the public domain NINDS resource Hope through research. So I went through and cited the facts mentioned here that needed citation and were in that publication. Unfortunately, now the article is peppered with citations from that resource. I tried to avoid citation where I didn't think it was necessary, but there are still quite a lot. I think the only way to avoid this is to find other souces to cite instead. Let me know if you think of another solution or have any problems with my edit. delldot | talk 15:55, 26 January 2007 (UTC)

Another edit

In my most recent edit, I've removed "in minor cases" from PTSD section, since the memory/PTSD link in head trauma is controversial (some researchers even believe that lack of memory predisposes patients to PTSD, and others doubt that it is a factor at all). I also removed wording in the prevention section that I felt was too vague and not related enough to the prevention issue. I made other edits as well. I hope this is ok with everyone. If not, definitely let me know and we'll figure something out. Thanks, delldot | talk 03:10, 12 February 2007 (UTC)

brain injury due the lack of oxygen

I am living in New Zealand and have a brain injury due to the lack of oxygen while having an operation and would liek to chat to other people who have had the same , if you can mail me on polkie [at] xtra [dot] co.nz so we can chat and see how many people have the same troulbe i do and if they can help me to understand it better Thank you Tony Polkinghorne

famous persons additions

Some possible additions to the list of famous people with TBI's

Roald Dahl--- Head injury in plane crash during WWII-- later grounded due to headaches

Ambrose Bierce -- Head injury during Civil war---

Abraham Lincoln --During childhood was kicked in head by horse/mule, comatose ~7 days--

Vladimir Konstantinov-- Detroit red wings '91-'97 —Preceding unsigned comment added by 208.158.5.176 (talk) 21:04, 28 September 2007 (UTC)

Those are a few off the top of my head-- Thought I'd put it to a discussion before anything was added. If anyone knows more about the aforementioned cases and feels they qualify, please add them to the links. —Preceding unsigned comment added by 208.158.5.176 (talk) 20:51, 28 September 2007 (UTC)

I'm okay with this if folks want to add it, but first I'd recommend having a look at Wikipedia:Manual of Style (medicine-related articles)#Notable cases. Some people feel that famous persons with... should be limited to people who changed the public perception of the disease (e.g. Stephen Hawking in ALS), and I tend to agree that we should only include really famous cases, especially with a topic this broad. Also, each one would need a source. But in general, thanks for helping out, and by all means please be bold! delldot talk 23:30, 9 January 2008 (UTC)

Graphic

I'm confused by the pie chart graphic- specifically, I had to follow the link to the chart's source to figure out what "19% Struck By/Against" means ("colliding with a moving or stationary object"). Maybe someone can figure out how to make this graphic more useful within the article. QuixoticKate (talk) 21:27, 30 January 2008 (UTC)

How about "struck by or against something"? Trying to keep it terse, but don't want to sacrifice meaning, of course. delldot on a public computer talk 02:03, 31 January 2008 (UTC)

Sure, or "struck by/against an object;" or even just clarifying the accompanying text might work.QuixoticKate (talk) 21:02, 6 February 2008 (UTC)

Ooh, if I can get away with just changing the caption, that would be easier. Let me know what you think, I'm glad to change the image too. delldot on a public computer talk 02:53, 9 February 2008 (UTC)

Nice change. I think that works.QuixoticKate (talk) 04:08, 9 February 2008 (UTC)

Great, thanks much for catching that! delldot on a public computer talk 08:58, 9 February 2008 (UTC)

Notable cases

I move that we get rid of the Notable cases section. WP:MEDMOS#Notable cases does not recommend the section, especially for conditions that aren't rare. Plus it says that unsourced people must be removed, and the list here is all unsourced. To me, it doesn't make sense to have a section like this for something as common as TBI; the list could include virtually every professional boxer and probably a good chunk of football players and other athletes. If we have sources for the info, we could integrate any of these names into the text (e.g. with Phineas Gage) Any strong objections to my removing it? delldot talk 08:51, 11 March 2008 (UTC)

Apparently no strong objections, so I'm going ahead. Let me know if there's any problem. delldot talk 13:39, 15 March 2008 (UTC)

Title not capitalized

how do I change the title to capital letters? at present only "Traumatic" starts with a capital letter. —Preceding unsigned comment added by Moyalvytn (talk • contribs) 12:11, 3 April 2008 (UTC)

You could use the 'Move' tab at the top of the page, but per the guideline Wikipedia:Naming conventions that's not something you want to do in this case, the article title is correct as it stands. Only proper names should be capitalized in article titles. Wikipedia:Manual of Style (capital letters) is also helpful as to section titles, etc. --CliffC (talk) 13:54, 3 April 2008 (UTC)

GA Review

This review is transcluded from Talk:Traumatic brain injury/GA1. The edit link for this section can be used to add comments to the review.

In the lead section, paragraph 2: "TBI is a major cause of death and disability worldwide and the leading killer of people under age 45". I see that is later referenced to Dolce: "Post-traumatic vegetative state". Is this really true worldwide? I thought that the leading killer in that age group was infectious disease? Axl ¤ [Talk] 20:05, 31 October 2008 (UTC)

I've seen this figure cited all over the place. That source says, "Traumatic brain injury is the primary cause of death in the first 45 years of life. Mortality during the early post-traumatic phase has been significantly reduced in developed countries..." (p. vii) This juxtaposition with 'developed countries' suggests to me that they're not writing about the US like it's the only place in the world (the way a lot of authors unfortunately do). I can probably find a source that explicitly says 'worldwide' if that's really the case, though. If I had to guess about the infectious disease question, I'd say the causes probably vary based on what the criteria are used in the epidemiological studies. delldot ∇. 06:23, 1 November 2008 (UTC)

Crap, the under 45 statistic is from the US. Sorry about that, removed. However, I found a source for "Traumatic injury remains the leading worldwide cause of death and a major cause of disability in children." So that I kept. delldot ∇. 06:49, 1 November 2008 (UTC)

I'm still not convinced. I'll have to dig out that Lancet paper later. Another WHO link. Axl ¤ [Talk] 12:24, 1 November 2008 (UTC)

Actually, looking at that again I realize it's not clear whether that quote means "of death (in children) and ... disability in children" (as I had assumed) or if these are stats for two different groups (in which case it's even less likely to be true). Also I notice now they said traumatic injury rather than TBI, so that was a big blunder on my part! Glad you caught it. Removed now. delldot ∇. 18:42, 1 November 2008 (UTC)

From "Classification", paragraph 1: "All traumatic brain injuries are head injuries, but head injury is not necessarily brain injury: it may involve structures within the skull and outside of it such as the face or jaw". This point seems unnecessarily laboured. Axl ¤ [Talk] 20:09, 31 October 2008 (UTC)

Shortened to All traumatic brain injuries are head injuries, but the latter term may also refer to injury to other parts of the head. delldot ∇. 05:43, 1 November 2008 (UTC)

Thanks. Axl ¤ [Talk] 12:19, 1 November 2008 (UTC)

From "Classification", paragraph 1: "However, the terms head injury and brain injury are used synonymously", referenced to Hannay: "Neuropathology for neuropsychologists". While this may be true for neuropsychologists who see patients in the post-acute setting when the injury has been formally imaged, diagnosed and treated, this is certainly not true in the emergency department. In the ED, people are often brought in unconscious with evidence of superficial injury to the head. However at the time of admission, the cause of unconsciousness may not necessarily be brain injury; alcohol/drug intoxication, hypoglycemia, convulsion, or any of a number of other reasons may cause unconsciousness. Hence "head injury" does not necessarily imply "brain injury". Axl ¤ [Talk] 20:18, 31 October 2008 (UTC)

Can I get away with may be used synonymously? Or should I go into detail about the situations where the terms are used? I could add something like "before diagnosis" but I haven't so far. delldot ∇. 05:43, 1 November 2008 (UTC)

How about "are sometimes used synonymously"? Axl ¤ [Talk] 12:19, 1 November 2008 (UTC)

The CT image in "Classification", "Focal vs. diffuse" shows a left parietal subdural hematoma. Is it possible to add an arrow to point it out? Axl ¤ [Talk] 20:28, 31 October 2008 (UTC)

Not a problem for me to do, but the hematoma is awfully big, maybe a series of arrows? Or just a reference in the caption like "seen on the right side"? delldot ∇. 05:43, 1 November 2008 (UTC)

I think that a single arrow would be enough. I'm reluctant to say "seen on the right side", because the hematoma is left-sided. Still, I don't have a strong opinion about this, and I won't withhold GA status regardless of whether you leave the image as it is or change it slightly. Axl ¤ [Talk] 12:31, 1 November 2008 (UTC)

From "Signs and symptoms", paragraph 1: "Unconsciousness tends to last longer for people with injuries are on the left side of the brain than for those with injuries on the right". Wow, I didn't know that. You should submit it to WP:DYK. Axl ¤ [Talk] 20:38, 31 October 2008 (UTC)

In "Causes", I presume that the 19% "struck by an object" (yellow in the pie chart) refers to accidental injuries (because assault constitutes a further 11%)? Axl ¤ [Talk] 20:48, 31 October 2008 (UTC)

I'm afraid this has more to do with how it was written up in the patients' charts reviewed in the original studies--that's one problem with these types of studies, often there's not a lot of info to work with. But yeah, I assume the researchers did their best to separate violence and accidental injuries and at the very least didn't put people in more than one category each. delldot ∇. 05:43, 1 November 2008 (UTC)

Okay. Let's leave it as it stands. Axl ¤ [Talk] 12:47, 1 November 2008 (UTC)

"Causes", "Sports" strikes me as US-centric sports trivia. Still, I don't have a strong objection to it. Axl ¤ [Talk] 20:52, 31 October 2008 (UTC)

Yeah, a new user added that really recently. Not a good reference either. My preference would be to take it out, but I didn't want to bite. I think it would be best if sports were mentioned as one or two sentences in with the rest of the causes section, especially given that it's not the biggest cause. Maybe I'll leave them another note. delldot ∇. 05:43, 1 November 2008 (UTC)

Okay. Axl ¤ [Talk] 12:38, 1 November 2008 (UTC)

In "Complications", "Emotional and behavioral problems", paragraph 1: "Problems that may persist for one half year to two years after the injury may include...". I'm not sure what the lower time limit is. Axl ¤ [Talk] 21:58, 31 October 2008 (UTC)

Now that you mention it, yeah, that doesn't make any sense. Obviously they can last less than that too. Maybe the authors of the source were listing different opinions about the maximum length. At any rate, changed to "up to two years". delldot ∇. 05:43, 1 November 2008 (UTC)

Thanks. Axl ¤ [Talk] 12:38, 1 November 2008 (UTC)

In "Epidemiology", "Mortality": does the pie chart specifically refer to US mortality? Axl ¤ [Talk] 22:13, 31 October 2008 (UTC)

Yes, the reference cites a West Virginia study. I've tried to present a global view but it's difficult here because there's so much more info about the US available. For example, that source says, "The role of TBI as a cause of death and disability in the United States [8] and in Canada [9] is well-documented" and then only gives the US data in that detail (whereas it presents a lot of info from various countries throughout the rest of the paper). I can add other info about mortality in other countries, but I doubt I'll find a breakdown by causes like this. Alternately I can take the chart out. delldot ∇. 06:23, 1 November 2008 (UTC)

Thanks for clarifying that. I initially suspected that the chart referred to US mortality because of the high number of "firearms" fatalities. Now the chart is fine. Axl ¤ [Talk] 12:43, 1 November 2008 (UTC)

I've been thinking about spinning out a separate Complications of traumatic brain injury article and leaving a summary here for the massive complications section. What do you think? delldot ∇. 06:23, 1 November 2008 (UTC)

Yes, a spinout article is a good idea. Axl ¤ [Talk] 12:43, 1 November 2008 (UTC)

In other news, I think the expansion from abbreviations in the table makes it too wide and squishes the text next to it. What do you think about linking but with GCS, PTA, and LOC? Those abbreviations are used in the sentence in the text that references the table. delldot ∇. 06:35, 1 November 2008 (UTC)

Yes, that would be fine. Axl ¤ [Talk] 12:43, 1 November 2008 (UTC)

GA pass

Another fine article by Delldot. It is well-written, accurate, well-referenced, comprehensive, stable, neutral, and nicely-illustrated. I am delighted to assign "Good article" status.

Points for further improvement:-

• From "Complications", "Emotional and behavioral problems": "About 9% [of people with TBI] suffer mania", referenced to Rao, "Neuropsychiatric sequelae of traumatic brain injury". This seems like a rather high proportion of serious psychotic illness from a large group including relatively minor injuries such as concussion. Perhaps Delldot could review this reference?
• From "Causes", please consider reducing the "Sports" section.
• Consider developing a "History" section.

Thanks. Axl ¤ [Talk] 12:59, 1 November 2008 (UTC)

Thanks much Axl! delldot ∇. 18:42, 1 November 2008 (UTC)

Mortality in children

"Traumatic injury remains the leading worldwide cause of death and a major cause of disability in children." Reference: Carli & Orliaguet (Feb 2004). "Severe traumatic brain injury in children". Lancet 363, 584–585, PMID: 14987880. The paper is a review of management.

This statement in the Lancet references two other papers:-

1. Orliaguet (1998). "Predictive factors of outcome in severely traumatized children". Anesthesia & Analgesia 87, 537–542, PMID: 9728823.
2. Suominen (1998). "Severe and fatal childhood trauma". Injury 29, 425–430, PMID: 9813697.

The first paper is by the same authors: Orliaguet & Carli. The opening sentence is "Traumatic injuries are the leading cause of death and a major cause of disability among children". Two references are provided. The paper itself is about children attending a single trauma centre in France.

The second paper begins: "In industrialized countries trauma remains the leading cause of death after the first year of life", with two further references. Clearly this is quite a different assertion from "Traumatic injury remains the leading worldwide cause of death ... in children".

Orliaguet's references

The references from paper 1:-

1. Rodriguez (1990). "Childhood injuries in the United States". American Journal of Diseases of Children 144, 625–626, PMID: 2346145.
2. Mazurek (1994). "Pediatric injury patterns; pediatric trauma anesthesia". International Anesthesiology Clinics 32, 11–25, PMID: 8144250.

Unsurprisingly, the first reference discusses cases in the United States. The second reference compares accidental death rates among a number of countries, but makes no comparison with non-accidental death rates.

Summary

In short, Carli & Orliaguet's paper in the Lancet does not derive its statement from the references that it claims. Axl ¤ [Talk] 14:38, 3 November 2008 (UTC)

Interestingly, Mazurek notes "children younger than 15 years have a 2.5% mortality rate secondary to head injury versus 10.4% for adults". Axl ¤ [Talk] 14:43, 3 November 2008 (UTC)

Thanks for digging that up Axl, that's pretty conclusive. Disappointing for a Lancet paper, no? Should I be suspicious of other stuff by them? I had already removed that sentence, feel free to alter or remove anything left in there you think is still problematic. delldot ∇. 05:24, 4 November 2008 (UTC)

In general, Lancet articles are very reliable. I only investigated this particular statement because it didn't fit with my expectation. I don't see any other problems or controversies with the Wikipedia article as it currently stands. Axl ¤ [Talk] 10:54, 5 November 2008 (UTC)

Merge from Head injury

Although these concepts aren't identical, the two are used interchangeably (see brain trauma#Classification) and I find it very likely that most people are going to type in "head injury" or "head trauma" rather than "traumatic brain injury" when they want info on the latter. Almost all of the info in Head injury is redundant to that in TBI, but it's much less thorough and organized. There's a discussion in brain trauma#Classification about the difference between head and brain injury anyway. Head injury would be a stub if the redundant info were removed. Any objections to the merge? I'm happy to perform it. delldot ∇. 01:11, 9 November 2008 (UTC)

• Head injury is a much broader term than TBI and also includes e.g. facial trauma which isn't covered here. Head injury could be a short article linking to more detailed articles or a disambiguation page but I don't think it should redirect here. --WS (talk) 01:31, 9 November 2008 (UTC)
• Oppose. The head is larger than just the brain. There is enough to say about head injury that includes trauma to all organs (including, for instance, cauliflower ear and blowout fracture), which should then have clear crosslinks with the TBI article. JFW | T@lk 19:49, 9 November 2008 (UTC)

OK, merge tags removed. delldot ∇. 02:02, 11 November 2008 (UTC)

Imaging after brain injury

The following paper from an anaesthesia journal seems pretty good in the discussion of imaging techniques of brain injury.

Coles JP (2007). "Imaging after brain injury". Br J Anaesth. 99 (1): 49–60. doi:10.1093/bja/aem141. PMID 17573394. Retrieved 2008-11-10. {{cite journal}}: Unknown parameter |month= ignored (help)

It might be worth having a look at to see if we're missing anything. Cheers. —Cyclonenim (talk · contribs · email) 07:35, 10 November 2008 (UTC)

 Done Thanks! delldot ∇. 02:02, 11 November 2008 (UTC)

Citations needed in intro

This article has reallly been improved since the last time I looked at it. Bravo! Some citations are needed in the first section - some claims are made that don't have any references cited. Although the information is correct, it needs sources. For numbers 1 snd 2 below, I can't edit the first paragraph, so I can't add those citations, but for numbers 3 and 4 below, I'm happy to add those citations/make those minor changes, if there is no disagreement that these are appropriate. I have a few other suggested citations beyond these 4, but limited time today to enter those here. Drvestone (talk) 21:14, 20 July 2012 (UTC)

Examples and citations below:

1) "Brain trauma can be caused by a direct impact or by acceleration alone."

In courtroom cases, the role of acceleration alone is sometimes disputed, which is why I think it is important to provide sound scientific citations for this particular point.

A citation to research on acceleration and brain injury with humans: Authors: Goldstein LE, Fisher AM, Tagge CA, Zhang XL, Velisek L, Sullivan JA, Upreti C, Kracht JM, Ericsson M, Wojnarowicz MW, Goletiani CJ, Maglakelidze GM, Casey N, Moncaster JA, Minaeva O, Moir RD, Nowinski CJ, Stern RA, Cantu RC, Geiling J, Blusztajn JK, Wolozin BL, Ikezu T, Stein TD, Budson AE, Kowall NW, Chargin D, Sharon A, Saman S, Hall GF, Moss WC, Cleveland RO, Tanzi RE, Stanton PK, McKee AC. Article title: Chronic traumatic encephalopathy in blast-exposed military veterans and a blast neurotrauma mouse model. Year: 2012 Journal: Science Translational Medicine, Vol. 4, Number 134, page 134ra60 DOI: 10.1126/scitranslmed.3003716

A citation to research on acceleration and brain injury with animal models: Authors: Li Y, Zhang L, Kallakuri S, Zhou R, Cavanaugh JM. Article title: Quantitative relationship between axonal injury and mechanical response in a rodent head impact acceleration model. Year: 2011 Journal: Journal of Neurotrauma, Vol. 28 number 9, pages 1767-82 DOI: 10.1089/neu.2010.1687

2) "These processes, which include alterations in cerebral blood flow and the pressure within the skull, contribute substantially to the damage from the initial injury."

This definitely needs citations, and in addition, needs to have something like the following phrase added to be more accurate:

"These processes, which include alterations in cerebral blood flow, pressure within the skull, and a cascade of neurochemical changes, all contribute substantially to the damage from the initial injury."

The omission of these neurochemical changes (often referred to in the literature as "the neurometabolic cascade") that unfold in the hours and days after the initial trauma is significant. The field of TBI research recognizes these as key changes, so the Wikipedia article needs to reflect that. It isn't just changes in blood flow and pressure, it's changes in: the potential across the neural membrane, calcium levels, glucose metabolism, and ongoing chemical changes in axons that contribute to diffuse axonal injury. New technologies are being developed to study these changes specifically in humans post-injury, such as magnetic resonance sprectroscopy, and DTI. (See second citation below.)

The citation for these chemical changes is classically: Authors: D.A. HOVDA, S.M. LEE ,M.L. SMITH,S. VON STUCK, M. BERGSNEIDER, D. KELLY,E. SHALMON, N. MARTIN, M. CARON, J. MAZZIOTTA ,M. PHELPS, D.P. BECKER Article title: The Neurochemical and Metabolic Cascade Following Brain Injury: Moving from Animal Models to Man Year: 1995 Journal: Journal of Neurotrauma, Vol. 12, Issue 5, pages 903-06 DOI: 10.1089/neu.1995.12.903

A second citation, which is more of a review article about more recent research on this, is: Authors: Signoretti S, Lazzarino G, Tavazzi B, Vagnozzi R. Article Title: The pathophysiology of concussion. Year: 2011 Journal: PM & R: , Vol. 3, Issue 10, Supplement 2, pages S359–S368. DOI: 10.1016/j.pmrj.2011.07.018

3) Classification of TBI/Severity: "Brain injuries can be classified into mild, moderate, and severe categories."

I think it would be appropriate to add an acknowledgement that the classification system for severity is currently being updated in a project sponsored by NINDS. Although the paragraph as written discusses more complex ways of categorizing TBIs as mild, moderate, and severe, it doesn't represent the most recent thinking, which is that although mild, mod, severe is current practice, clinicians know this is a limited classification system, and neuroscientists are trying to find better ways to predict patient outcomes using much more information than just GCS, PTA, and LOC.

Perhaps a sentence could be added as below: Brain injuries can be classified into mild, moderate, and severe categories.....Grading scales also exist to classify the severity of mild TBI, commonly called concussion; these use duration of LOC, PTA, and other concussion symptoms.

In recognition of the limitations of the mild, moderate, severe classification, an NINDS project is working towards a new empirically-based classification system for TBIs that include a greater range of information about the injury.  Citation to add:
Miller, G (2010). New guidelines aim to improve studies of traumatic brain injury.  Science, V. 328 (16 April), p. 297, DOI:10.1126/science.328.5976.297

4) The figure shown in the Epidemiology section, with the citation to a 2005 article, is very different from the numbers the CDC reports for 2010. I think it could be updated to reflect a little bit more recent data. I suggest changing the percentages in the figure, and the citation to this more up-to-date report on epidemiology of TBI in the US:

Falls: 35.2% Motor vehicle accidents: 17.3% Struck by/against something: 16.5% Assault: 10% Other or unknown: 21%

Citation to add: Faul, M, Xu L, Wald MM, Coronado VG (2010). Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths.  Centers for Disease Control and Prevention, National Center for Injury Prevention and Control Atlanta, GA.Drvestone (talk) 21:14, 20 July 2012 (UTC)

By the way, I do look at the talk page here, but I don't really use my Wikipedia contact page. I am, however, happy for other contributors to this page to contact me directly by email vestone at-sign g mail. Drvestone (talk) 21:18, 20 July 2012 (UTC)

Complications

This section needs some updating, as some of the references are out of date (2001, a 2005 book chapter that was probably written in 2003-04) and some of the "facts" about long-term psychiatric sequelae of TBI have now been disproved with more careful research. I have added updated citations and taken out any reference to TBI causing schizophrenia, because more recent careful research shows it's no more likely after a TBI than before a TBI. (See the 2009 Hesdorffer article I cited.) I also changed the sentence so that it doesn't list anxiety and panic disorder separately, but instead just says "anxiety disorders" and provides a link to the relevant Wiki article. These all amount to rather small changes, but I hope make real improvements in the scientific accuracy and up-to-date-ness of this article. Drvestone (talk) 19:13, 9 August 2011 (UTC)

I also removed this whole sentence, because it doesn't square at all with current research and is based on a citation to an article that includes only mild TBI, rather than all levels of TBI, making its generalizability questionable:

"Different behavioral problems are characteristic of the location of injury; for instance, frontal lobe injuries often result in disinhibition and inappropriate or childish behavior, and temporal lobe injuries often cause irritability and aggression. Folzer, 2001"

With diffusion tensor imaging providing us info about neural connections, we know now that it's not so much the *location* of the injury that makes a difference, it's the circuits that get disrupted that create problems (see imaging work by Erin Bigler and colleagues). TBI often causes damage to circuits (uncinate fasciculus, particularly) that link the frontal and temporal lobes, whether focal lesions can be seen in those areas or not. In fact, aggression can be linked to damage to circuits connecting the orbitofrontal cortex and the amygdala, not to "temporal lobe damage" per se (see work by James Blair of NIMH). Difficulties with social judgment arise from damage to the uncinate fasciculs and to the corpus callosum. (Scheibel et al., 2011, Social Neuroscience) Given all this new knowledge, I actually think it's a little bit dangerous to lead anyone to believe that they can predict someone's behavioral/social/emotional outcomes just based on visible frontal vs. temporal lesions, so that's why I deleted that sentence. Drvestone (talk) 19:13, 9 August 2011 (UTC)

New contributor

Hello, may I be allowed to add to the article? I am an intensive care doctor in the UK. I would like to contribute to the medical complications of TBI, and do some work on TBI in children. Thank you. — Preceding unsigned comment added by Mr croc (talk • contribs) 12:01, 27 July 2011 (UTC)

Please do contribute, add cites, etc! Drvestone (talk) 16:21, 9 August 2011 (UTC)

Hello, I have added a small section. It includes ref. 89. It is supposed to be a chapter in that book but I cannot get the cite tool to recognise a book chapter rather than a whole book. What am I doing wrong?Mr croc (talk) 23:44, 11 September 2011 (UTC)

Peer review bot

The review has been automatically ended. I could countinue here if you are interested. I would very much like to collaborate taking this article to FA with you.--Garrondo (talk) 17:47, 8 December 2008 (UTC)

Yes, thanks, I would very much like that too and I'm eager to keep getting your input. Are we not supposed to keep writing on that page or can we continue there to keep it together? I can't imagine why anyone would mind. delldot ∇. 18:03, 8 December 2008 (UTC)

Seconded, if you need a hand with anything just ask. It's in my watchlist, anyway, so I'll always be keeping an eye out. —Cyclonenim (talk · contribs · email) 18:04, 8 December 2008 (UTC)

Thanks much! Maybe once the content is more stable you could give it a copy edit? delldot ∇. 18:16, 8 December 2008 (UTC)

Sure thing, give me a shout if I forget! —Cyclonenim (talk · contribs · email) 18:20, 8 December 2008 (UTC)

Causes

From the section "Causes": "In the US, falls account for 28% of TBI, motor vehicle (MV) accidents for 20%, being struck by an object for 19%, violence for 11%, and non-MV bicycle accidents for 3% (chart at right)." However the chart seems to have disappeared. Axl ¤ [Talk] 21:13, 8 December 2008 (UTC)

Much of the numerical information in the "Causes" section would be better placed in "Epidemiology". Axl ¤ [Talk] 21:17, 8 December 2008 (UTC)

Whoops, thanks for catching that Axl. I had removed the chart because I was worried it was putting too much of a US bias on the section to have all that focus on US statistics (plus that image was bumping the others down).

I think you're right that it's kind of epidemiology info, but I'm not sure about moving it, because what will that leave in causes? Just a list of ways to get injured? For a straightforward type of trauma like this, I guess the causes section is always going to be pretty sparse: "here are some ways that you can get hit in the head"! Also the epidemiology section is pretty massive already, I hate to bulk it up more. Maybe "Causes" should be turned into a subsection of epidemiology? I would think that for trauma articles that might make more sense than following MEDMOS, which doesn't seem to have been designed with trauma articles in mind. Of course that doesn't do anything to reduce the massive epidemiology section. What do you think? delldot ∇. 17:40, 18 December 2008 (UTC)

Good idea, delldot. For this article, it would be sensible to move "Causes" into "Epidemiology". Then the numerical information is presented together. I don't see a problem with the size of the "Epidemiology" section; it is nicely broken up into subsections. Axl ¤ [Talk] 18:06, 18 December 2008 (UTC)

For the "Causes" section, I just updated some of the citations with more recent information: 1. I took out the Langlois 2006 reference and its accompanying sentence, which has been superceded by a 2010 CDC publication. 2. I added that 2010 publication to the list of cites of what the leading causes of TBI are - it seemed odd to cite number 35, which was only an article on mild TBI, as the main citation for causes of TBI in general. Adding the CDC report fixes that. 3. I substituted a more recent reference (2009) on blast injury for the old 2007 Lancet opinion piece that had been the citation for that. Statements in the 2007 Lancet article have already been taken over by new research - e.g., we do have good experimental models of blast injury now. Drvestone (talk) 17:33, 9 August 2011 (UTC)

Spam

In the last weeks somebody has repeatedly included links to an online site (brainline). Please stop doing it since it is not a reliable source per wikipedia policies. Best regards.--Garrondo (talk) 08:34, 17 December 2008 (UTC)

Prognosis

As I told Delldot in his userpage I plan to continue reviewing and editing the article with his help after my partial review.

I have tried to simplify the prognosis section. I feel that the fact that severity is associated with a poor outcome is repeated many times in different ways. I have completely eliminated the following sentences as they were only specific examples of "high severity is poor outcome", but I leave them here since they are properly referenced and maybe could be of use in the future:

• A low Glasgow Coma Score at the time of resuscitation after the injury is an important predictor of worse outcome, and with the lowest score, three, the prognosis is usually dismal. People with TBI who have GCS higher than nine, no lesions visible on CT scan, and no evidence of alcohol intoxication, low blood oxygen, or shock are tentatively expected to have a good outcome.
• Scores greater than 40 on the Injury Severity Scale, abnormal pupil response to light, and excessive pupil dilation are also significantly correlated with a worse outcome.

Another volunteer

G'day Delldot and other contributors. I wonder if I might be some use to you in editing this excellent article. I'm a PICU nurse, and I work with TBI patients in the critical care setting on a regular basis.

In particular I'm looking at the treatment section and thinking that there was no mention of CPP (cerebral perfusion pressure), and that the mention of mechanical ventilation cites proper oxygen supply without explaining that tight control of CO2 is absolutely esential in these patients (alluded to as hyperventilation in the next subsection). Mention of benzodiazepines for seizure prevention, but no mention of phenytoin which is used in almost all our patients. I might have a go at gently modifying that section with your approval, but I'm cautious because you've deservedly achieved a GA status for the article! Is it still ok for me to make edits to that section? Cheers, Basie (talk) 10:35, 7 January 2009 (UTC)

Feel free to do any edits: main users involved in the article are Delldot and me, and as long as you use citations from review articles from peer-review journals or first-line manuals it would be great to have another person involved in the article; specially one who can improve the treatments section. We aim to take the article to FA status, and any help would be welcomed. Best regards. --Garrondo (talk) 12:21, 7 January 2009 (UTC)

Absolutely Basie, feel free to make any edits you'd like! We're pleased to have your expertise and experience for the article. Personally I'd hate it if an article's GA or FA status kept it from getting improved. Besides, any changes can be discussed if there are any concerns. I'd echo Garrondo's recommendation of using journal reviews and other high-quality references. Thanks again for your willingness to contribute! delldot ∇. 15:39, 7 January 2009 (UTC)

Thanks guys, I'll take a look. Cheers, Basie (talk) 19:13, 7 January 2009 (UTC)

Pictures

Do you feel as if you have enough images? Working where I do, I have the opportunity to take digital shots of the various equipment used. The patients themselves probably not so much, but I could for example get images of an ICP waveform on a monitor, a Codman bolt in use (ICP sensor), a cooling blanket, and so on. I would have to check as to the legal bits and pieces and ask permission of course, but I can't imagine there would be much of a problem getting GFDL on images so long as they didn't show the patient. Cheers, Basie (talk) 19:29, 7 January 2009 (UTC)

I think that would be most excellent. Even if we don't end up using all the images in this article, they'd likely be really useful for the articles about the equipment and for various other purposes once they're on commons. (Plus, some of the images in the article are sort of more decorative, e.g. the football shot, so we could afford to remove them in favor of more informative images if we want). I imagine images of equipment would be more useful than some other types of images simply because most people probably don't know what these things look like, and maybe seeing them can give better insight into how they work. delldot ∇. 00:48, 8 January 2009 (UTC)

Right, next time we get a TBI admission I will try to remember to ask about this. The issue of licensing images has probably come up before, so hopefully they can tell me yes or no quickly! Cheers, Basie (talk) 03:48, 8 January 2009 (UTC)

I think if you take the picture yourself, you're the copyright holder and can license it how you want (unless it's of a work of art, or some other exceptions). If someone else takes the picture, then it's definitely more of a mess. I'm not sure about what your hospital's policy is on taking photos though, of course a lot of places are super careful about that. delldot ∇. 14:28, 8 January 2009 (UTC)

Yeah, I have been burned before when taking pictures in the hospital so I will be extra-cautious in seeking the right permissions. Cheers, Basie (talk) 19:07, 8 January 2009 (UTC)

Just FYI, I have been given permission to use non-identifying images that I take on the wiki. Next time we have someone with TBI I'll grab some pics. Cheers, Basie (talk) 02:03, 12 January 2009 (UTC)

Damage prevention

Control of ICP is a subset of the whole 'damage prevention' theme. We aim to keep ICP below 20 mmHg in order to prevent further damage to the brain during the post-injury days in ICU. Damage prevention is therefore a rather vague term, and I'm wondering if there is a better title for that subsection, or if we should consider changing the order? For example:

• Treatment
  • Control of ICP
  • Other non-surgical measures
    • Fluid resuscitation, antiepileptics, sedation, hypothermia etc.
  • Surgery
  • Rehabilitation

"Other non-surgical measures" isn't perfect, but I'm struggling to think of an alternative at the moment! Cheers, Basie (talk) 20:28, 7 January 2009 (UTC)

We'll have to think on it. Maybe "limiting secondary injury"? Or we could get rid of that subheader and leave it all under the "Treatment" header, with ICP control after. delldot ∇. 00:48, 8 January 2009 (UTC)

Heh, it's not simple is it? Limiting secondary injury is similar to damage prevention, in that almost all the measures described under "Treatment" fit that description. Most of what we do in PICU does, certainly. In fact, you could argue that fluid resus, sedation and hypothermia are all related to ICP control. I might have a go at a reorganisation of the section keeping the content intact. Cheers, Basie (talk) 03:45, 8 January 2009 (UTC)

Yeah, I think a reorganization is a good idea, go for it! delldot ∇. 14:28, 8 January 2009 (UTC)

Sounds a good idea a reorganisation. It is great to have somebody who wants to help and knows about TBI. Only a minor comment: rehabilitation is also a non-surgical measure; so maybe it would be better to say: Other non-surgical acute measures?. --Garrondo (talk) 14:47, 8 January 2009 (UTC)

That's a good thought. How about rather than dividing it by type of treatment, which as we've seen presents problems, we divide it by time frame? So "Immediate and acute" (with surgery and everything included) and "Long term"? We can have subheaders like "surgery" too (although this might reintroduce the original concern). delldot ∇. 17:15, 8 January 2009 (UTC)

I have been planning to reorganize symptoms and complications merging both subsections (although I do not know when I would have time to do it), and my idea was to merge them depending on time frame (onset symptoms, acute-subacute (hospital), and chronic); so it would be great if treatments were organized the same way: It would make a lot of sense.--Garrondo (talk) 17:34, 8 January 2009 (UTC)

Ah, there you go, that makes sense. I have a little sandbox area on my user page for this section, I'll look at our options there and let you know when I have something worth checking out. Cheers, Basie (talk) 19:00, 8 January 2009 (UTC)

TBI: the first five days

Well here's how it happens on our unit at least. For the first few days, really up to a week, we go for:

• tight control of ICP (maintain below 20),
• CPP (maintain above 50),
• CO2 (sufficient ventilation to keep below about 5 kPa usually)
• cooling (doing a study at the moment with some patients cooled to below normothermia, and some patients kept at normothermia ie any fevers are suppressed)
• sedation (often continuous using a midazolam infusion and a morphine infusion) and muscle relaxation, which is something the article doesn't mention yet, unless I missed it. The two subjects go hand in hand, but are not equivalent.
• draining of CSF via an extraventricular drain (might be another great picture if I can get one)
• maintenance of normal to moderately elevated sodium using 3% saline solution (about three times as strong as regular saline)
• maintenance of normal to moderately high blood pressure using a noradrenaline infusion and fluids
• back to CT scan if anything changes that we can't fix straight away, or if the general picture seems to be worsening
• sometimes an MRI although this is often further down the track

I better stop before I reproduce our entire protocol! You get the picture, and those are the highlights.

Every time we have to move the patient, or suction their airway, or do personal cares, sometimes even if we touch them their ICP spikes as they wake up or are cerebrally irritated. Typical spikes can go into the 40s and I've seen them as high as the 60s although hopefully this is a rarity! Treating these spikes follows a strict protocol that both the docs and nurses use which is based on the best evidence we have available at this time. I really must go back and ask them which sources they used when writing it. Cheers, Basie (talk) 19:04, 8 January 2009 (UTC)

Treatment section structure revision

Ok, with some trepidation I have gone ahead and moved things in the treatment section around. Let me say that I will have no complaints whatsoever if you want to revert this edit! It certainly needs more work, but I was looking for a structure that made more sense to me. Not completely sure about the use of 'initial' either. Anyway, will hold off on further edits to the section until folks are happy with the overall approach. Cheers, Basie (talk) 06:41, 9 January 2009 (UTC)

Oh, there was one sentence that didn't seem to fit anywhere, even under rehab. I include it here in case you want to reinsert it.

No specific treatment exists for concussion;<ref name="Willer06">{{cite journal 
|author=Willer B, Leddy JJ 
|title=Management of concussion and post-concussion syndrome 
|journal=Current Treatment Options in Neurology 
|volume=8 
|issue=5 
|pages=415–426 
|year=2006 
|pmid=16901381 
|doi=10.1007/s11940-006-0031-9 
|issn=1534-3138}}</ref> rather treatment is focused on management of and education 
about symptoms and deficits and assistance in resuming work and social routines.
<ref name="Bay07"/>

Everything sounds great. Impressive work for somebody who has only been here for a week... :-) Best regards. --Garrondo (talk) 08:34, 9 January 2009 (UTC)

Thanks! Actually I feel like I'm just groping around for the right edit most of the time, so I'm counting on you guys to rein me in when I screw up :) Cheers, Basie (talk) 11:50, 9 January 2009 (UTC)

Looks good Basie! That's cool if we go light on the concussion stuff, since there's a whole concussion article. About the "initial" wording, it sounds awkward to me too, maybe "emergency"? But this would exclude mild concussions and is not quite right either. I think whatever we end up with we should define our time frames (e.g. "0-24 hrs"), and we could end up with those time frames themselves as the section headers if we can find a consistent trend in the literature to delineate the treatment along those lines. delldot ∇. 00:39, 10 January 2009 (UTC)

Hrm, yeah I take your point but it's not easy to nail down time frames. Some patients take longer than others, some are more unstable etc, depending on nature and severity of injury. One phrase that gets used a lot is "Pre-hospital care", which might make a first subsection. It's tough to figure out though, and I'm leaning more and more toward doing away with the subsections altogether if they're causing such problems! Cheers, Basie (talk) 09:29, 10 January 2009 (UTC)

No worries, we'll figure out the subsections eventually as that section evolves. Prehospital care isn't that exciting, it's pretty much the same as for other injuries. The only thing we have on that is the where to bring them sentence. Thanks for all your hard work on this Basie. delldot ∇. 23:14, 11 January 2009 (UTC)

Treatment, Rehabilitation

Ok. The subheadings are not working for me. I've played around and I just can't find a solution that makes sense.

I feel as if I'm over-complicating the whole thing. So I'm going back to basics. Rehab becomes its own section, since it doesn't really relate to the other more technical items we're covering. Other subheadings are removed, to be added back if we think they're necessary. As always, please revert me if I'm screwing it up!

Next step (for my money) would be to write/arrange the treatment paragraphs with a bit more flow and relate it all back to control of ICP, which is the goal of almost everything mentioned. Cheers, Basie (talk) 02:36, 11 January 2009 (UTC)

Happier with progress now. Copying removed barbiturate ref here. Basie (talk) 04:44, 11 January 2009 (UTC)

Stopping there, too many edits at once! Hopefully the result is an improvement, will come back to it tomorrow or the next day. Cheers, Basie (talk) 05:00, 11 January 2009 (UTC)

[[Barbiturate]]s can be used to [[induced coma|induce coma]] in order to decrease ICP.<ref name="Finfer01">
{{cite journal 
|author=Finfer SR, Cohen J 
|title=Severe traumatic brain injury 
|journal=Resuscitation 
|volume=48 |issue=1 
|pages=77–90 
|year=2001 |month=January 
|pmid=11162885 
|doi= 10.1016/S0300-9572(00)00321-X |url=}}</ref>

Some peds quotes

Storing these while I have the book in my hands, till I figure out whether or not we can use them. Feel free to add material from these if you like. They are from Tasker, Robert C (2008). "Head and Spinal Cord Trauma". In David G Nichols (ed.). Roger's Textbook of Pediatric Intensive Care (4th ed.). PA: Lippincott Williams & Wilkins. pp. 887–911. ISBN 9780781782753. which is first cited in treatment section.

TBI is the leading cause of death and disability in children, and in the US, 200,000 head injuries occur in children each year. Ten percent of children who are hospitalized with TBI have severe brain injury--as definied by a Glasgow Coma Scale (GCS) score < 9 at presentation--and are usually admitted to a PICU. In the UK, the prevalence rate for children (0-14 years of age) admitted to intensive care with TBI (the majority of whom are intubated and ventilated) is 5.4 per 100,000 population annually. Chilren admitted to the PICU with TBI come from more deprived households, and the commonest mechanism of injury is pedestrian accident.

And then this:

Inflicted Traumatic Brain Injury (iTBI) includes one or more of the following features: shaking injury, cerebral lesions as a result of direct impact, compression, and penetrating injuries. Shaking injury is the most frequent form of iTBI in infants (birth to 12 months). Population-based studies in Scotland indicate that the annual incidence is 24.6 per 100,000 children younger than 1 year [95% confidence interval (CI), 14.9-38.5]. In the US, in North Carolina, the incidence is 17 per 100,000 per person-year during the first 2 years of life (95% CI, 13.3-20.7).

There's probably a fair bit of room for a non-accidental injury article, whether part of or linked from child abuse. Dunno how much of this belongs in TBI. Cheers, Basie (talk) 03:14, 25 January 2009 (UTC)

Yeah, this is good info, don't know how much we can fit given that we're already bumping up against the upper page length limit. I had actually been toying with the idea of creating pediatric traumatic brain injury or traumatic brain injury in children, but I haven't been interested in writing much lately. There's definitely enough info on it for a long article. Maybe we can work together on it in a while!

Axl mentioned that infectious disease is the leading worldwide cause of death in children, so this source might be one of the unfortunate cases that's actually only writing about the US. It'd be good to get an explicitly worldwide stat for the epidemiology section. We can hold onto this info in case we need it to fill something out later though. Keep up the good work Basie! delldot ∇. 04:26, 25 January 2009 (UTC)

The trick is in how you define a child. For example, causes of death in children 0-5 tend to be different than if you take the age range 0-14 and look again. Also, the phrase they use is "death and disability" (not just death) so I'd have to go back and look at the sources they cite to figure out how they calculated it.

I'm definitely up for looking at the paediatric angle, but you're right... at this point we need to be trying to trim TBI rather than inflating it! Basie (talk) 07:45, 25 January 2009 (UTC)

Ohhh, that makes complete sense, I hadn't thought of that! But yeah, how about we collect peds info in a sandbox or something so we can get it if it's requested at FAC, or we can use it to make a new peds article if either of us ever has time? delldot ∇. 08:50, 25 January 2009 (UTC)

Yeah good call--User:Basie/PTBI. Cheers, Basie (talk) 21:52, 25 January 2009 (UTC)

Treatment section

I have given a new try to the treatments section: I have unified again treatment and rehabilitation dividing it into acute (what was formerly as treatment) and chronic (rehabilitation). However I have also added an introduction that gives more sense to the division by stages. Finally I have improved the chronic stage adding info on pharmacology (it is used for seizures control) and on caregiving and nursing for the most disabled. Basie: As I have only added a line on caregiving feel free to improve it if you feel something is missing. I have not searched for refs for some of the things I mention, but I promise to do it during the week. Bests.--Garrondo (talk) 15:52, 26 January 2009 (UTC)

You know, I feel like I've looked at this section so many times that I no longer have any perspective on it! I like what you've done, I think it's simple and clear. I actually don't know a whole lot about rehab nursing because I'm involved with the bit immediately post trauma, but what you have looks fine.

I took a swing at the opening paragraph of the section with a view to brevity... I suspect the first thing an FA reviewer will say to us is, "too long"! I hope the edit doesn't seem too severe, I wanted to see what was the least we could get away with. See what you think (and thanks for persevering with this difficult section). Cheers, Basie (talk) 19:35, 26 January 2009 (UTC)

Looks good Garrondo! But I agree on the length issue. I went through and tried to cut down on the length and redundant wording, I think we could cut some detail from the surgery if we want (e.g. "For intracranial hematomas, the collected blood may be removed using suction or forceps or it may be floated off with water"). Here's a tool that shows you length of readable prose (the upper limit for an FA is 50, I believe). By the way, I also have a collection of info that I couldn't or didn't want to fit into the article here, you're welcome to add to it if you'd like to keep it handy for future reference or whatnot. If you want to take something out but want to keep it around to maybe put back in later, feel free to stick it there. delldot ∇. 06:18, 27 January 2009 (UTC)

Oh, two questions: does "Rehabilitation is the main treatment..." make sense? I mean, do people say "rehab is treatment"? And the image of the woman doing leg lifts--is that an exercise that a TBI patient would do during rehab? If not, I'd advocate for finding a different image in the treatment section. delldot ∇. 06:24, 27 January 2009 (UTC)

I would say it is a treatment. Many different medical pathologies (specially trauma) are treated only or mainly with physical rehabilitation. If something changes the course of the disease (and rehab does) we can talk about treatment. Regarding the image: I have no idea if it is used in TBI. Nevertheless, since TBI sequels are so varied I am quite sure that the exercise will be used in some cases. --Garrondo (talk) 08:51, 27 January 2009 (UTC)

Aside from things dr's might do in the emergency room immediately after the injury (surgery for a hematoma, etc.), there really is no treatment for TBI except for rehabilitation. There is no medication that is yet proven to work, the way to improve symptoms is through rehab -- I hear this over and over again at national conferences on TBI, neurology, neuropsychiatry. Research from the military has found that there are some nutrition and dietary changes that can ameliorate symptoms, but those are not exactly a treatment either. (I can find that reference.) So, yes, it is very appropriate scientifically to call rehabilitation a treatment. Drvestone (talk) 16:27, 9 August 2011 (UTC)

Surgery on Phineas Gage

If others don't object, I'd like to perform a radical, so to speak, on the material on Gage:

• Qualify the text (e.g. personality "reportedly" changed in such-and-such ways) to reflect uncertainty about what the changes in Gage really were and how long they lasted; and
• Remove all the cites except to Phineas Gage. This might seem severe, but most of the existing cites are the usual tertiary stuff (e.g. 'Gazzaniga says Gage would "discuss things of a sexual nature in situations where it was not appropriate," which is based on nothing) and even a broader paper such as Damasio et.al. is best cited in the context of the difficulty of interpreting Gage. This of course is at Phineas Gage, where the interested reader will find a (slowly) growing list of references. There is no single paper which it would be fair to cite, alone, on Gage -- not even Harlow.

OK? EEng (talk) 02:35, 18 March 2009 (UTC)

This is not an article about Phineas; so the important point is not so much if the reported consequences were true but the fact that this "reported" consequences did gave insight on brain damage so you would have to be very careful on what you add or eliminate. On the other hand it would also have to be summary style; since this article is already over the top length. Maybe it would be a good idea if you could propose here your changes before posting them in the article. Bests.--Garrondo (talk) 07:57, 18 March 2009 (UTC)

What you're saying is something like what I had in mind. I'll propose something for comment. By the way, in my post above I don't know where I got the Gazzaniga reference (now struck out)—can't find it in the current article. I must be losing my mind. I was right the first time (above) about Gazzaniga --- see above and [1]. There is no evidence Gage ever showed sexually inappropriate behavior. See cites at Phineas Gage. EEng (talk) 15:56, 18 March 2009 (UTC)

Hey EEng, welcome, thanks for helping out. I'm happy to add 'reportedly', and certainly cutting it down could be good. I don't agree with removing the citations though, I'm not sure I understand the rationale for doing that. Unlike scientific journals, WP actually prefers to use secondary and tertiary sources (see WP:PSTS) because it's an encyclopedia. And since it's open to anyone to edit, we have to be super careful to provide our sources for everything. It's less important, in my book, to find a definitive paper on it, although that would be fine if we could. Thanks for improving the article EEng! Looking forward to hearing more from you. delldot ∇. 16:42, 18 March 2009 (UTC)

Hi all, I thought I could offer to help out a bit with this article. I've done research on TBI for years, am on the editorial board of the journal "Social Neuroscience", and keep up with the research on the topic. I wonder if it might be better to reduce the emphasis on Phineas Gage, and instead note that there are many, many cases since him where a non-penetrating TBI has caused personality change, and where clinicians and researchers have documented that changes such as socially inappropriate behaviour, problems with social perception, decreases in social skill, and problems with conversation are common outcomes of moderate-severe TBI. I have the cites. How about if I get those together, and propose an edit to the History section? It might shorten it slightly; I don't think it would lengthen it. Drvestone (talk) 23:13, 29 March 2009 (UTC) Drvestone (talk) 23:21, 29 March 2009 (UTC)

Here is what I suggest adding to the "History" section, to de-emphasize Gage a little, and to emphasize the large number of cases with similar personality changes (citations are all to top neuroscience journal articles): SHORTENED THIS TO ADD MORE RECENT CITES NOTING PREVALENCE OF PERSONALITY CHANGES: One of the most famous early cases was Phineas Gage, a railroad worker who was in an explosives accident in 1848 that drove an iron rod through his frontal lobe.[105] Previously a restrained, capable man, Gage underwent a dramatic personality change after the injury, becoming extremely socially inappropriate and impulsive.[104, 106] Since then, research on TBI shows that many cases of traumatic brain injury are "Gage-like", involving similar personality changes, in which the person goes from socially appropriate behavior to behavior far outside social norms. citations:

• [Eslinger & Damasio, 1985; Mattson & Levin 1990; Cummings 1993; Stone, Baron-Cohen & Knight, 1998; Stone, 2000; Kim, 2002; McDonald et al 2003; Milders, Fuchs, & Crawford, 2003; Devinsky & D'Esposito, 2004]
• Eslinger, P. J., & Damasio, A. R. (1985). Severe disturbance of higher cognition after bilateral frontal lobe ablation: patient EVR. Neurology, 35(12), 1731-1741.
• Mattson, A. J., & Levin, H. S. (1990). Frontal lobe dysfunction following closed head injury. A review of the literature. J Nerv Ment Dis, 178(5), 282-291.
• Cummings, J. L. (1993). Frontal-subcortical circuits and human behavior. Arch Neurol, 50(8), 873-880
• Stone, V.E., Baron-Cohen, S., & Knight, R.T. (1998).
• Stone, V. E. (2000). The role of the frontal lobes and the amygdala in theory of mind Baron-Cohen, Simon; Tager-Flusberg, Helen; Cohen, Donald J. (2000), Reprinted 2005 Understanding other minds: Perspectives from developmental cognitive neuroscience (2nd ed.). (pp. 253-273). New York, NY, US: Oxford University Press. xix, 530 pp.
• Kim, E. (2002). Agitation, aggression, and disinhibition syndromes after traumatic brain injury. NeuroRehabilitation, 17(4), 297-310.
• McDonald, S., Flanagan, S., Rollins, J., & Kinch, J. (2003). TASIT: A New Clinical Tool for Assessing Social Perception After Traumatic Brain Injury. Journal of Head Trauma Rehabilitation, 18(3), 219-238.
• Milders, M., Fuchs, S., & Crawford, J. R. (2003). Neuropsychological impairments and changes in emotional and social behaviour following severe traumatic brain injury. J Clin Exp Neuropsychol, 25(2), 157-172.
• Devinsky, O., & D'Esposito, M. (2004). Neurology of Cognitive and Behavioral Disorders (Vol. 68). New York: Oxford University Press.

Drvestone (talk) 15:51, 9 April 2009 (UTC)

Hi Drvestone, welcome! I'm psyched to have you helping out, I think your expertise is just what this article needs. I think the suggested reworking of the history section is fine, especially anything that cuts it down in length. From what I had read the Gage case was seminal, hence the emphasis, but if that's not your understanding that should indeed be corrected. The literature reviews and text book articles are great, that's the ideal kind of source for WP articles. Sorry I didn't see these notes earlier! Let me know if I can be of any help or anything with the Wikipedia side of things. Peace, delldot ∇. 18:55, 9 April 2009 (UTC)

I took Drvestone's changes a bit further by doing the following. (1) Reduced text on Gage to the simplest possible, letting the interested reader learn more at "Phineas Gage"; almost any statement beyond that his accident was followed by behavioral changes would require more qualifying explanation than would be appropriate here (and as Delldot said, this isn't an article on Gage). An explicit part of that was eliminating the Harlow and Damasio refs, both of which are in the Gage article, and neither of which is appropriate even if we wanted one or two refs on Gage here (one being hard-to-interpret primary material and the other being obsolete as a presentation of Gage). (2) For similar reasons, removed characterization of modern pts as "Gage-like": such a statement needs much more clarification than would be appopriate in not-the-article-on-Gage. EEng (talk) 16:23, 2 November 2009 (UTC)

Pediatric TBI

I have a few references on pediatric TBI. I think I can summarize them in a sentence and add them without adding much length, if people still think that is an important topic here.Drvestone (talk) 23:21, 29 March 2009 (UTC)

Yes, I think this is a great idea. Actually I was thinking of creating a separate article for this and leaving a couple sentences here, what do you think? delldot ∇. 18:40, 9 April 2009 (UTC)

Imaging and TBI

A sentence on diffusion tensor imaging (DTI) as a method to show the white matter damage after TBI, and the fact that DTI is an excellent predictor of outcome, with accompanying references (I can get them together) would bring the article a little more up to date. Again, I'll propose some stuff on here, and then after I get people's suggested edits, add them to the article.Drvestone (talk) 23:21, 29 March 2009 (UTC)

As long as any info you add is backed up with high quality refs feel free to add it without asking. (Seems great to me). --Garrondo (talk) 07:20, 30 March 2009 (UTC)

Thanks Garrondo, got lots of refs from top journals - too bad DTI is so expensive, because it seems like what's been needed for years. Details below.Drvestone (talk) 15:39, 9 April 2009 (UTC)

Sounds great, thanks for bringing that up. It would be extra great if we could find a free image of it! Probably hard to come by since it's expensive though. delldot ∇. 19:10, 9 April 2009 (UTC)

Pathological features
Systems also exist to classify TBI by its pathological features.[12]
I SUGGEST TAKING THIS NEXT SENTENCE OUT, SINCE IF THE LESION IS EXTRA-AXIAL, IT IS NOT A "BRAIN INJURY", AND MOVING THIS SENTENCE INSTEAD TO THE WIKI ARTICLE ON HEAD INJURY:
Lesions can be extra-axial, (occurring within the skull but outside of the brain) or intra-axial (occurring within the brain tissue).[17]

From my reading of the topic, head injuries like epidural hematoma are classed with brain injuries because of the effect they can have on the brain, e.g. mass effect. If it sometimes is and sometimes isn't, we should specify that. delldot ∇. 19:10, 9 April 2009 (UTC)

True enough - pressure from such a thing can interfere with brain function. Thanks for pointing that out.Drvestone (talk) 21:36, 30 September 2009 (UTC)

Damage from TBI can be focal or diffuse, confined to specific areas or distributed in a more general manner, respectively.[18] However it is common for both types of injury to exist in a given case.[18] Diffuse injury manifests with little apparent damage in neuroimaging studies
ADDED THIS PHRASE
using CT and MRI scans,
but lesions can be seen with microscopy techniques post-mortem [18][19]. Types of injuries considered diffuse include concussion and diffuse axonal injury, widespread damage to axons in areas including white matter and the cerebral hemispheres.[20]
ADDED THIS SENTENCE
In the early 2000's, researchers discovered that diffusion tensor imaging (DTI), which shows white matter tracts, was an excellent tool for displaying the extent of diffuse axonal injury.[CITEs: ARFANAKIS et al. 2002, Kraus et al., 2007; Kumar et al., 2009]]
Arfanakis, K., Haughton, V. M., Carew, J. D., Rogers, B. P., Dempsey, R. J., & Meyerand, M. E. (2002). Diffusion tensor MR imaging in diffuse axonal injury. AJNR Am J Neuroradiol, 23(5), 794-802.
Kraus MF, Susmaras T, Caughlin BP, Walker CJ, Sweeney JA, Little DM. (2007). White matter integrity and cognition in chronic traumatic brain injury: a diffusion tensor imaging study. Brain, V. 130(Pt 10):2508-19.
Kumar R, Husain M, Gupta RK, Hasan KM, Haris M, Agarwal AK, Pandey CM, Narayana PA. (2009). Journal of Neurotrauma, April. Drvestone (talk) 15:58, 9 April 2009 (UTC) I'll get these refs in wiki format and add this to the page.Drvestone (talk) 16:49, 9 April 2009 (UTC)

Looks good! We might change the wording from "excellent" to avoid seeming to give commentary. 'Highly effective'? 'Sensitive'? delldot ∇. 19:10, 9 April 2009 (UTC)

I've added this, with the wording changed to "effective" - thanks for the suggestion.Drvestone (talk) 21:31, 30 September 2009 (UTC) I've also made a couple of small corrections in the "Pathological features" section. White matter and axons are the same thing. The section on diffuse injuries was worded in a slightly confusing way: "Types of injuries considered diffuse include concussion and diffuse axonal injury, widespread damage to axons in areas including white matter and the cerebral hemispheres." Since the white matter is all axons, with those axons projecting to the cerebral hemispheres, I made the following small change: "diffuse axonal injury, which is widespread damage to axons, including white matter tracts and projections to the cortex." Also, this is another picky wording thing: concussion is not a "type of diffuse injury", it is a condition in which diffuse injury is likely. As noted elsewhere in the article, concussion is just mild TBI. It's most likely to involve only diffuse injury, but in rare cases could include focal damage. So, I suggest removing the word "concussion" here, and instead detailing the other type of diffuse injury, which is edema or swelling. Since it's a small change, I've gone ahead and made it, but we can always change it to a different way of clarifying this issue if folks don't like my change.Drvestone (talk) 22:18, 30 September 2009 (UTC)

Research Directions

Actually, I think this whole paragraph should be deleted. It would save space, and it is impossible to do a comprehensive job of covering current research deirections in TBI. I can think of about 20 research directions that are left out of this current section, and the HBO section is controversial - perhaps that could be moved to the Wiki article on HBO. Since space in this article is limited, what about just eliminating this research section since we can't cover it comprehensively?Drvestone (talk) 16:01, 9 April 2009 (UTC)

I think we should have a research directions section since the fact that it's undergoing research is such a key aspect of head trauma, but I agree that the current section is not so great. I agree that the HBO info is probably too detailed, especially with the amount of info it has here. If there's a lot to say, we should make general statements and direct readers to a daughter article on the topic, e.g. Research in brain trauma. (We can create a stub to start it out, moving excessive detail from here). See also Wikipedia:Summary style for the idea of what we're trying to do with an article this general. delldot ∇. 19:15, 9 April 2009 (UTC)

Baby Drop and other cases

I'm surprised I haven't found any information about this in the article (or using Google) since it happens so often. What's the prevalence of brain injury from being dropped on the head as a baby? And if there is brain injury, what is it most likely to consist of, and to what degree (e.g. visual impairment? How much?). How can you know, by examining the baby after it has just hit his/her head, whether he/she has suffered brain damage? There should be more info about this, either in this article or via links in this article. ...... Another inquiry I have is the following: what is the prevalence of brain injury from being hit on the head hard enough to form a small hole (several cm) in the head, causing a fair amount of bleeding and the need for staples -- but not hard enough to cause the person to become unconscious during impact? Such impacts may be caused by, for example, a horse landing on top of you, or a large slab of a chair falling on your head (two cases I personally know about). From my experience, such cases typically don't cause any [detectable] brain damage, but it would be great to have more information about this nonetheless. ...... In summary, there should be more reference to specific examples of impacts that may or may not lead to brain damage, and the prevalence and diagnosis of brain damage in such cases (if there is brain damage). I know such cases could be highly variable due to all of the factors involved (the force of impact, or where you are hit on the head, for example), but there should be, I would think, enough empirical evidence that can be listed in order to provide one some notion of what seems LIKELY to happen. --216.165.95.64 (talk) 11:00, 20 April 2009 (UTC)

I couldn't find reliable sources for this kind of information. Of course if we find such sources, we could add this to the article. Axl ¤ [Talk] 16:58, 20 April 2009 (UTC)

These queries are about very specific types of injuries rather than TBI in infants generally, so probably are better addressed by a website devoted to pediatric TBI rather than a Wiki article with length constraints. We might add a reference to such a website(s) in the references section. Drvestone (talk) 16:32, 9 August 2011 (UTC)

Lead

The lead is no longer compliant with WP:LEAD. In addition I think it's too chatty and borders on an NPOV violation by seeming to give advice or try to convince the reader of something. Can we put it back the way it was or rewrite a new lead section? delldot ∇. 18:09, 1 May 2009 (UTC)

Correct on all points. I recommend we just revert to the 29 April version. --CliffC (talk) 19:54, 1 May 2009 (UTC)

Material moved from article

I'm moving this info here for now:

The potential seriousness of seemingly minor head injuries received international notice in March 2009 when English stage and screen actress Natasha Richardson died from an epidural hematoma after suffering a head bump that both she and some bystanders thought was quite minor. Richardson was reported to have slipped and fallen while taking a skiing lesson at a Canadian resort. Although she is said to have appeared unhurt, she later developed a headache and was taken by ambulance to a hospital. Neurosurgeon Dr. Eugene Flamm commented, "It is a common syndrome where someone gets hit on the head, seems fine, and then falls down unconscious. It takes that much time for the pressure to build up on the brain."

I feel it's too detailed for this general of an article (the article's already way too long). The person is not massively famous and there's nothing particularly notable about her case. It's illustrative of how serious seemingly minor injuries can be and thus may be appropriate for a magazine article or something, but not for an encyclopedia article, in my opinion. Our aim here should be to explain, not to convince. The paragraph is definitely too detailed for the lead, at any rate.

In other news, I've received complaints in peer reviews and FACs about having the popular press cited in medical articles (e.g. Time); we should be aiming to use review articles from peer reviewed journals or textbooks as the ideal sources. I'm a little concerned about the medline references because I've received criticism for using similar sources before. Sorry, I'm being really picky. Thanks to all for helping out with this article. delldot ∇. 17:24, 2 May 2009 (UTC)

delldot, you raise excellent points. Thank you for taking the time and trouble to post your comments on my personal Talk page. (Very few editors are that conscientious, I've found.) I appreciate your courtesy, respect, and explanation. Absolutely no offense was intended, and none was taken! In my first rewrites, you'll note that I tried to stay within your first comments after I appeared on the scene.

But I am having difficulty with removing a current example of minimizing the seriousness of virtually all head bumps and the fatality that resulted from treatment delay. True, she's not exceptionally well known although her husband, Liam Neeson, is. Search engines verify that this news was heard and seen around the world. You're right that my verbage is too detailed and therefore too long. (I wish I could hire a word-reducer.) Please allow me to do a rework. This story, if told well, can go far to reduce the very dangerous comments like "It'll never happen to me" and "What's wrong with you...it's just a little bruise, that's all." You are not being picky, and you were in no way offensive--quite the contrary. Please allow me another try. And a sincere THANK YOU! Afaprof01 (talk) 18:37, 2 May 2009 (UTC)

Suggestion - insert the linked word 'emergency' (it wouldn't hurt to link one of the earlier instances as well) in the first sentence of the Treatment section: It is important to begin emergency treatment within the so-called "golden hour" following the injury and follow that sentence with a more pithy summary of the Richardson tragedy such as The actress Natasha Richardson died from brain injuries after suffering a skiing-lesson fall that she and some bystanders at first thought quite minor. --CliffC (talk) 19:22, 2 May 2009 (UTC)

Thanks for being so understanding and cool about my comments Afaprof. :) I'm right with you on needing a word reducer! I'm happy to leave in your changes, if people ask us to take it out during FAC we can deal with it then (personally I still don't think the incident is central enough to head trauma to belong in this general of an article, but it's not a big deal to me). I don't want the article to come across as trying to convince the reader of something (even something as basic and important as "head injuries can be very serious"), but if we use a "show don't tell" approach and present the facts I think we can avoid that. Thanks again for the hard work on the article. delldot ∇. 13:51, 4 May 2009 (UTC)

I do not want to discourage anybody, but the truth is I feel that last editions are all for the worse: Most what has been added was with other words in the article, additionally sources are of much less quality, it does not follow WP:MEDMOS, has destroyed what was a good lead and tone is much less professional... From my point of view all editions of this last week should be reverted and at most any info which is not present right now in the article added after consensus in talk page... It may be drastic, but it is the easiest way of not destroying what was a great article. With all this additions not only the article should not enter FAC but should be GA reviewed. --Garrondo (talk) 15:18, 5 May 2009 (UTC)

I'd be in favor of reverting as well, or failing that putting a bunch of stuff back the way it was while leaving other changes. It looks like there were some errors or something: a section is blanked, part of a table has been removed. Is there at least consensus to revert those changes? delldot ∇. 16:39, 5 May 2009 (UTC)

As mentioned in section "Lead" above, I recommend reversion to the 29 April version. Then we can build gradually, with discussion, on that. --CliffC (talk) 17:18, 5 May 2009 (UTC)

I hope you won't mind my adding my opinion, even though I've contributed little to development of this page... The article has lost its focus recently. It's beginning to read like a government pamphlet on "Head Injuries and You": "How to recognize them... what to do if a loved one hits his head... add grab bars to your bathtub." This material belongs elsewhere, if anywhere. EEng (talk) 22:34, 5 May 2009 (UTC)

No problem EEng, your input is welcome. It looks like the consensus is to revert to last week's version, I recommend we go ahead and do it. Any objections? This is not meant to discourage anyone's editing or improving the article or to disregard the work that has been put in. I suggest that after reverting we discuss particular additions or subtractions here. delldot ∇. 16:16, 6 May 2009 (UTC)

I respectfully object to the RV. Like many others of you, I have a sincere investment in this important article. I have implemented every suggestion made for the sections I've edited. If I have introduced error, please point it out and I will quickly change it. If I have violated any Wiki policies, let me know and I will fix it. But please don't summarily trash all my work. It most definitely will discourage any editing or improving the article by me and it a flagrant disregard of the work I have put in. Please reconsider. Thank you. Afaprof01 (talk) 20:32, 6 May 2009 (UTC)

Let me see if I can help you feel less offended. Everybody gets reverted sooner or later. One might even say, "If you don't get reverted once in a while, your editing is too timid." Reversion does not mean your material isn't useful -- perhaps people feel it's not organized in the best way, or would be more at home in another article. In the case of this particluar article, it could mean that because your changes affected so much of it, people realized how much it needs reorganizing.

When there's disagreement about a large number of changes, there are two choices. One is to leave things as they are, then discuss whether one change or another should be removed or modified. This time, the consensus is to revert everything now, then discuss which ones to build back. That isn't because your changes are less valuable, but simply because people think that's the easiest way to go. Don't be offended.

Text doesn't have to be in violation of Wikipedia policy for modification to be justified; modification is justified whenever and wherever it would improve the article. Disagreement over what is or is not an improvement? Start a discussion and form consensus!

Reversion does not "trash" your contributions: you can open the last pre-reversion revision of the article, then copy from it any text removed by the reversion. Paste that text somewhere on your own computer to use as a source as you propose changes to the article.

The article's waaaay too long. Why not start by discussing creation of subsidiary articles (e.g. on acute treatment & rehabilitation, etiology & prevention, etc.) leaving the main article to carry summaries of each? That discussion will focus the overall question of what new material belongs in the article, and where . EEng (talk) 06:40, 7 May 2009 (UTC)

Thanks, EEng, for taking the time to point out the above. I appreciate your caring and informative/constructive approach.Afaprof01 (talk) 23:48, 7 May 2009 (UTC)

Think nothing of it. You'll get my bill. (Serioously: you will find Garrondo and Delldot to be thoughtful collaborators. Good luck.) EEng (talk) 19:24, 8 May 2009 (UTC)

Thanks to both of you. :) So is it ok for us to revert and add changes back after discussion? delldot ∇. 17:52, 13 May 2009 (UTC)

Merger proposal

It seems to me that brain damage is largely redundant with this page, and this page is considerably more developed. Would it make sense to merge that page into this one? --Tryptofish (talk) 17:33, 7 May 2009 (UTC)

No, brain damage can occur from a variety of causes, e.g. hypoxia, stroke. If that page only contains TBI info, it's missing a lot. You might discuss it at acquired brain injury, though. delldot ∇. 18:30, 7 May 2009 (UTC)

You make a very interesting point, thank you. I took a quick look at acquired brain injury, and I think I saw in the talk there that you had opposed an earlier merger of that sort. In any case, a significant part of my concern comes from issues of article name. My attention was drawn when, recently, an IP editor wanted to add an external link to a site about brain damage to neuroscience, and there was discussion about it being the wrong page for it. I think that, to a lay person, brain damage, brain injury, and so forth, all sound like synonyms for the same thing (as they do to even a PhD neuroscientist like me!). Acquired versus traumatic, that makes sense to me, but it is not intuitively obvious. I think it would be very difficult for a general reader to navigate to the appropriate page here. So, perhaps, this may be less a question of merger, than of disambiguation. Should there be more prominent "see also"s? Should there be a disambiguation page (brain damage (disambiguation) isn't it!)? --Tryptofish (talk) 18:57, 7 May 2009 (UTC)

Ah, I see what you're saying. This sounds like the work of the articles themselves: explaining the meanings of the terms in the lead sections, or definition or classification sections. delldot ∇. 19:12, 7 May 2009 (UTC)

Yes, that may in fact be it. I'm going to wait a bit longer before deciding whether to delete my merger proposal, to see what other editors might say, but I'm starting to suspect that that's it. I'm thinking also of creating a "brain injury (disambiguation)" page. --Tryptofish (talk) 19:59, 7 May 2009 (UTC)

Agreed with Delldot: each of the terms mentioned is an specific case of a more general one: brain damage is the lesion of the brain structures independently of age or cause; acquired brain injury on the other hand most commonly only refers to the damage produced after 2-3 years of age independently of cause, finally traumatic brain injury refers to the acquired damage produced by impact. If the 3 articles are redundant is a problems of the articles themselves but not the terms...--Garrondo (talk) 06:24, 8 May 2009 (UTC)

Do not merge. Delldot is right. Axl ¤ [Talk] 19:05, 8 May 2009 (UTC)

Thank you all for your feedback, which has been very helpful and (to me!) informative. I'm withdrawing my merge proposal, and have removed the tags. At the same time, I would ask those of you who have been close to these articles to take to heart my observations about disambiguation. It's truly unclear to the general reader. I plan to to create a disambiguation page. I'll discuss it here, and will appreciate any advice that you can give me as I do it. --Tryptofish (talk) 19:45, 8 May 2009 (UTC)

I've created and linked Brain injury (disambiguation). Any improvements or corrections to it would be welcome. Thanks. --Tryptofish (talk) 19:37, 13 May 2009 (UTC)

Focal damage in TBI

I would like to add some material here. There is quite a bit of research on where focal lesions are most likely, based on compiling lesion evidence from hundreds of patients, and I think this section should be updated to include that. I am including citations to relevant peer-reviewed articles from the medical literature. Here's what I've done. It used to say "Focal injuries often produce symptoms related to the functions of the damaged area,[10] manifesting in symptoms like hemiparesis or aphasia when motor or language areas are respectively damaged.[21][22]". My change: "Focal injuries often produce symptoms related to the functions of the damaged area[10]. Research shows that the most common areas to have focal lesions in non-penetrating traumatic brain injury are the orbitofrontal cortex (the lower surface of the frontal lobes) and the anterior temporal lobes, areas that are involved in social behavior, emotion regulation, olfaction, and decision-making; hence the common social/emotional deficits following moderate-severe TBI. [Mattson 1990, Bayly 2005, cummings 1993, Devinsky 2004.] Less common symptoms such as hemiparesis or aphasia can occur when motor or language areas are respectively damaged.[21][22]" Drvestone (talk) 22:30, 30 September 2009 (UTC)

Looks great! I say go ahead. delldot ∇. 03:53, 1 October 2009 (UTC)

Signs and Symptoms

Neuropsychologists are involved in the care and rehabilitation of people with TBI for the long term, because many of the consequences of TBI are changes in mental function. I deal with a lot of neuropsychologists in my work, and lawyers, who are trying to figure out disability cases involving TBI. Generally, the feeling was that this article emphasized short-term symptoms rather than long-term symptoms, and therefore did not have sufficient emphasis on the problems with cognition and social judgment that are caused by the damage in TBI. So, I added two sentences to add more emphasis on long-term problems following TBI, and added citations: "Common long-term symptoms of moderate to severe TBI are changes in appropriate social behavior, deficits in social judgment, and cognitive changes, especially problems with sustained attention, processing speed, and executive functioning. [6][7][8][9] [10] Cognitive and social deficits have long-term consequences for the daily lives of people with moderate to severe TBI, but can be improved with appropriate rehabilitation.[11][12][13][14]" It seemed that this was the appropriate section to add these points to. Happy to discuss this with others here, make changes, etc. Drvestone (talk) 05:47, 1 October 2009 (UTC)

<posting at the bottom of the page per custom>

I thought the long-term effects were important enough to merit their own section, which I turned into "complications". Then that section grew so long that I spun it out into its own article, complications of traumatic brain injury, leaving a summary here. I think signs and symptoms should stay mainly short-term, because to me that section is kind of about "how to tell if someone has this". That said, I think the sentences you added would be fine in complications. delldot ∇. 17:28, 1 October 2009 (UTC)

Since the "Signs and symptoms" section refers specifically to signs and symptoms in the acute phase, what would folks think about changing that heading to "Acute signs and symptoms". That would specifically let readers know that these signs and symptoms are in the early phases of TBI. Then the longer-term symptoms can be in "Complications". "How to tell if someone has a TBI" is an equally valid question whether the person is 1 hour post-TBI or 10 years post-TBI. In forensic contexts, there is a lot of emphasis on how to tell whether someone had a TBI that might have occurred years before, with reliance on neuropsych testing and brain scans (and obviously, older medical records) to answer the question. But, as you say, it makes sense to put that in "complications." Drvestone (talk) 17:49, 9 August 2011 (UTC)

Epidemiology

This section does not fit well under complication. Therefore rearranged a few things and place it a level up.Doc James (talk · contribs · email) 20:21, 18 December 2009 (UTC)

I don't understand--now info on the global epidemiology is discussed in the 'Complications' section. So that section is now massive, and discusses complications, and then launches into "TBI is a leading cause of death and disability around the globe..." I think the other changes were mainly fine, but I think this rearrangement should be reverted. It might also be worth noting that the order of the sections was in compliance with WP:MEDMOS before. Perhaps we could compromise on something. What specifically was the problem you were trying to correct? delldot ∇. 22:26, 18 December 2009 (UTC)

I was trying to give epidemiology its own section as before it was listed under complications. Some text still need to be moved to achieve this. Did not have time to finish.Doc James (talk · contribs · email) 23:11, 18 December 2009 (UTC)

Oh, I'm sorry, I thought it was you who put it under complications in the first place, that's what I was saying I didn't like! I just moved the "Epidemiology" header up to be over all epidemiology info for now, you can finish tweaking later if you want. delldot ∇. 23:25, 18 December 2009 (UTC)

Edit request from SharonRoseLAc, 11 June 2011

A major cause of TBI is explosions. Many veterans returning from Iraq and Afghanistan suffer from poor memory, difficulty thinking, heachaches, and eye injuries (detached retina, etc) from exposure to explosions. SharonRoseLAc (talk) 18:47, 11 June 2011 (UTC)

Already included in the Causes section. Feezo (send a signal | watch the sky) 23:16, 11 June 2011 (UTC)

And citations to info on blast injury updated in the Causes section, Aug. 2011. Drvestone (talk) 17:37, 9 August 2011 (UTC)

edit request

Is there any feedback on this? Can this be posted to the main page?

---

Hello, I would like to submit some content under the Research section. The purpose of this information is to help create awareness of novel and emerging therapies for TBI.

---

Despite the enormity of the problem, scientists have yet to identify an effective drug treatment for TBI. TBI (Alderson and Roberts, 2005; Brain Trauma Foundation, 1996; Cochrane Collection, 2005; Fan et al., 1996; Roberts et al., 1998). Progesterone is a 21-carbon steroid hormone that is being evaluated as a neuroprotective therapeutic agent for the treatment of TBI. Progesterone is a potent neurosteroid, and progesterone receptors are abundant and widely distributed in the central nervous system. Progesterone is not only synthesized in the gonads and adrenal glands, but also produced by glial cells in the brain and by Schwann cells in the peripheral nervous system(Gerhart). In addition, allopregnanolone, a metabolite of progesterone preferentially produced in the central nervous system, has been shown to be an active neuroprotectant molecule(Stein). Previous clinical trials, conducted in the U.S.(Wright) and China(Xiao), suggest that progesterone can improve outcomes for TBI victims. Both studies showed about a 50 percent lower mortality in the progesterone-treated group as compared to placebo (Xiao and Wright). The Chinese study also showed a statistically significant functional improvement(Xiao) and the U.S. study showed a similar trend. Building on these promising results, in 2010 BHR Pharma, LLC initiated SyNAPSe® (Study of the Neuroprotective Activity of Progesterone in Severe Traumatic Brain Injuries), a global Phase 3, multi-center clinical trial. SyNAPSe® is designed to evaluate the effectiveness of BHR’s proprietary BHR-100 intravenous progesterone infusion product as a neuroprotective agent for treating severe TBI patients. The U.S. Food and Drug Administration has granted orphan drug status to BHR-100 and has placed the drug on a Fast Track Development Program designed to accelerate its potential approval. (http://www.synapse-trial.com/)

---

References:

Alderson P, Roberts I, et al. Corticosteroids for acute traumatic brain injury. Cochrane Database Syst Rev. 2005:CD000196.[PubMed], http://www.ncbi.nlm.nih.gov/pubmed/15674869

Brain Trauma Foundation. Guidelines for management of severe head injury. Brain Trauma Foundation, American Association of Neurological Surgeons, Joint Section on Neurotrauma and Critical Care. J Neurotrauma. 1996; 13:641-734. [PubMed], http://www.ncbi.nlm.nih.gov/pubmed/8941879

Cochrane Collection. The Cochrane Collection Brain Injury Review 2005

Fan L, Young PR, Barone FC, Feuerstein GZ, Smith DH. Mcintosh TK, et al. Experimental Brain injury induces different expression of tumor necrosis factor-alpha mRNA in the CNS. Brain Res Mol Brain Res. 1996;36:287-91. [PubMed], http://www.ncbi.nlm.nih.gov/pubmed/8965649

Roberts I, Schierhout G, Alderson P, et al. Absesnce of evidence for the effectiveness of five interventions routinely used in the intensive care management of severe head injury: a systematic reviews, J Neurol Neurosurg Psychiatry. 1998;729-33. [PMC free articles] [PubMed], http://www.ncbi.nlm.nih.gov/pubmed/9810947

Gerhart J. Progesterone Synthesized by Schwann Cells during Myelin Formation Regulates Neuronal Gene Expression, Mol. Biol. Cell July 1, 2000 vol. 11 no. 7 2283-2295. http://www.molbiolcell.org/content/11/7/2283.full#aff-1

Stein, D.G. (2008). Progesterone exerts neuroprotective effects after brain injury  Brain Res. Rev., 57, 386-397.

Wright, D.W., Kellermann, A.L., Hertzberg, V.S., Clark, P.L., Frankel, M., Goldstein, F.C., et al. (2007). ProTECT: A Randomized Clinical Trial of Progesterone for Acute Traumatic Brain Injury Ann Emerg Med., 49,391-402.

Xiao, G. et.al. (2008). Improved outcomes from the administration of progesterone for patients with acute severe traumatic brain injury: a randomized controlled trial  Critical Care, 12, R61.

Thank you, Jeffrey — Preceding unsigned comment added by Tmacallister (talk • contribs) 21:42, 30 November 2011 (UTC)

Are there more details for the refs such as "title" and "PMID". ThanksDoc James (talk · contribs · email) 17:04, 16 December 2011 (UTC)

Merger proposal 2

I'm suggesting we merge head injury here. While technically head injury is a broader category encompassing scalp injury etc., there's zero information in that article about those other types of injuries--it's all just random scraps of info about TBI that are covered much better here. So it's just a really poor replica of the TBI article. I think in part that's because people keep adding random bits of info there because it's what they find when they're searching for TBI (which is commonly referred to as head injury). The head injury article points out that the terms are used interchangeably (with a ref). So my concern is that people are looking for this article but instead are finding the head injury article, which is a start class and really not informative. delldot ∇. 02:38, 11 December 2011 (UTC) I'm not sure if I've proposed this before, sorry if I have but I can't find it if so.

Do not merge. The term "head injury" encompasses several other injuries, including superficial injuries, scalp injuries and types of intracranial bleeding. Moreover, the term "head injury" is a frequent "diagnosis" in Emergency Departments, where the presence of brain injury may not be apparent immediately upon arrival. The "Head injury" article requires clean-up, with appropriate links to "main articles" such as "Traumatic brain injury". Axl ¤ [Talk] 17:33, 11 December 2011 (UTC)

Do not merge Agree with Axl. Doc James (talk · contribs · email) 04:52, 13 December 2011 (UTC)

Closing as no consensus... Doc James (talk · contribs · email) 19:17, 1 January 2012 (UTC)

Edit request on 4 June 2012

Please insert new copy marked below:

No medication to halt the progression of secondary injury exists,[55] but the variety of pathological events presents opportunities to find treatments that interfere with the damage processes.[2] Neuroprotection, methods to halt or mitigate secondary injury, have been the subject of great interest for their ability to limit the damage that follows TBI. Two current Phase III clinical research programs are designed to prove that progesterone is a safe and effective neuroprotective agent for treating TBI. The SyNAPSe Trial, based on licensed technology from Emory University, is studying severe (Glasgow Coma Scale (GCS) 3 - 8) TBI patients. ProTECT III, a National Institutes of Health-sponsored trial led by Emory, is studying the safety and efficacy of progesterone for severe to moderate (GCS 4 - 12) TBI patients. Previous clinical trials to test agents that could halt these cellular mechanisms have met largely with failure.[2]

Source: Emory University

170.140.107.186 (talk) 15:56, 4 June 2012 (UTC)

Per WP:MEDRS, article text should be based on secondary sources. I couldn't find secondary sources about these trials. (This is typically the case for Phase III trials.) This research is at too early a stage to be included in Wikipedia's article. Axl ¤ [Talk] 21:06, 4 June 2012 (UTC)

Edit request on 2 November 2012

This is a request for an established user to add the following to the "Treatment: Chronic Stage" section of the Traumatic Brain injury page:

Modulating neuroinflammation is an emerging treatment option for chronic brain dysfunction due to traumatic brain injury and stroke. Etanercept, a biologic TNF inhibitor, previously demonstrated in animal models to reduce microglial activation and improve traumatic brain injury, has been documented to reduce motor impairment and spasticity in patients with TBI, even years after brain injury.<ref>{{cite journal |last1=Chio |first1=C.C. et al. |title=Therapeutic evaluation of etanercept in a model of traumatic brain injury |journal=J Neurochem |year=2010 |volume=115 |issue=4 |pages=921-929 |pubmed=20796174}} </ref><ref>{{cite journal |title=Selective TNF Inhibition for Chronic Stroke and Traumatic Brain Injury – An Observational Study Involving 629 Consecutive Patients Treated With Perispinal Etanercept |author=Tobinick E., et. al. |journal=CNS Drugs |year=2012 |volume=26 |issue=12 |pubmed=23100196}}</ref><ref>{{cite web |url=http://www.sciencedaily.com/releases/2012/10/121031125522.htm |title=New Hope for Survivors of Stroke and Traumatic Brain Injury |work=Science Daily |date=31 October 2012 |accessdate=09 November 2012}}</ref>

70.46.72.146 (talk) 18:37, 2 November 2012 (UTC)

Done. -Nathan Johnson (talk) 23:50, 9 November 2012 (UTC)

This is an experimental treatment. Tobinick's paper is an early observational study and therfore a primary source. Another reference describes testing in rats while the other is a science magazine reporting Tobinick's findings. The treatment is at too early a stage to be included in this article. If/when this treament becomes established and is described in reliable secondary sources, it could be included in the article. For the time being, it should not be here. Axl ¤ [Talk] 12:10, 10 November 2012 (UTC)

Mr. Johnson's edit is correct and deserves to stay. The crieria Axl has pointed out has been fulfilled, the article has been cited by a reliable secondary source - see Clark, Ian, New Hope for survivors of chronic stroke and traumatic brain injury, CNS Drugs, volume 26, issue 12, Dec. 2012, available online Nov. 7, 2012. http://www.ncbi.nlm.nih.gov/pubmed/23100197 ; Clark's independent commentary specially addresses the article, and cites to additional literature (see Clark reference 1) that discusses inflammation as a therapeutic target. Wonderful to see Wikipedia be current with important new medical advances.

I am bringing this matter to the attention of WikiProject Medicine so that we can reach a clear consensus. Axl ¤ [Talk] 19:49, 11 November 2012 (UTC)

Please read the Clark editorial and it's first reference, the consensus statement from the worldwide stroke group, before making an incorrect decision. Readers are not served by suppression of information. — Preceding unsigned comment added by 63.130.249.171 (talk) 23:17, 11 November 2012 (UTC)

• Comment (coming over from WPMED) The addition is inappropriate, particularly the section in which it is placed. If anywhere, this belongs in "Research" as it is far from established. Editorials are primary sources, and they are not peer-reviewed. -- Scray (talk) 23:40, 11 November 2012 (UTC)

That is debatable, in that this an off-label use in the clinic of an FDA-approved medication; this off label use is not experimental. Also there is another secondary source- please see the press release by Springer, the second largest medical publisher, on their website:

Extended content

PRESS RELEASE New hope for survivors of stroke and traumatic brain injury Single dose of etanercept targets brain inflammation years after damage New York / Heidelberg, 31 October 2012 A new ground-breaking study about to be published in the Adis journal CNS Drugs provides clinical evidence that, for the first time, chronic neurological dysfunction from stroke or traumatic brain injury can rapidly improve following a single dose of a drug that targets brain inflammation, even years after the stroke or traumatic event. The observational study¹ of 629 patients, conducted over the course of nearly two years, documents a diverse range of positive effects, including statistically significant rapid clinical improvement in motor impairment, spasticity, cognition, etc. in the stroke group, with a similar pattern of improvement seen in the traumatic brain injury (TBI) group. The study involved 617 patients treated an average of 42 months after stroke and 12 patients treated an average of 115 months after TBI, long after further spontaneous meaningful recovery would be expected. The study was conducted at the Institute of Neurological Recovery (INR) in the USA. The drug utilized was etanercept, a therapeutic that selectively binds and neutralizes an inflammatory immune molecule that may remain elevated for years following stroke. Etanercept was administered utilizing a novel delivery method, invented by Edward Tobinick M.D., lead author of the study. “These results represent a sea change in the therapeutic possibilities for stroke and TBI patients,” said Steven Ralph PhD, Associate Professor at Griffith University School of Medical Science in Australia. “Rarely do we see such a radical breakthrough in medical treatment as this for stroke. A previous example was the advance with thrombolytic therapy using drugs such as tissue plasminogen activator (t-PA) for the treatment of acute stroke with their significant impact when applied at the early stages. However, no similar treatment has existed for chronic stroke until now.” Professor Ralph recently led a team of physicians to the INR for training in the new etanercept delivery method, prior to their initiation of randomized trials in Australia. “Our team observed, first hand, rapid clinical improvement in stroke patients following this brief office treatment,” said Professor Ralph. In an accompanying editorial², Professor Ian Clark, a world expert on tumor necrosis factor (TNF) and brain dysfunction, discusses the science underlying the novel treatment method and clinical results. The high prevalence of chronic post-stroke and post-TBI neurological disability, with millions of individuals affected worldwide, highlights the study’s significance. References 1. Tobinick E, Kim N, Reyzin G, et al. Selective TNF Inhibition for Chronic Stroke and Traumatic Brain Injury – An Observational Study Involving 629 Consecutive Patients Treated with Perispinal Etanercept. CNS Drugs. 2012;16(12). DOI 10.1007/s40263-012-0013-2 2. Clark, I. New Hope for Survivors of Stroke and Traumatic Brain Injury.CNS Drugs. 2012;16(12). DOI 10.1007/s40263-012-0014-1 — Preceding unsigned comment added by 63.130.249.171 (talk) 23:57, 11 November 2012 (UTC)

Press releases aren't good/real/standard/independent secondary sources. Biosthmors (talk) 17:29, 12 November 2012 (UTC)

• This claim clearly requires a highly reliable source. None has been provided, so I've reverted. Because the bar is quite high for medicine-related content, this edit should not be restored without proper secondary sources. -- Scray (talk) 23:14, 12 November 2012 (UTC)

I simply made the edit for the IP because it was not vandalism (the reason for page protection) and seemed reasonable. It was reverted. Now the IP should discuss the proposed edit in an attempt to change consensus as outlined in WP:BRD. -Nathan Johnson (talk) 02:30, 13 November 2012 (UTC)