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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES
Programme 2. - Head Injuries
RADIO 4
TUESDAY 06/02/07 2100-2130
PRESENTER:
MARK PORTER
REPORTER: CAROLINE SWINBURNE
CONTRIBUTORS:
RICHARD GREENWOOD
STUART ROSS
JANE POWELL
KATE LEWIS
VEER DHILLON
STEVE TWIGDEN
JOHN FIRTH
PRODUCER:
GERALDINE FITZGERALD
NOT CHECKED AS BROADCAST
KENT
I think my sons would most probably say that perhaps dad has changed in certain ways. Before I was reasonably a patient man, yes, I mean I know I used to have me moments of losing my temper but not over sometimes the trivial things until one day it wasn't the sort of same normal day, it sort of totally changed my life.
PORTER
Alan Kent, one of a half a million people in the UK who have survived a serious head injury, and been left with long term after effects.
It's a topic that has received a lot of attention recently, following Richard Hammond's return to Top Gear at the end of January. He spent five weeks in hospital recovering from head injuries sustained when the rocket powered car he was driving overturned last September. His recovery was remarkable, as is evident from this interview with Jonathan Ross just three months after the crash.
CLIP FROM JONATHAN ROSS SHOW
HAMMOND
I had post-traumatic amnesia, which basically means I had sort of a five second memory. So the guys would come round - it just meant whilst I was in hospital I was completely useless - so they'd come round with a menu of what was up for lunch and then show me and - Ooh look, cottage pie, that's my favourite, I'll have that please. Five minutes later it would arrive - cottage pie. Oh my favourite, how did you know? Then they brought it again for tea, they'd come round and do the same again, five days on the trot. My wife eventually said - Can you just tell him it's off?
PORTER
Richard Hammond who would be the first to admit that he has been unusually fortunate - few people make such a speedy, or complete recovery.
I'll be finding out more about the long term effects of head injury - including changes in personality - a bit later on.
But first, the immediate risks. How do you manage someone with a brain injury?
Stuart Ross is consultant neurosurgeon at Leeds General Infirmary and the man who looked after Richard following his crash.
ROSS
The key priorities are to stabilise the patient and try to support them as best as possible - checking the airway, breathing, making sure that the circulation is good enough to deliver oxygen to the injured brain. Thereafter you begin to think of the things that might make things worse and one of the principal things that we look for is evidence of bleeding or clot formation within the head. And that leads to a scan. If there is a clot that is putting a lot of pressure on the brain then it may be wise to remove that by operation.
PORTER
So assuming that you don't need to progress to surgery but the patient has still suffered a significant brain injury, as happened in Richard's case, what do you do then?
ROSS
One of the principal things that we need to look at is the level of consciousness. We have a system called the Glasgow coma scale, which tells us different levels of consciousness. If the patient is at the lower end of that scale of consciousness then it's often helpful to have some other handle on how the brain is getting on and the commonest way to do that is to measure the inter-cranial pressure.
PORTER
That's the pressure within the skull?
ROSS
That's right. It tells us how much the brain swells after the injury.
PORTER
But looking at a case like Richard's, by the time they get to the hospital if there isn't a bleed there but you're then worried about brain swelling, when that's likely to occur, is it something that occurs within a few hours of an accident or can it take longer than that?
ROSS
Well usually in the case of a severe head injury we would see swelling within a few hours. But actually the swelling continues for several days and in a typical case the maximum swelling might be at around two to three days after the injury.
PORTER
You obviously take steps to make sure that the brain's in as good a condition as possible by looking after the blood supply and the other factors that we've talked about and minimising any swelling but is there anything you can actually practically do to speed up the healing or is that just something we have to leave to nature?
ROSS
To a large extent it's left to nature. There are things that we can do to help, for example if the pressure inside the head rises to extreme levels we have drugs that will help to suppress that and help to get over that situation. But it's still a problem that Mother Nature has given us a mechanism by which we recover from head injuries and on occasion despite her best efforts that recovery does not happen.
PORTER
Neurosurgeon Stuart Ross talking to me earlier.
My guest today is Dr Richard Greenwood, he's a neurologist at the Acute Brain Injury Unit at the National Hospital in London.
Richard, are certain parts of the brain more susceptible to injury than others?
GREENWOOD
Well I'm not sure that it's that they're more susceptible so much as they're injured more frequently. And the particular areas of the brain that are injured are the frontal lobes and the temporal lobes.
PORTER
And this is the part of the brain basically in your forehead, it's the front of the brain?
GREENWOOD
That's right, yes.
PORTER
And what's actually happening to that brain?
GREENWOOD
Those parts of the brain bang against the inside of the skull and get bruised. With that sort of bruising injury, which is called contusional injury, you may also get shearing of the brain, which is a more widespread injury, and you may sometimes get the effects of pressure from blood clots forming between the skull and the brain pushing the brain and secondarily injuring it.
PORTER
Because we heard there that the immediate threats are often the bleeding and the swelling and that's presumably because it's pushing on the brain and that kills the brain does it or how does pressure damage the brain?
GREENWOOD
It shifts the brain and therefore squeezes the blood vessels that supply the brain, they become blocked, the brain lacks its blood supply and it gradually infarcts or strokes out secondarily to the effects of the pressure.
PORTER
So the pressure can actually lead to parts of the brain dying?
GREENWOOD
That's right.
PORTER
We heard about Richard Hammond's case there, I mean I don't know when he was discharged from the neurosurgical unit but it was fairly early on, but he spend five weeks in hospital in total, so what's happening for the rest of the time and is that time critical?
GREENWOOD
So when somebody like him leaves the care of the neurosurgeons the brain is still swollen and bruised, so it's not working properly, so the person may be even unconscious when they leave the neurosurgical unit and at least confused, as he described. So during that time you're not able to look after yourself and you need support to be - so that you're protected against various complications that may occur, for example infections of the - chest infections or bladder infections, falling - you're trying to preserve the body in as normal a state as possible, so that when they regain some ability to learn then they have a useful body to learn with. And if you can prevent those complications then probably their rehabilitation is optimised.
PORTER
Are there any early indicators that you can use to predict the long term outlooks? I mean one of the questions you must get asked all the time by worried relatives is, is he going to be alright doc.
GREENWOOD
Yes, you can predict ballpark outcomes. That gets easier the further you are from the actual injury, so acutely neurosurgeons, for example, have particular difficulty in predicting useful ballpark outcomes. The initial appearances on a head scan, the initial level of consciousness or unconsciousness when a patient's at the scene of the accident or admitted to hospital and the time for which they're amnesic after an injury are crude indicators of outcome long term.
PORTER
And by amnesia you mean that they can't remember what's happened to them?
GREENWOOD
That's right, this is called post-traumatic amnesia. So unable to remember things moment to moment after an injury and that may be a matter of minutes after a mild head - so called mild head injury or it may last for days, weeks or even months after an exceptionally severe injury. And the length of post-traumatic amnesia is a crude predictor of somebody's abilities in the long term.
PORTER
What about the effects on personality? Richard Hammond became obsessed with Lego, according to the newspaper reports, at the time he didn't think there was anything unusual about that. Do the patients themselves have much insight into the fact that they're not behaving normally?
GREENWOOD
Well often they don't because obviously insight is a brain function and the brain's injured, so their insight is impaired, as well as their other behaviours. They may, what's called, perseverate on an activity, so they do an activity and they're unable to change to doing another activity and they may perseverate on doing Lego.
PORTER
They get stuck in a theme, in his case was Lego.
GREENWOOD
It may be - may be that that was a perserverative activity.
PORTER
And that's a phase that they pass through?
GREENWOOD
It's something that's well recognised yes.
PORTER
Well even subtle personality changes can present difficulties - and not just for the person who has sustained the injury, but for their family and friends too. Builder Alan Kent is aware that his character has changed since falling from some scaffolding just over three years ago.
KENT
I went through a stage, sadly to say, where through sometimes sheer frustration really I tend to be a little bit quick tempered. I feel very ashamed at being that way because that wasn't like me at all. But when I actually spoke about this to one of the doctors that I was seeing he did say that it's something that you've had a tremendous injury and I'm afraid it's got to come out, sometimes it can be a short term thing, sometimes it isn't. So what you're going through at the moment is a very natural thing and to just sort of bear it and try to overcome it as much as possible. When I did lose my temper, sometimes over perhaps something trivial really, I sort of realised that I'd gone through all this treatment and sort of made this recovery but I felt that I'd come back into this life as a different man.
PORTER
Professor Jane Powell is a clinical neuro-psychologist and Professor of Psychology at the University of London's Goldsmiths College.
POWELL
First of all if you think about what we mean by personality really that's the way that people think, the way they feel about things, their attitudes, how they communicate, how they express their feelings and how they behave. After a brain injury all of those aspects of somebody's functioning can be altered through two main routes. On the one hand damage to one or many parts of the brain can result in what we call an organically based disturbance of people's ability to process information in the way that they did before and also to process emotion. So depending on where in the brain somebody's sustained their injuries they may no longer be able to understand things as they did, to experience emotions as they did or to control their emotions in the same way that they previously did. On the other hand anybody who's been involved in a serious accident or injury is going to be subject to limitations - they may not be able to return to work, they may be more dependent on the people who they loved - their family members - and those limitations and alterations can be hugely frustrating, not only for the person who's suffered them but also for the people in their immediate circle.
PORTER
Looking at the changes that occur we think as a result of structural damage, is it possible to predict what's likely to happen to somebody having looked at the damage on a CT scan?
POWELL
To a limited extent one can make predictions, the brain is a hugely complicated organ. But just to give an example, if somebody's involved in an accident where their head is traumatically struck, perhaps a car accident or an assault, in many cases people can then show a constellation of changes in their personality. So on the one hand you can have people whose emotional state is actually very blunted, who seem to show little emotional reaction to things, who lose their initiative and their spontaneity. On the other hand you can have people who lose their inhibitions, so they may become much more impulsive, much more outgoing, say things that they shouldn't say, find it difficult to control their emotions.
PORTER
And presumably that dis-inhibition can be quite hard for patients near and dear to cope with, their friends and family?
POWELL
It can be enormously difficult because of course in the immediate aftermath of a brain injury everybody's very sympathetic, understanding, tolerates and accepts a certain amount of volubility or inappropriate behaviour by the patient as part of the consequences of the head injury ...
PORTER
And by inappropriate behaviour - I mean what sort of thing might you see?
POWELL
Well for example you can have people making sexual comments that normally we would inhibit or they may laugh at things which they shouldn't laugh at that could cause offence and upset to other people. On the other side of the coin if they feel angry about something they may act that out by shouting or swearing or sometimes even throwing things or hitting. And those changes, that failure to inhibit the spontaneous emotions that we feel, can be very, very stressful for other people both to understand and to respond to.
PORTER
Professor Jane Powell talking to me earlier. You are listening to Case Notes, I'm Dr Mark Porter and I am discussing head injury with my guest neurologist Dr Richard Greenwood.
Richard, how long does the brain go on recovering following injury?
GREENWOOD
Well I think it's true to say that from the basic science perspective nobody really knows the answer about the question as to when nerves stop regrowing, resprouting. And you have to remember that in parallel is a process of learning and reorganisation of nerve connections that happens in everybody as they learn new skills. So the reason why people improve is in a way beside the point because as long as a structured rehabilitation programme of whatever sort is provided for people then they can continue to learn appropriate behaviours and new skills. And whether that's because the nervous system is recovering, regrowing, or whether that's because the nervous system is reorganising itself as ...
PORTER
To compensate for the injury.
GREENWOOD
... as happens during normal learning doesn't matter in a way.
PORTER
But you know if you're looking at an injury and you were to say well the patient has some form of deficit at one month or at six months or a year, that's likely to be permanent to some degree, can you put that sort of big scale on things?
GREENWOOD
You can, yes. So you can fairly reliably advise people about the ceiling to their recovery in the long term. So that you can, for example, tell somebody that they probably will get back to work but they may need to look at altering their roles at work or the time that they work during the day and avoid - so they may have to avoid overtime.
PORTER
And you're in a position to predict that at what sort of stage - how long after the injury might you have a fairly good idea of how their progress is going?
GREENWOOD
Sometime within the first - certainly the first few months, often the first few weeks. This is not something that one necessarily discusses at that time because people are interested in other aspects of their recovery but it does enable you to discuss constructively how they might approach their return to normal social life and their work if they're going back to work.
PORTER
How good is the NHS at providing the sort of long term rehabilitation required to help and support people who've had serious brain injury?
GREENWOOD
There are difficulties in many parts of the country in getting appropriate support for improving one's skills after severe head injury in the longer term.
PORTER
Well Headway is a national charity which runs "Headway Houses" across the country providing maintenance therapy for people who have sustained brain damage. The centre in Cambridge caters for over 60 members providing everything from tailored exercise programmes in the gym, to computer instruction in the IT suite. Chief Executive Kate Lewis showed Caroline Swinburne around.
LEWIS
Now we're going into our gym, which we're very fortunate to have.
ACTUALITY
Have a rest before you go on to leg extension, yeah?
A lot of our clients have physical disabilities as well as any kind of impairment that their brain injury has brought them. And Veer, our gym instructor, works with the members individually on whatever it is that they need to develop. So you'll see that we have got exercise bikes that can be used by a person who's in a wheelchair, we have parallel bars that people can walk up and down to help them with their stability and balance and we have some of the more traditional gym equipment to help people just with their general overall fitness and strength.
ACTUALITY
Nice and slowly yes? Make sure you control it coming up and coming down. Well done.
DHILLON
My name is Veer Dhillon, I work at Headway as a fitness instructor. Before the members are coming to the gym they have to have a letter from their doctor or their GP saying that they can actually come and do any physical exercises, activities. And when they do come into the gym it's done on each individual basis and since I've been here the amount of results I've seen it's unbelievable, it's just wow.
MACKAY
My name is Bob Mackay. The doctor said I would never walk or talk again. It frustrated me because I was able bodied at one time and being in a wheelchair restricted me from being me.
SWINBURNE
Was it through coming here, through using the gym here, that you managed to get walking?
MACKAY
I still waddle a bit but I think mainly using the gym and a brilliant instructor and he pushes me, if I slow down he says Bob try a bit harder and this [indistinct word] has done me a world of good, never give up.
DHILLON
I've had some members actually get emotional because they've actually started walking again and I'm a grown man and sometimes I've had tears in my eyes as well, seeing people actually get up and walk and take a step. Why and how they get better I do not know, but they do get better.
ACTUALITY
Right, so first of all, we have to understand that men think differently from women ...
LEWIS
Okay so this is our drama group and our drama tutor Steve will either be doing what you might consider to be quite straightforward traditional drama exercises with the group but he also runs very, very lively discussion groups and he'll take often quite a controversial topical issue and encourage the group to state their opinions, have arguments - it really is to bring people out of their shells and get them communicating.
ACTUALITY
Where are you coming from? Well if I'm talking rubbish Tony then obviously you have an opinion on that, so give your opinion, don't just say I'm talking rubbish.
TWIGDEN
My name is Steve Twigden, I'm the drama tutor at Headway House. The basic idea is really first of all to get them talking but secondly for them to be able to say what they think and feel and that's to do with thought processes, to get them to think things through - if they're feeling angry or sad or happy about what they've heard, why is that so and then take that forward.
ACTUALITY
Do you agree or disagree? You agree that you have to accept that?
LEWIS
We're trying to help people cope with daily life and that means really going back to basics, to find a way that works for them to be able to do those things and that might be going with them and taking the bus with them and so giving them the confidence that they can remember that they get on the Number 2 bus and that they give the driver a £1. People rely a lot on some external things, such as diaries and post-it notes and alarms on their mobile phones to remind them to do things.
CAROLINE
My name's Caroline, I've been coming to Headway I think about five years. One thing Headway's helped me with is money management. I used to spend things but I don't know how much I spent. I actually have an allowance a week but I try to keep to my allowance but they've helped me more to make me manage my money. I have to write things down - how much I've spent.
SWINBURNE
So now you can cope with that okay, it is easier to cope with shopping and everything?
CAROLINE
Yeah.
PORTER
Caroline Swinburne at Headway in Cambridge.
So far we have looked at what can be done to help minimise the effects of head injuries - but what about preventing them in the first place? Retired neurosurgeon Professor John Firth sits on Headway's Injury Panel and has seen major changes since taking up his first post in the sixties at the renowned National Hospital for Neurology and Neurosurgery at Queen's Square in London.
FIRTH
When I went to Queen's Square my first job there, the principal purpose of my job, was to ensure that before anybody was admitted they had to sign the consent form to their own post-mortem. And most of those consent forms were used. Now you may say that's outrageous, how can that be, but that is the natural history of neurological conditions. And the only way progress is made is through every case in which the patient does die that the entire management of that case is scrutinised and reviewed by post-mortem. And that was really the basis upon which the progress in the neurosciences has been based. So now if someone dies, I mean it's a scandal, an uproar. So here we've seen something if you like has gone almost from the cave age to the space age in one person's lifetime.
PORTER
And what about the sort of head injuries that we're seeing - the advent of helmets for motorcycles, the wearing of seat belts in cars - has that changed the sort of head injuries that are coming into casualty units, is that part of the reason why people stand a better chance these days?
FIRTH
Well it has completely changed, in any one night one could be operating on up to half a dozen head injuries and these were people who'd largely come off motorcycles without any form of protection. And then the fashion for space age helmets came in, so almost overnight a pure fashion item completely revolutionised head injuries, so going from half a dozen a night and if you had half a dozen a week - head injury almost became a rarity after that. Before seat belts we had still people going through the windscreen, after seat belts they were surviving but their heads have still been subjected to very high accelerations. And so if you like there's now another generation of challenge - how do we attenuate these very high accelerations? Richard Hammond's accident was a good example of that and the Formula One people have shown how you can survive high accelerations but it needs a lot of technology and a lot of it is not readily applicable to normal motorcars.
PORTER
John Firth talking to me earlier.
Richard, he talks there about the effects of acceleration on the brain, you alluded to it at the beginning of the programme - the shear effect - you don't actually have to have direct trauma to the skull to damage your brain do you.
GREENWOOD
You can die after a head injury - as a result of head injury without any fractures to the skull, just because of very, very severe shearing injury to the brain or you can be vegetative, what's called vegetative, unconscious, unaware long term, without having had any sort of fracture to the skull.
PORTER
Because this analogy I was given as a medical student was that of the blancmange, you know you've got - the brain has a consistency of a blancmange, you put it in a crash helmet and hurl that crash helmet against a wall, that sudden stopping will tear that blancmange and that's basically what happens to the brain. Is that a useful analogy?
GREENWOOD
I think it is, I mean it's a rather solid blancmange but I think it is instructive.
PORTER
Let's move on. What about less obvious injuries - how do we assess their significance? I'm thinking here - the rugby player concussed on the pitch, or the child who is temporarily knocked out after falling down the stairs. Presumably we don't get to follow these people up that much, I mean is it possible that they could be doing long term damage?
GREENWOOD
Yes, they're slightly different types of injury, in that sports injuries are sustained in the absence of surrounding circumstances which might cause secondary psychological problems due to, for example, post-traumatic stress disorder, whereas sports injuries are much more pure head injuries. Now if you lose awareness for - if you have post-traumatic amnesia - for 10 minutes after a head injury that means that your brain has been injured, it doesn't mean your skull's been injured, the skull doesn't operate memory obviously, it means that your brain has been injured. And if you have a number of those episodes during a season, for example, then you may have measurable decrease in your ability to process information during neuropsychological tests, for example.
PORTER
So you're damaging - you're damaging your brain. What about the child who falls down the stairs who's knocked out, how might you assess the risks of an acute problem there? When I was a paediatrician we used to admit children who'd been knocked out. Explain the reasoning behind that.
GREENWOOD
Well there are criteria for admitting patients after minor head injury of that sort which losing consciousness at the time of the injury is one criterion.
PORTER
And that's because the insult enough - if there's enough of an insult for you to lose consciousness, it's enough of an insult to perhaps cause bleeding and swelling.
GREENWOOD
And that bleeding may enlarge and need neurosurgical evacuation. So the fact that you've lost consciousness is an index of the severity of injury and the fact that you may need evacuation of a blood clot.
PORTER
And the sort of things that would make you worried as a doctor looking after that patient once they've been admitted, what would - how would you be monitoring them?
GREENWOOD
So these are patients who are monitored with the Glasgow coma scale score and if that deteriorates then they need urgent scanning and perhaps neurosurgery.
PORTER
Because they could be fine after the initial insult and then start to go downhill?
GREENWOOD
That's right. And there is a case which the neurosurgeons will know much more about than somebody like me for immediate scanning of patients with those sort of indices of injury.
PORTER
But significant clinical features are someone who was at home or - I mean the sort of things that would worry you, the symptoms in the patient, would be what?
GREENWOOD
Vomiting is a particular worry because it represents - probably or often represents blood in the spinal fluid circulating around the brain, indicating the nature of the injury.
PORTER
I am afraid we must leave it there. Dr Richard Greenwood, thank you very much.
Next week's programme also focuses on the brain. I'll be investigating the latest developments in Parkinson's disease. From new treatments, to the realisation that there is much more to the condition than the classic triad of shaking, stiffness and difficulty moving.
Ends
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