Head Injury

Head injury is a trauma to the skull or brain. Head injury also known as intracranial injury/ Traumatic brain injury (TBI). It is an insult to the brain caused due to any external force that usually leads to alteration in the state of consciousness in the person & impairs cognitive & physical function along with behavioral & emotional disturbances. Head injury, is a leading cause of death & disability worldwide. It is estimated that nearly 1.5 to 2 million persons are injured and 1 million succumb to death every year in India.
The classification of head injury:

  • According to mechanism of injury:
  1. Open injury: it is caused due to external force & associated with skull fracture (type of skull fracture- depressed, linear, communited, simple, compound).
  2. Closed injury: it occurs only in isolation with skull fracture.
  • According to pathophysiology:

Primary causes to head injury: {primary involvement of brain acceleration, deceleration, rotation force}

  1. Focal/ Coup- countercoup: injury is localized to area of brain under the site of impact in the skull. Blow is not only to the direct site of impact, but also exactly opposite due to bouncing back of brain after collision. Example: head strike against stering wheel of car. Common sites: prefrontal lobes, anterio- inferior temporal lobes.
  2. Diffuse axonal injury: it is a worst form of brain damage. It is characterized by widespread shearing& retraction of the damaged axons. It involves separation of soma, corneal white matter, cerebellum, basal ganglia, brain stem, cerebral cortex. It occurs due to road traffic accident, fall.
  3. Concussion: It implies a violent shaking or jarring of the brain & a resulting transient reversible loss of brain function. Example- blow on head by object or head striking against object.
  4. Contusion: It is bruising of cerebral tissue without interruption of its architecture. It is a direct injury to brain parenchyma, loss of white & grey matter, break in pia & archnoid with formation of blood clots.
  5. Vascular laceration to blood vessel or nerve lesions (especially facial, optic nerve).
  6. Penetrating:
  • High velocity: surrounding areas are also injured [bullets, missiles] due to generation of shock waves.
  • Low velocity: it has only site of impact[ toys].

Secondary causes to head injury:

  1. Increased intracranial pressure: [normal pressure- 4-15 mm Hg] it occurs due to swelling or heamatoma. It results in distortion of brain structure & herniation to opposite side. It has abnormal fluid dynamics. It is secondary to cell death due to cellular events that follow tissue damage of calcium, release of free radicals, etc.
  2. Electrolyte imbalance & acid-base imbalance: It is bursting of swollen cells & changes in DNA within cell.
  3. Infection secondary to open wounds.
  4. Seizures due to scarring or pressure( 6 months to 2yeras).
  5. Cerebral hypoxia or ischaemia: Rupture or compression of blood vessels in brain, lack of oxygen or blood, systemic hypotension, anoxia, damage to vascular territories, global damage.
  6. Intracranial heamorrhage: It is a lack of blood supply to those parts of brain supplied by haemorrhaging blood vessels [blood clots inside the brain].
  • According to severity:
  1. Mild head injury- There is minimal damage to the neuroanatomical structures with slight or no permanent impairment. On Glasgow coma scale, the patient scores more than 13.
  2. Moderate head injury- It can be placed between mild & severe type of injury. On Glasgow coma scale, the patient scores between 8 -13.
  3. Severe head injury: It doesn’t allow restoration of consciousness. The patient is unaware of the surrounding environment. On Glasgow coma scale, the patient scores less than 8.

  • Others:
  1. CSF leaks:
  • CSF otoria- (CSF leak through ear) Fracture of mastoid or temporal bone.
  • CSF rhinorrhea: (CSF leak through nose) Fracture of Anterior skull base.
  1. Pneumocephalis: (Air inside skull) sinus are closed, that are proximal to skull. If ruptured, air enters cranial cavity.

The clinical impairments are:

  • Mild head injury:
    • Patient is conscious, alert, oriented
    • Giddiness
    • Headache/ vomiting
    • Irritable state
    • Pain at injury site
    • Presence/ absence of neurological deficit
  • Moderate head injury:
    • Altered consciousness/ confused
    • Disoriented/ irritable state
    • Patient is abusive
    • Vomiting
    • Seizures
    • Presence / absence of neurological deficits
  • Severe head injury:
    • Patient is unconscious
    •  Patient is in deep coma
    • Abnormal response
    • Decorticate rigidity
    • Pupillary asymmetry
    • Hypotension/ bradycardia
    • Seizures

Prognosis differs depending on the location and severity of the injury and access to immediate and specialized acute management. Management for head injury includes immediate intensive care & resuscitation, anticonvulsants, anti edema measures, surgical decompression and evacuation of intracranial hematomas. It will be followed by long term cognitive and physical rehabilitation. Despite all the above a significant number of patients are left with debilitating neurological deficits for which there was no treatment so far. The availability of Stem Cell therapy now offers new hope to these patients.

Stem Cell Therapy in Head Injury:
With the potential of the brain to regenerate the neurons as a result of neuroplasticity, cellular therapy is aimed at carrying out the process of regeneration by neurorestorative mechanisms and reinforcing the ongoing neuroplasticity. Recent researchers prove stem cell transplantation can be an adjunct along with other treatment options for patients with head injury.
Stem cells migrate towards the damaged areas of brain and initiate a repair process and promote angiogenesis, axonal remodeling, neurogenesis, and synaptogenesis, which may to an extent help in repairing the damage caused by the head injury. The various growth factors and neurotrophic factors help to stimulate the repair and neuroprotection.  The transplanted cells replace the lost cells by proliferation and differentiation in to nerve cells (neurons, astrocytes, oligodendrocytes and endothelial cells) which help in re-establishment of functional neuronal circuitry. The formation of these neural networks can be correlated by clinical improvement in the form of function and on radiological tools like PET-CT scan brain.

Improvements after stem cell therapy:

Our Experience:
Overall, we have treated 20 cases of head injury. 94.22% patients showed improvements on analaysis. Mild improvements were observed in 41.17% of patients, moderate in 23.52% of patients, whereas, 29.41% of patients showed significant improvements. Improvements were seen in higher mental functions, posture, trunk activity, upper limb activity, lower limb activity, coordination, oromotor, ambulation and Activities of Daily Living.
In patients with head injury, especially those who are young, stem cell therapy has helped to ameliorate aggressiveness, improve understanding & cognition, which is not possible by conventional rehabilitation. Recovery of brain function in concern with active rehabilitation, helps reduce spasticity/ tightness in the limbs, which occurs due to brain damage. After the cellular therapy, patient under goes neuro rehabilitation, a multidisciplinary rehabilitation protocol including physiotherapy, occupational therapy, speech therapy, psychological counseling, yoga and dietary advice based on the patients need. Overall, balance, co-ordination, speech, communication is also improved. Stem cell therapy conjunction with multidisciplinary rehabilitation has shown improvements in patients with neurodeficit after head injury in over 85% of patients.
Thus stem cell therapy provides a newer, more effective treatment option for head injury which helps to repair the damage that occurs at the tissue level.  Therefore, SCT improves the quality of patient’s life who suffers from the crippling neurological sequelae of severe head injury.

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