Electroencephalography (EEG) based detection, management, recovery and brain retraining tracking of Traumatic Brain Injury (TBI) when "Only Time Can Tell"
Traumatic brain injury (TBI) can be caused by accidents like road traffic accidents (RTA) sports injuries, and injuries at home. It is a major health issue, very often fatal and causing high morbidity, changing the lives of both the person injured and the families involved. Anticipating and preventing secondary injury and seizures post trauma, defining severity of TBI, predicting TBI outcomes and arousal from coma or declaration of vegetative state or brain death form pivotal checkpoints in TBI management. Other challenges faced include identifying malingerers from genuine individuals with post TBI morbidity, defining the severity of previous TBI in the field or previous injuries when reports are lost. Depending on both its severity and location it can cause a variety of post TBI cognitive, sensory and tactile, and motor impairments. In such instances the present paper looks at how the electroencephalographs (EEG) like NeuralScan can and do contribute uniquely and significantly aiding in assessment, continuous/periodic evaluation during the course of recovery, brain retraining and rehabilitation in evaluating temporal changes in neuronal functionality following TBI. *Correspondence to: Jonathan RT Lakey, PhD, MSM, Department of Surgery, 333 City Blvd West, Suite 1600, Orange, CA 92868, E mail: jlakey@uci.edu Received: May 28, 2020; Accepted: June 19, 2020; Published: June 21, 2020 Vital statistics on traumatic brain injury (TBI) To better appreciate the unique and valuable contributions that the high temporal resolution electroencephalograph (EEG) like NeuraScan provide in the detection, classification, treatment, management and rehabilitation of traumatic brain injury (TBI) a brief review of the key epidemiology, consequences, co morbidities, neuropathophysiology and outcomes of TBI is appropriate. In 2016, the incidence of traumatic brain injury (TBI) was 27*08 million and prevalence was 55*50 million [1] In 2018 the global incidence of TBI was 69 million individuals worldwide and predicted to be the third leading cause of mortality in 2020 [2 5] Incidence rates based on TBI severity determined using 6 studies are that mild TBI affects approximately 55.9 million people each year (740 cases per 100,000 people) moderate TBI affects 7.64 million people each year (101 cases per 100,000 people) and severe TBI affects 5.48 million people each year (73 cases per 100,000 people) with the proportion of mild, moderate and severe being 81.02% 11.04% and severe 7.95% respectively [5 10] The causes of traumatic brain injury (TBI) range from falls, motor vehicle accidents (traffic and pedestrian) self harm (falls, gunshot wounds GSW) abuse/domestic (adult or children) violence, street violence, work/industrial/construction incidents (falls, blasts) and military maneuvers/terrorism, (falls, fire arms, blasts, explosions) Following a TBI the duration from injury to recovery (Figure 1: LORETA images tracking injury to recovery taken using NeuralScan by Medeia) can vary depending on the duration between injury and commencement of treatment, severity and location of the injury. While earlier it was thought that only moderate severe TBI survivors (50 65% experience debilitating emotional, psychological and neurocognitive consequences (Figures 2a and 2b) in recent year's studies have shown that individuals (athletes, military personnel and elderly) with mild TBI (mTBI) also share the same risk [4 7,11 16] mTBI accounts for 1.63.8 million sports related 320,000 military related concussions [17 20] The consequences of TBI affect personal, social and work life as well as influence the rate of age related cognitive decline [20 29] Military veterans with mTBI have been shown to be at a 56% increased risk of Parkinson disease (PD) [30] Studies on TBI and the risk of dementia or Alzheimer's disease (AD) have shown no similar association [31] Whether it's mild or, moderate or severe TBI though for some individuals return to normal it is uneventful for many others it requires a concerted and integrated approach on the part of a myriad medical specialties extending to family, social and occupational support where rehabilitation is concerned [32 38] an individual. Further compounding the issue is that many individuals with possible/probable mild TBI following sports injury, falls and road traffic accidents (RTA) etc do not seek treatment. A survey of 1381 individuals with TBI found 42% did not seek treatment with age, severity of TBI and injury occurring at home being factors associated with not seeking treatment [32,39] Similarly, less than half of patients (41% [343 patients] reported having seen a medical practitioner about their mTBI at 2 weeks, and 44% (367 patients) reported seeing a medical practitioner by 3 months [40 42] Another feature of mTBI is that very often individuals do not seek medical care, among those who do seek care there is a lack of followup care even if they tested positive on computed tomography (CT) Miranda P (2020) Electroencephalography (EEG) based detection, management, recovery and brain retraining tracking of Traumatic Brain Injury (TBI) when "Only Time Can Tell" J Syst Integr Neurosci, 2020 doi: 10.15761/JSIN.1000230 Volume 7: 2 15 Figure 1. Working example of the dual use of eLORETA/sLORETA: To "track TBI" from injury to recovery, To "track Z score retraining of the brain" LORETA Images taken using NeuralScan by Medeia and post mTBi symptoms exist/persist symptoms this in turn results in longer lasting symptoms which may have long term consequences [40 42] Another key aspect about TBI is it is dynamic. A brief overview of the neuropathology of TBI is presented in Figure 3 which illustrates how both the primary and secondary injuries influence outcomes [43 45] Figure 3a presents the different types of primary injury that can occur, the consequences of which is the secondary injury (Figure 3b) which can happen within minutes or days following the trauma. The secondary injury is the result of the cascade of events (molecular, chemical, and inflammatory) that are activated following the primary injury [43 45] Hence one of the main goals of TBI treatment protocols is to repair the primary injury and prevent secondary injury which if left unchecked can cause further cerebral damage [43 45] Short and long term outcomes of traumatic brain injury (TBI) vary depending on the severity of injury (primary and secondary) comorbidities during hospitalization and following discharge, location of the injury, medical history prior to the TBI, previous TBI, presence of polytrauma [16,32 38,46 48] At 8 years following a TBI, 19.8% and 46.5% were severely and moderately disabled respectively with 33.7% with good recovery among 86 individuals who participated in the study. Somatic complaints were balance 47.5% motricity 31% and headaches 36% cognitive complaints: memory 71% slowness 68% concentration 67% 25 had anxiety and 23.7% for depression. 48.7% were employed in a productive job and 38% declared a salary loss since the TBI [46] When only time can tell Among the several studies aimed at determining blood, imaging and electrophysiology (EEG) based markers to classify, monitor and Miranda P (2020) Electroencephalography (EEG) based detection, management, recovery and brain retraining tracking of Traumatic Brain Injury (TBI) when "Only Time Can Tell" J Syst Integr Neurosci, 2020 doi: 10.15761/JSIN.1000230 Volume 7: 3 15 Figure 2. Prevalence of co morbid conditions among a) Children (parent reported) and b) <65 and =65 year old Adults following TBI Jain, K. K. (2008) Drug Discovery Today https:/www.nap.edu/read/13121/chapter/6 Chapter 3 Figure 3. Trauma brain injury and its neuropathophysiology Miranda P (2020) Electroencephalography (EEG) based detection, management, recovery and brain retraining tracking of Traumatic Brain Injury (TBI) when "Only Time Can Tell" J Syst Integr Neurosci, 2020 doi: 10.15761/JSIN.1000230 Volume 7: 4 15 treat TBI the EEG (machines like NeuralScan by Medeia) remains one of the earliest neurodiagnostic assessment tools that was used [49,50] Denis Williams recommended and demonstrated the use of the EEG both in evaluating progress in cerebral repair and when the damage is so slight that it cannot be detected by other imaging techniques [50] He advocated the EEG as a useful tool when monitoring the brain following initial trauma, monitoring to prevent secondary injury and when planning treatment and rehabilitation (Figures 4a and 4b) Following a TBI there are several time points (as mentioned below) at which the high temporal resolution, quantitative EEG (QEEG) and LORETA for spatial resolution that EEG machines like NeuralScan by Medeia offer is key (Figures 1, 4a, 4b and 5) Identification, Monitoring and treatment of Seizures following TBI: The portable non invasive EEG allows for evaluating a patients electrophysiological status at the trauma site or bedside (emergency room/ trauma unit/operation theatre/intensive care unit ICU) enabling identification of nonconvulsive seizures (NCS) following cerebral, trauma monitoring of treatment and categorization of the severity of the TBI [51 56] NCS and periodic discharges (PD) following TBI contribute to disruption of brain metabolism [51 56] Of the 94 patients with moderate to severe TBI seizures occurred in more than one in five patients during the 1st week following primary injury [51] As NCS are found to occur frequently following a TBI and require continuous EEG (cEEG) monitoring for timely detection, prevention or treatment of NCS After I was released from the hospital (a week and a day after the fall) my physiatrist followed up regularly during the first month and adjusted exercises as needed. I had absence seizures and was on anticonvulsant medications until I was around 21 years old. I had regular blood work, electroencephalograms (EEGs) and follow ups with neurologists and neurosurgeons to make sure