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Mild traumatic brain injury in persons with multiple trauma: the problem of delayed diagnosis

Journal of Rehabilitation, Jan-March, 1997 by Andrea D. Clements

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Though decorated in the military and a model employee prior to injury, shortly after injury this man attempted to pay bills that were not due and make payments with canceled checks. He became angry when others attempted to correct him to such a degree that the canceled check was accepted by a utility company and his wife was notified. Depression and concentration continue to be his most serious areas of deficit, and as predicted by Cullum et al. (1990), neither has resolved entirely. His IQ score did return to the normal range, which is assumed to be comparable to his premorbid level, but function did not follow.

Case 2

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This 47 year old man was injured in a motor vehicle accident at the age of 43. He sustained lung, rib, knee, shoulder, and facial injuries. Even though facial injuries were evident, no TBI assessment was performed until almost 2 years post injury. Fatigue, forgetfulness, frustration, debilitating headaches, angry outbursts, depression, and seizures were present from the time of injury, but no diagnosis was made until 1 year 9 months post injury. Again, multiple surgeries, including nasal and dental procedures, and effects of medication, could have overshadowed the concern about TBI symptoms.

Seizures are associated with TBI (Brown et al., 1994; Verduynl 1992), but are not as common as forgetfulness, emotional lability, headaches, and confusion, and have multiple possible etiologies. One noteworthy functional deficit peculiar to seizure activity is that the patient can not drive until the seizures are controlled. In the case of this man and others, the seizures were not controlled, and physicians have suggested that they may not be. Verduyn (1992) noted that although some benefit is typically derived from anticonvulsant medication, premorbid levels of social and vocational function were rarely observed.

Prior to injury this individual was a very successful businessman possessing one graduate degree, and was pursuing a doctoral degree. He obviously had a high level of intellectual functioning, but even with a significant drop, he was not diagnosed for quite a long time.

Case 3

This 33 year old man was injured in an industrial accident when he fell from a height of approximately 25 feet onto a paved roadway, landing on both feet. He sustained multiple orthopedic injuries including ankle, heel, and back injuries, for which he continued to undergo physical rehabilitation for at least four years post injury. There was no loss of consciousness, and no investigation of possible MTBI at the time of injury. Three years, eight months post injury, during an interview, it was noted that he had memory deficits, noticeable mood swings, including uncharacteristic tearfulness and angry outbursts, and severe headaches almost daily. When referred to a neuropsychologist for evaluation of possible MTBI, it was conclusively established that he had sustained MTBI, having such severe deficits that it was recommended that he discontinue driving a motor vehicle.

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Mild traumatic brain injury in persons with multiple trauma: the problem of delayed diagnosis

Journal of Rehabilitation, Jan-March, 1997 by Andrea D. Clements

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