Carbon monoxide poisoning involves the colorless, odorless gas that comes from engine exhausts, furnaces, or other gas-powered equipment. People who survive carbon monoxide poisoning experience initial symptoms such as headache, nausea and confusion, but often patients will experience a carbon monoxide encephalopathy several days later. This results in a subtle, but often permanent, set of symptoms such as depression, cognitive deficits, or motor impairments.

In the brain, carbon monoxide displaces oxygen in hemoglobin binding, resulting in lowered oxygen delivery and respiration. The brain therefore becomes injured from lack of oxygen. Certain parts of the brain are particularly vulnerable because of an already limited supply of blood vessels: white matter, the basal ganglia found deep in the brain, the hippocampus, and the cortical (outer) areas of brain.

Studies that use structural imaging techniques (CT or MRI) have shown that around a third of carbon monoxide poisoning patients will show normal imaging results. However, functional imaging techniques that measure blood flow (fMRI, SPECT, or PET) can detect abnormalities not seen in structural imaging. These imaging techniques not only give a more accurate picture of initial damage, but they can also clearly illustrate the time-course of the delayed damage.

Additionally, functional imaging studies can provide a correlation of brain damage to cognitive and motor impairments, providing further confirmation of delayed symptoms. In a recent case study, a man developed parkinsonian symptoms several days after carbon monoxide poisoning. A PET scan showed damage in the substantia nigra (an area deep in the brain that is associated with Parkinsons disease) that the MRI failed to show. The clinical observance of this damage led to an excellent recovery a year and a half later, with the patient returning to work.

Hurley RA, Hopkins RO, Bigler ED, & Taber KH. Applications of functional imaging to carbon monoxide poisoning. Windows to the Brain: Insights from Neuroimaging. American Psychiatric Publishing, Inc. (2008).

Rissanen E, Paavilainen T, Virta J, et al. Carbon monoxide poisoning-induced nigrostriatal dopaminergic dysfunction detected using positron emission tomography (PET). Neurotoxicology. (March 2010).

Hearing loss in head injury poses a difficult problem—patients are sometimes unaware of their hearing problems because of cognitive impairment, and others may mistake their hearing loss as a memory or communication problem. It has long been known that hearing loss is common in head injury, and yet it is not always properly diagnosed.

Direct damage can occur to the middle and inner ear, or by tearing the neuronal pathways to the auditory areas of the brain. Secondary damage can occur from bleeding and pressure, or from diffuse axonal injury. A recent study of 290 head injury patients was conducted in order to confirm the prevalence and type of hearing loss found after head injury. Patients received a broad range of audiological assessments and the results confirmed that about 30% of the patients suffered from hearing loss. In most patients, the hearing loss was mild.

Even mild hearing loss can be potentially frustrating, not only for the patient but also for family members and rehabilitation specialists. In addition, proper rehabilitation and recovery can be delayed if the hearing loss is mistaken for cognitive impairment. With the relatively high prevalence of hearing loss in head injury confirmed in this study, clinicians should consider adding hearing tests to their battery of assessments for head injury.

Munjal SK, Panda NK, & Pathak A. Audiological deficits after closed head injury. The Journal of Trauma: Injury, Infection, and Critical Care. (January 2010).

In the early days after a traumatic brain injury, when symptoms are most acute and much time is devoted to recovery and rehabilitation, survivors often do not realize the full extent of their limitations. Self-awareness is often limited in the early stages of recovery. As self-awareness recovers, the survivor gradually begins to understand the consequences of their injury and may often develop depression, anxiety, or other emotional distress.

Past studies have shown that increased age may also be associated with increased emotional distress after a traumatic brain injury. To better understand the relationship of age and time after injury with emotional response, researchers recently conducted a controlled study of traumatic brain injury survivors from 5 to 22 years after injury.

They found that age itself was not associated with emotional distress. Likewise, the amount of time past injury was, in itself, not associated with emotional distress. What the researchers did find was that there was an interaction between age and the amount of time after injury—with younger survivors showing increasingly higher levels of emotional distress as time passed.

The researchers suggested a few theories to explain this finding. Over time, younger people may become more distressed about their inability to complete life goals. Younger people may also be less likely to have established relationships that provide continued support as years pass. Survivors who were young at the time of injury, whether the injury was recent or from several years ago, should therefore be identified and evaluated for additional treatment.

Senathi-Raja D, Ponsford J, & Schonberger M. The association of age and time post injury with long-term emotional outcome following traumatic brain injury. Journal of Head Trauma Rehabilitation. (February 2010).

Post-traumatic stress disorder (PTSD) can occur after experiencing a traumatic event and may lead to poor recovery and psychological difficulties. Studies over the past few years have shown that admission to an intensive care unit (ICU) is associated with the development of PTSD.

There are several established reasons why PTSD might be associated with admittance to ICU. For instance, life-threatening injuries and the psychological trauma associated with witnessing a traumatic event can increase the risk of developing PTSD. Additionally, people with a psychiatric history are more likely to be admitted to ICU for a traumatic injury than the general population.

An Australian team of researchers recently conducted a study to determine if admittance to ICU itself increased the risk of developing PTSD, and to uncover any other factors that might increase that risk even further. They found that, independent from any other risk factor, people admitted to ICU were three times as likely to develop PTSD. Other factors that increased this risk were:

1. The presence of a mild traumatic brain injury
2. Female gender
3. History of trauma or psychiatric disorder
4. Longer length of hospital admission

The research team cited 3 possible reasons that ICU admission could increase the risk of PTSD. Sleep disturbance, increased stress, and delirium from certain drugs could all play a role in how the brain processes traumatic events. Screening tools to identify high-risk patients and low doses of sleep agents may be effective interventions.

O’Donnell ML, Creamer M, Holmes ACN, et al. Posttraumatic stress disorder after injury: Does admission to intensive care unit increase risk? Journal of Trauma Injury, Infection, and Critical Care. (February 2010).

Complete spinal cord injuries do not often occur in professional sports, but they can produce devastating results when they do. Although the primary injury is serious, a substantial amount of damage occurs during the secondary response to the injury. Much research has focused on reducing this secondary response, by slowing inflammation, cell death, or bleeding.

One treatment that has been proven useful in reducing secondary damage in traumatic brain injury and stroke is hypothermia, or the cooling of body temperature. A well-timed treatment of hypothermia can lower metabolic demands, which helps to decrease inflammation and cell death—hopefully to stop further damage and aid in recovery.

A medical team recently reported a case study of an NFL football player who sustained a spinal injury during a helmet-to-helmet hit. The player had complete paralysis and sensory loss below the clavicles at his initial evaluation. His medical team applied a moderate hypothermia treatment during his ambulance ride, which was continued throughout his standard treatment.

Within 3 days, the player was showing considerable motor and sensory improvement, and continued to improve even after his subsequent discharge. Although the researchers noted that it was difficult to evaluate the amount of recovery directly related to the systemic hypothermia, they believe the treatment was a valuable one.

Cappuccino A, Bisson LJ, Carpenter B, et al. The use of systemic hypothermia for the treatment of an acute cervical spinal cord injury in a professional football player. Spine. (January 2010).

Women are more likely to be depressed in the early stages of traumatic brain injury.

An article by Michigan researchers in The Journal of Neuroscience Nursing recently reported that women are more likely than men to suffer from depression after traumatic brain injury. Additionally, women are more likely than men to have post-traumatic difficulties with memory, communication, body pains, and control of body movements.

The difference between men and women, however, was only significant within the first 6 months after the injury. After 6 months, there was no difference in the rate of depression between men and women.

Symptoms of depression in the early stages of recovery seem to be related to the amount of stress and pain a brain injury survivor perceives—both of which are more common in women than in men. The exact reasons for this is still unknown, but the researchers suggest that differences in hormones or brain structure could be the cause.

Bay E, Sikorskii A, & Saint-Arnault D. Sex differences in depressive symptoms and their correlates after mild-to-moderate traumatic brain injury. The Journal of Neuroscience Nursing. (December 2009).

On Thursday, November 19, 2009, The Senate voted to pass a package of veteran’s bills (S1963) that included both S. 801 and S. 252, both important Veteran’s health care measures supported by BIAA.

The bill would expand services in rural areas and ensure that veterans who are catastrophically disabled or who need emergency care in the community are not charged for those services. It would also authorize VA hospitals to contract with non-VA providers to ensure that our returning service members have access to the care that they so desperately need and deserve.

Thank you to all of our grassroots advocates that responded to the two action alerts that helped to move this measure successfully through the Senate!

On July 17, 2009, the House Appropriations Full Committee acted on legislation that would fund labor, health and education programs for Fiscal Year 2010. The overall numbers for this year’s reported bill are as follows:

Bill Total
2009 Comparable: $155.049 billion
President’s Request: $160.706 billion
Committee Mark: $160.654 billion

Currently, further details regarding TBI Act and TBI Model Systems of Care funding have not been released, however, look for a special edition of Policy Corner on Monday, July 27, 2009 for a special appropriations report. BIAA will continue to monitor the appropriations process closely and will be sure send out grassroots action instructions when the bill is scheduled for floor action.

On Tuesday, March 3, 2009, the House Appropriations Subcommittee on Defense held a hearing to address the need to improve the quality of care for servicemembers suffering from traumatic brain injury.

The witness list included, Ellen Embry, the Deputy Assistant Secretary of Defense for Force Health Protection and Gen. Loree Sutton, the Special Assistant to the Assistant Secretary of Defense for Psychological Health and Traumatic Brain Injury.

General Sutton shared with the Committee that the Defense Centers of Excellence is committed to research that is aimed at understanding the differences between blast injuries that would occur on the battlefield and concussions that may be experienced on a football field or during civilian activities. The spectrum of ingredients that include life-threatening situations, psychological stressors, and moral conflicts are all factors that contribute to the unique nature of brain injury incurred through battle.

As many of you know, this week has been both historical and chaotic in the city of Washington. With the federal holiday on Monday and the monumental inaugural celebration on Tuesday, Congress had just three days to continue their work on pressing items.

As reported by Congressional Quarterly, two House Committees, Ways and Means and Energy and Commerce, approved economic stimulus legislation on Thursday which included extra funding to support state Medicaid programs, as well as $20 billion dollars to speed up the development of electronic medical records.

In terms of Medicaid funding, the legislation would provide $87 billion of critical Medicaid aid to states, increasing through the end of FY 2010 the share of Medicaid costs the Federal government reimburses all states by 4.8 percent. This funding is intended to prevent cuts to health benefits in state Medicaid programs at a time when state revenues are declining. BIAA continues to strongly support this increase in federal support for Medicaid, to prevent states from having to cut back on vital Medicaid services that many individuals with brain injury depend on.

Very importantly, the bill would also extend the moratorium, (which BIAA has been strongly supportive of), on harmful Medicaid and Medicare regulations through October 1, 2009. The legislation also adds a moratorium on the Medicaid Outpatient Rule.

Earlier today, BIAA signed on to a Coalition for Citizens with Disabilities letter to House Speaker Nancy Pelosi (D-CA), expressing strong support for the legislation, and commending the House on including these important Medicaid provisions.

Additional funding contained in the stimulus bill to speed development of electronic medical records would be vital for the government to create standards for the technology, implement electronic medical records systems for public insurance programs like Medicare and Medicaid, and pay private hospitals and physicians to do the same. Electronic records are thought to result in both increased efficiency, reducing health care costs, and reduced medical errors.