Lifelong consequences of brain injuries during development: From risk to resilience

Chronic Refractory Insomnia in a Patient With Undiagnosed Bipolar Disorder and Long-Standing Traumatic Brain Injury

Traumatic brain injury (TBI), a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain. TBI can result when the head suddenly and violently hits an object or when an object pierces the skull and enters brain tissue. TBI can be classified into primary and secondary brain injury. Primary injury refers to the structural damage caused upon impact. Secondary injury refers to the damage from subsequent cellular processes following a prior injury, such as excitotoxicity, free radical generation, calcium-mediated damage, hypoxia, and increased intracranial pressure. Unsurprisingly, these mechanisms can produce structural, biochemical, and genetic changes implicated in sleep disturbance. A coup-contrecoup injury typically occurs at the base of the skull in areas of bony prominences, hence, the anterior temporal and inferior frontal regions, including the basal forebrain, are frequently injured. Because the basal forebrain contributes to sleep initiation, injury to this region can lead to insomnia symptoms. In this report, we present a case study of a 41-year-old Caucasian male who experienced a TBI at the age of seven due to a motor vehicle accident. The left frontotemporal lobe was affected as a result of the incident. He was admitted to the emergency room in March 2023 for safety concerns in the context of extreme anger and irritability, which could endanger others and himself. Additionally, he struggled with chronic insomnia. The chart review showed that the patient's chronic insomnia was poorly controlled and probably contributed to the current presentation. The patient was observed in the days following admission while various medication changes were attempted to treat his chronic insomnia. Unique limitations were encountered in managing this patient's insomnia, as he has multiple drug allergies, including some of the commonly used medications to treat insomnia. A particularly unique observation was that the medications that finally worked for this patient had anticholinergic side effects. They are usually contraindicated in post-TBI patients. However, it was beneficial to use them in this case, which can be explored further.

Association between pediatric TBI and mental health and substance use disorders: A scoping review

BACKGROUND

The relationship between pediatric Traumatic Brain Injury (TBI) and long-term mental health and substance use disorders is not well known, resulting in inadequate prevention and management strategies. The aim of this scoping review is to review the evidence on pediatric TBI and the development of mental health disorders and substance use later in life and to identify gaps in the literature to inform future research.

METHODS

We searched multiple databases for original articles published between September 2002 and September 2022 on TBI-related mental health and/or substance use disorders in children and youth. Two independent reviewers performed the screening using Arksey and O'Malley and Levac et al.'s scoping review framework.

RESULTS

A total of six papers are included in this scoping review. Studies included are comprised of cross-sectional and prospective longitudinal cohort studies.

DISCUSSION

A correlation between pediatric TBI and development of certain mental health disorders and substance use is suggested, although much of the current evidence is mixed and does not account for confounding variables. Future studies should aim to closely examine these links and identify modifiers that can influence these relationships.

The role of the stress system in recovery after traumatic brain injury: A tribute to Bruce S. McEwen

Traumatic brain injury (TBI) represents a major public health concern. Although the majority of individuals that suffer mild-moderate TBI recover relatively quickly, a substantial subset of individuals experiences prolonged and debilitating symptoms. An exacerbated response to physiological and psychological stressors after TBI may mediate poor functional recovery. Individuals with TBI can suffer from poor stress tolerance, impairments in the ability to evaluate stressors, and poor initiation (and cessation) of neuroendocrine stress responses, all of which can exacerbate TBI-mediated dysfunction. Here, we pay tribute to the pioneering neuroendocrinologist Dr. Bruce McEwen by discussing the ways in which his work on stress physiology and allostatic loading impacts the TBI patient population both before and after their injuries. Specifically, we will discuss the modulatory role of hypothalamic-pituitary-adrenal axis responses immediately after TBI and later in recovery. We will also consider the impact of stressors and stress responses in promoting post-concussive syndrome and post-traumatic stress disorders, two common sequelae of TBI. Finally, we will explore the role of early life stressors, prior to brain injuries, as modulators of injury outcomes.

Epidemiology of Chronic Effects of Traumatic Brain Injury

Although many patients diagnosed with traumatic brain injury (TBI), particularly mild TBI, recover from their symptoms within a few weeks, a small but meaningful subset experience symptoms that persist for months or years after injury and significantly impact quality of life for the person and their family. Factors associated with an increased likelihood of negative TBI outcomes include not only characteristics of the injury and injury mechanism, but also the person’s age, pre-injury status, comorbid conditions, environment, and propensity for resilience. In this article, as part of the Brain Trauma Blueprint: TBI State of the Science framework, we examine the epidemiology of long-term outcomes of TBI, including incidence, prevalence, and risk factors. We identify the need for increased longitudinal, global, standardized, and validated assessments on incidence, recovery, and treatments, as well as standardized assessments of the influence of genetics, race, ethnicity, sex, and environment on TBI outcomes. By identifying how epidemiological factors contribute to TBI outcomes in different groups of persons and potentially impact differential disease progression, we can guide investigators and clinicians toward more-precise patient diagnosis, along with tailored management, and improve clinical trial designs, data evaluation, and patient selection criteria.