Readers can scarcely open a newspaper today without being confronted by the subject of this issue of CONTINUUM. Traumatic brain injury-especially mild traumatic brain injury (mTBI)-is the subject of article after article on the sports pages of our daily newspapers as athletic authorities debateits consequences and seek ways to prevent it, especially in such violent contact sports as football. At the same time, society grapples with the tragedies of modern warfare and the effects of terrorism in which the widespread use of improvised explosive devices has created a new epidemic of blast-induced head injuries.
Neurologists have always been involved in the care of patients with head injuries, particularly those that are less severe and require no neurosurgical intervention. Today, more than ever and with the increased public attention, we must be up-to-date on this subject. In this issue of CONTINUUM, Dr Jack Tsao and colleagues will provide the latest information on this timely topic.
In the first article, "Mild TraumaticBrain Injury Update", Victoria Anderson-Barnes and SharonWeeks join Dr Tsao to introduce the subject, providing appropriate definitions, describing the scope of the problem, and addressing pathophysiology and symptomatology. The subjects of diagnosis and management are expanded in the subsequent article by Drs Geoffrey Ling, Scott Marshall, and David Moore. The unique aspects of concussion in athletes present a number of challenges, which Drs Jeffrey Kutcher, Christopher Giza, and Anthony Alessi address, including a discussion of specific pediatric considerations. Neurologists confronted by questions about return to activity, especially athletic competition, will benefit greatly from these authors' insights.
Frequently, neurologists will first encounter patients with TBI well after the original injury because of the occurrence of new or persistent specific neurologic symptoms. The next few articles in this issue address some of these areas. Drs Jay Erickson, Edward Neely, and Brett Theeler discuss posttraumatic headaches, emphasizing the similarities to many headache syndromes quite familiar to neurologists, but also pointing out areas of difference and controversy. Memory impairment after mTBI is, undoubtedly, a source ofmuch concern as it represents one of the most debilitating consequences of such events and may be progressive, especially in those with repeated head injury. Dr Frederick Flynn provides a detailed analysis of this issue, examining various aspects of memory disturbance as well as offering guidance about its assessment and management.
In the next article, Drs Karen Parko, Gary Abrams, Justin Campbell, and Graham Glass address three other frequent consequences of TBI: epilepsy, sleep disturbances, and psychiatricmanifestations. Although these issues may occur independently, they often coexist in the head-injured patient. Although seizures may be more common among patients with severe head injury, they certainly develop, at times, in patients with mTBI. Sleep disturbances are prevalent among patients with mTBI, particularly soon after the injury. Posttraumatic stress disorder is a frequent psychiatric comorbidity in patients with TBI. While this may be more likely to occur in a military setting, it is not confined to this population. Your comfort level in dealing with these common problems will rise after reading this chapter.
While most patients with mTBI fortunately recover rapidly, healing may be a protracted process. For those with a slower recovery, rehabilitation is an important aspect of care. Some rehabilitation may be rendered or coordinated by neurologists. Even in those patients with minor head injury expected to get better quickly, education is an important dimension of care. Drs Ronald Riechers II and Robert Ruff will inform you about these aspects of management.
Decisions about returning to competitive sports may be difficult, and the neurologist may be confronted by the desires of the athlete or the coach to clear the individual to return. This can create ethical dilemmas; Drs Michael Russo and Kevin Crutchfield describe such a situation in this issue's Ethical Perspectives in Neurology section. Head injuries can be devastating, not only to the victim, but also to the families and loved ones. Dr Jay Rosenberg discusses strategies for communicating with these concerned parties in the Practice Issues in Neurology section. As usual, we also provide a coding table, developed by Drs Laura Powers and Marc Nuwer, to help in your practice with TBI patients.
After you have read the articles so thoroughly organized and prepared by Guest Editor Tsao and the other contributors, be sure to challenge yourself with the Patient Management Problem and the Multiple-Choice Questions. The former, prepared by Drs Dalila Lewis and Stephen Sharp, will allow you to integrate your knowledge of the management of a patient with mTBI. The latter, developed for this issue by Drs Ronnie Bergen and Julie Hammack, will augment your education while simultaneously permitting self-assessment of your understanding of this subject.
The brain is not a paired organ. Society, in general, but we, as neurologists, in particular, must help to protect it better and facilitate its recovery when injured. Next Sunday, as you sit, popcorn in hand, watching your favorite National Football League team, I hope you will keep in your other hand to focus your attention on the important subject of head injury.
Aaron E. Miller, MD