The study was supported by the National Institute of Neurological Disorders and Stroke (NINDS), part of the National Institutes of Health (NIH). The findings were published in JAMA Psychiatry.

The researchers said the discovery indicated the importance of follow-up care for such patients. The scientists also identified factors that may increase the risk of developing post-traumatic stress disorder (PTSD) and/or major depressive disorder following mild mTBI or concussion.

“Mental health disorders after concussion have been studied primarily in military populations, and not much is known about these outcomes in civilians,” said Patrick Bellgowan, Ph.D., NINDS program director. “These results may help guide follow-up care and suggest that doctors may need to pay particular attention to the mental state of patients many months after injury.”

In the study, Murray B. Stein, M.D., M.P.H., professor at the University of California San Diego, and his colleagues investigated mental health outcomes in 1,155 people who had experienced a mild TBI and were treated in the emergency department. At three, six, and 12 months after injury, study participants completed various questionnaires related to PTSD and major depressive disorder. For a comparison group, the researchers also surveyed individuals who had experienced orthopedic traumatic injuries, such as broken legs, but did not have head injury.

“Contrary to popular assumptions, mild head injuries can cause long-term effects.”

The results showed that at three and six months after suffering an injury, people who had experienced mTBI were more likely than orthopedic trauma patients to report symptoms of PTSD and/or major depressive disorder. For example, three months after injury, 20 percent of mTBI patients reported mental health symptoms compared to 8.7 percent of orthopedic trauma patients. At six months after injury, mental health symptoms were reported by 21.2 percent of people who had experienced head injury and 12.1 percent of orthopedic trauma patients.

Stein and his team also used the data to determine risk factors for PTSD and major depressive disorder that are experienced after mTBI. The findings revealed that risk was higher in patients who had lower levels of education, self-identified as African-American, or had a history of mental illness.

Additionally, if the head injury was caused by a violent attack, that increased the risk of developing PTSD, but not major depressive disorder. However, risk of mental health symptoms was not associated with other injury-related occurrences such as duration of loss of consciousness or posttraumatic amnesia.

“Contrary to common assumptions, mild head injuries can cause long-term effects. These findings suggest that follow-up care after head injury, even for mild cases, is crucial, especially for patients showing risk factors for PTSD or depression,” said Stein.

This study is part of the NIH-funded TRACK-TBI initiative, which is a large, long-term study of patients treated in the emergency department for mTBI. The goal of the study is to improve understanding of the effects of concussions by establishing a comprehensive database of clinical measures including brain images, blood samples, and outcome data for 3,000 individuals, which may help identify biomarkers of TBI, risk factors for various outcomes, and improve our ability to identify and prevent adverse outcomes of head injury. To date, more than 2,700 individuals have enrolled in TRACK-TBI.

A recent study coming out of TRACK-TBI suggested that many TBI patients were not receiving recommended follow-up care.

“TRACK-TBI is overturning many of our long-held beliefs around mTBI, particularly in what happens with patients after they leave the emergency department. We are seeing more evidence about the need to monitor these individuals for many months after their injury to help them achieve the best recovery possible,” said Geoff Manley, M.D., professor at the University of California San Francisco, senior author of the current study and principal investigator of TRACK-TBI.

Future research studies will help identify mental health conditions, other than PTSD and major depressive disorder, that may arise following mTBI. In addition, more research is needed to understand the biological mechanisms that lead from mTBI to mental health problems and other adverse outcomes, such as neurological and cognitive difficulties.

A nationwide study, led by scientists at the University of California San Francisco and the University of Southern California, was published in JAMA Network Open on May 25, 2018. The research found that among 831 patients treated in hospital emergency departments for concussion, or mild traumatic brain injury (TBI), only 44 percent saw a physician or other medical provider within three months, the scientists report.

Concussion and other more serious forms of traumatic brain injury affect between 3.2 million and 5.3 million Americans, according to the Centers for Disease Control and Prevention. An expanding volume of research has found that traumatic brain injuries are associated with an elevated risk for neurodegenerative and psychiatric disorders. Research includes two UCSF studies published earlier this month that found a link between concussion and Parkinson’s disease, and concussion and dementia.

“The focus of concussion has been directed at a very narrow segment of the population – football players and professional athletes,” said the study’s co-author Geoffrey Manley, MD, PhD, a professor of neurosurgery in the UCSF Department of Neurological Surgery and member of the UCSF Weill Institute for Neurosciences. “Everyone who falls off their bike or slips off their skateboard or down the steps needs to be aware of the potential risks of concussion.”

“This is a public health crisis that is being overlooked,” said Manley, who is the principal investigator of TRACK-TBI, which has collected and analyzed clinical data on close to 3,000 traumatic brain injury patients from 18 top-level trauma centers nationwide, and was used in this study. “If physicians did not follow up on patients in the emergency department with diabetes and heart disease, there would be accusations of malpractice. For too many patients, concussion is being treated as a minor injury.”

The researchers found that of those patients who saw a provider within three months, 15 percent visited a clinic that specialized in concussion or traumatic brain injuries, while approximately half saw a general practitioner, who may or may not have training in managing this condition. More worrisome was the finding that even among those concussion patients with more serious signs and symptoms, many had no further care after hospital discharge. Of the 236 patients whose CT scans indicated a lesion, and 279 patients with three or more moderate-to-severe post-concussive symptoms, 40 and 41 percent, respectively, did not see a physician or health provider within three months after discharge.

Additionally, approximately half of the patients were discharged without a handout explaining symptoms and red flags requiring follow-up.

“The lack of follow-up is concerning because these patients can receive adverse and debilitating symptoms for a very long time,” said lead author Seth Seabury, PhD, director of the Keck-Schaeffer Initiative for Population Health Policy at the University of Southern California. “Even patients who reported experiencing significant post-concussive symptoms often failed to see a provider. This reflects a lack of awareness among patients and providers that their symptoms may be connected to brain injury.”

Undiagnosed and untreated traumatic brain injuries are endemic in the homeless and incarcerated populations, said Manley, who is also chief of neurosurgery at the Zuckerberg San Francisco General Hospital and Trauma Center.

“We have all these people untreated and no real system of care,” he said. “Even in the best trauma centers in the country, patients with concussion are not getting the follow-up care they desperately need.”

Among the patients in the study, who had been recruited from 11 trauma centers throughout the country, 58 percent were white, 65 percent were male and their average age was 40. Approximately one-third suffered moderate-to-severe post-concussive symptoms. In total, 59 percent of the concussions resulted from a road traffic incident; versus 24 percent from falls and 6 percent from assaults.

The finding, from investigators at Stanford University, was reported in Physical Review Letters.

Combining data recorded from football players with computer simulations of the brain, a team working with David Camarillo, an assistant professor of bioengineering, found that concussions and other mild traumatic brain injuries seem to arise when an area deep inside the brain shakes more rapidly and intensely than surrounding areas. But they also found that the mechanical complexity of the brain means there is no straightforward relationship between different bumps, spins and blows to the head and the likelihood of injury.

“Concussion is a silent epidemic that is affecting millions of people,” said Mehmet Kurt, a former postdoctoral fellow in Camarillo’s lab. Kurt and Kaveh Laksari, also a former postdoctoral fellow with Camarillo, are co-lead authors on the paper. Yet exactly how concussions come about remains something of a mystery. “What we were trying to do is understand the biomechanics of the brain during an impact,” Kurt said. Armed with that understanding, he explained, concussions could be better diagnosee, treated and hopefully prevented.

In previous studies, Camarillo’s lab had outfitted 31 college football players with special mouthguards that recorded how players’ heads moved after an impact, including a few cases in which players suffered concussions.

Laksari and Kurt’s idea was to use that data, along with similar data from NFL players, as inputs to a computer model of the brain. That way, they could try to infer what happened in the brain that led to a concussion. In particular, they could go beyond relatively simple models that focused on just one or two parameters, such as the maximum head acceleration during an impact.

The key difference between impacts that led to concussions and those that did not, the researchers discovered, had to do with how – and more importantly where – the brain shakes. After an average hit, the researchers’ computer model suggests the brain shakes back and forth around 30 times a second in a fairly uniform way; that is, most parts of the brain move in unison.

In more serious cases, the brain’s motion is more complex. Instead of the brain moving largely in unison, an area deep in the brain called the corpus callosum ­- which connects the left and right halves of the brain – shakes more rapidly than the surrounding areas, placing significant strain on those tissues.

Concussion simulations that point to the corpus callosum are consistent with empirical observations – patients with concussions do often have damage in the corpus callosum. However, Laksari and Kurt emphasize that their findings are predictions that need to be tested more extensively in the lab, either with animal brains or human brains that have been donated for scientific study. “Observing this in experiments is going to be very challenging, but that would be an important next step,” Laksari said.

Perhaps as important as physical experiments are additional simulations to clarify the relationship between head impacts and the motion of the brain – in particular, what kinds of impacts give rise to the complex motion that appears to be responsible for concussions and other mild traumatic brain injuries. Based on the studies they have done so far, Laksari said, they know only that the relationship is highly complex.

Still, the payoff to uncovering that relationship could be enormous. If scientists better understand how the brain moves after an impact and what movement causes the most damage, Kurt said, “we can design better helmets, we can devise technologies that can do onsite diagnostics, for example in football, and potentially make sideline decisions in real time,” all of which could improve outcomes for those who take a nasty hit to the head.

A car accident. A football tackle. An unfortunate fall. These things—and more—can cause head injuries. Head injuries can happen to anyone, at any age, and they can damage the brain.

Here’s how damage can happen: A sudden movement of the head and brain can cause the brain to bounce or twist in the skull, stretching and injuring brain cells and creating chemical changes. This damage is called a traumatic brain injury, or “TBI.”

Today, the FDA continues to research TBI—and encourage the development of new medical devices to help diagnose and treat it.

Symptoms and Diagnosis

A TBI is often caused by a bump, blow, jolt, or explosive blast to the head, or a penetrating head injury that disrupts the brain’s normal function. Not all hits to the head result in a TBI. But when it happens, TBI can range from “mild” (such as a brief change in mental status or consciousness) to “severe” (such as an extended period of unconsciousness or major problems with thinking and behavior after injury).

A concussion is a form of mild TBI.

About 2.5 million emergency department visits were associated with TBI in 2010, and these injuries contribute to about 30 percent of all injury-related deaths in the United States, according to the Centers for Disease Control and Prevention (CDC).

Symptoms of mild TBI include headache, confusion, blurred vision, and behavioral changes. Moderate and severe TBI can include those symptoms plus repeated vomiting or nausea, slurred speech, weakness in the arms or legs, and problems with thinking abilities. (The National Institute of Neurological Disorders and Stroke has more information on symptoms.)

A medical exam is the first step in diagnosing potential head injury. Assessment usually includes a neurological exam, a typically painless exam that includes an evaluation of thinking, motor function (movement), sensory function, coordination, and reflexes.

But it can be hard to officially diagnose TBI. Universally accepted “gold standard” diagnostic standards have not yet been established, though the CDC, the American College of Rehabilitation Medicine, and some others have published guidelines for diagnosing TBI.

Imaging tests, including computerized tomography scans (“CT” scans) and magnetic resonance imaging (MRI) tests do not diagnose TBI, but they can help doctors rule out a life-threatening injury to the brain (particularly bleeding that resulted from the traumatic injury that can require immediate medical or surgical attention).

Those who survive TBI can face short- or long-term complications that affect thinking, sensation (including sight or balance), language, or emotions. People with their first, mild TBI may just need to rest and reduce vigorous activity for a short period of time, while those with moderate to severe TBI may require physical, occupational, or psychiatric therapy and other support.

FDA Research

More sensitive and objective diagnostic methods to detect TBI are needed. Timely diagnosis is important to prevent repetitive injury and to help develop new therapies. So the FDA is researching diagnostic measures of mild TBI.

“Repetitive injury carries the risk of ‘second impact syndrome.’ If people who have not recovered from a head injury have a second head injury, this can result in more significant injury to the brain and more neurological deficits. And, in some cases, repetitive injury can be fatal,” explains Meijun Ye, Ph.D., an FDA neuroscientist who is researching TBI with principal investigator Cristin Welle, Ph.D.

FDA scientists are studying biomarkers (measurable, biological indicators of a particular state or condition), such as brain imaging, biofluid (specific proteins in blood), and physical indicators such as eye tracking and electroencephalography (EEG). “EEG is the measurement of electrical activity in the brain along the scalp. It holds promise because it’s fast, portable, and typically less expensive than MRI and CT,” Ye says.

Highlights? After scientists developed a small animal “blast” TBI model with high-intensity focused ultrasound, and checked accuracy (called “validation”), they found EEG can detect mild TBI in this model. “These results, and others by FDA regulatory science labs, contribute to the TBI scientific community and efforts to develop diagnostic devices,” Ye notes.

The FDA is now validating results from other animal models (such as when injuries are produced by a bump or jolt). Scientists also are working with human volunteers with Walter Reed National Military Medical Center in Bethesda, Maryland. And they’re recruiting more adult patients—and healthy people—for more research.

In addition to EEG, they are investigating using other portable imaging devices to detect mild TBI, such as diffuse correlation spectroscopy that can monitor blood flows in the brain from the scalp.

FDA Regulation: Moving Devices to Patients

The FDA does not develop medical devices for marketing, but it does review and evaluate them.

When evaluating medical devices, including those that might treat and diagnose TBI, the agency considers the safety and effectiveness of a product by evaluating the potential benefits and risks that it poses. Input from patients, based on their experiences and preferences, also gives FDA scientists valuable information.

To date, the FDA has cleared devices that can help determine the need for imaging following a head injury. In 2016, the agency also allowed marketing of two new devices that assess cognitive function following suspected brain injury in adults and children. But the FDA has not yet cleared standalone medical products that are intended to specifically diagnose or treat TBI.

“The FDA is committed to reviewing and evaluate evaluating new devices for safety and effectiveness to aid in the diagnosis and treatment of TBI,” explains Christian Shenouda, M.D., a clinician and medical device reviewer in the FDA’s Division of Neurological and Physical Medicine Devices.

The FDA works with companies early in the process to make sure they collect the right evidence for their products and to confirm the obligations for marketing a device in the United States.

The FDA also is working with the research and clinical community to develop better-designed clinical studies so new medical products can be developed. For instance, the FDA hosted a public meeting in 2016.

“We’re excited about today’s advances in research and development,” adds Shenouda. “And we hope these advances will lead to further patient access to additional diagnostics and treatments.”

What to Do if You Suspect Traumatic Brain Injury

Anyone with signs of moderate or severe TBI should receive medical attention as soon as possible, advises the National Institute of Neurological Disorders and Stroke (NINDS).

Little can be done to reverse the initial brain damage caused by trauma, NINDS reports. But medical professionals will work to stabilize the patient and try to prevent further harm.

Long-term effects depend on the seriousness of the injury, location of the injury, and the age and general health of the patient. For any TBI, it’s important to follow up with medical professionals as needed.

This article appears on the FDA’s Consumer Updates page, which features the latest on all FDA-regulated products.

A release from the college notes that the findings run counter to earlier soccer studies suggesting concussion injuries mainly result from inadvertent head impacts, such as collisions with other players or a goalpost.

The release quotes study leader Michael L. Lipton, M.D., Ph.D., professor of radiology and of psychiatry and behavioral sciences at Einstein and director of MRI Services at Montefiore, as saying, “The prevailing wisdom is that routine heading in soccer is innocuous and we need only worry about players when they have unintentional head collisions. But our study suggests that you don’t need an overt collision to warrant this type of concern. Many players who head the ball frequently are experiencing classic concussion symptoms such as headache, confusion, and dizziness during games and practice, even though they are not actually diagnosed with concussion. Concussion sufferers should avoid additional collisions or head impacts during the following days or weeks, when their risk of incurring a second concussion is extremely high. Because these injuries go unrecognized and unmanaged, there may be important clinical consequences for the short and long term.”

Studies clearly show that single or repeated concussion causes neurologic problems. But little is known about the effects of frequent but lesser impacts, such as those experienced while heading a soccer ball. Some research, notably a recent study of adolescent players published in JAMA Pediatrics, suggest that heading is not a common cause of concussion. “However, these studies did not actually measure heading, and thus they were unable to separate the relative contributions of intentional and unintentional head impacts,” says Dr. Lipton.

In the current study, a part of the Einstein Soccer Study, Dr. Lipton and his colleagues asked 222 adult amateur soccer players (80 percent men, ages 18 to 55) to fill out online questionnaires on their soccer-related activities during the previous two weeks, including details about heading and other unintentional head impacts and any resulting headaches, pain and dizziness as well as more severe symptoms, such as feeling dazed, needing medical attention, and becoming unconscious. Some of the 222 players filled out questionnaires for more than a single two-week span, resulting in a total of 470 questionnaires during a nine-month period in 2013-2014.

Approximately 35 percent of the participants reported one unintentional head impact, and 16 percent reported more than one such impact. The median number of headings during the two-week reporting period for all respondents was 40.5. Twenty percent of the participants reported experiencing moderate-to-very severe concussion symptoms, with 18 percent reporting severe and 7 percent very severe symptoms. Although these symptoms were more strongly connected with unintentional head impacts, heading was shown to be an independent risk factor for concussion symptoms.

“This finding is consistent with one of our previous studies, where 30 percent of soccer players who’d had more than 1,000 headings per year had a higher risk of microstructural changes in the brain’s white matter, typical of traumatic brain injury, and worse cognitive performance,” says Dr. Lipton

In the new study, players who headed the most were the most susceptible to concussion. “The extent to which lesser degrees of exposure to heading lead to cumulative injury over time is not known and deserves further study,” Dr. Lipton says. “Our findings certainly indicate that heading is more than just a ‘sub-concussive’ impact, and that heading-related concussions are common. We need to give people who have these injuries proper care and make efforts to prevent multiple head impacts, which are particularly dangerous.”

A release from the university quotes senior study author Mark Tuszynski, MD, PhD, professor in the Department of Neurosciences and director of the Center for Neural Repair at UC San Diego School of Medicine, and a neurologist with the VA San Diego Healthcare System, as saying, “This has implications for medical practice and medical insurance. Typically, insurance supports brief periods of rehab to teach people to get good enough to go home. These findings suggest that if insurance would pay for longer and more intensive rehab, patients might actually recover more function.”

In recent years, numerous studies have documented the surprising plasticity or ability of the adult central nervous system to recover from injury. The emerging question has been how to best encourage the repair and regrowth of damaged nerve cells and connections.

To better understand what happens at the molecular and cellular levels and how rehabilitation might be made more effective after brain injury, researchers studied rats relearning skills and physical abilities. They found rats that received intensive therapy for an extended period of time showed significant restructuring of the brain around the damage site: Surviving neurons sprouted greater numbers of dendritic spines, which made more connections with other neurons. The result, said Tuszynski, was a dramatic 50 percent recovery of function.

Animals that did not undergo intensive rehabilitation did not rebuild brain structure or recover function.

Additionally, the researchers found that a key system in the brain – the basal forebrain cholinergic system – is critical to rehabilitation. Structures in this part of the brain, such as the nucleus basalis, produce acetylcholine, a chemical released by nerve cells to send signals to other cells. Specifically, motor neurons release acetylcholine to activate muscles.

Damage to the cholinergic system, which can occur naturally during aging, completely blocks brain plasticity mediated by rehabilitation and significantly reduces functional recovery. Tuszynski said the finding suggests that a class of drugs called cholinesterase inhibitors, which boost the levels and persistence of acetylcholine and are used in some treatments for Alzheimer’s disease, might further improve functional outcomes after brain injury.

“We did not try to do this in our study,” said Tuszynski, “but we did suggest future studies could be done to look at this possibility.”

The first week of this riddle, the patient reported her symptoms to her PCP. The doctor proceeded with the examination using the classic S-O-A-P notes as follows:

S=Symptoms or Chief Complaint

O=Objective Findings

A=Assessment or Analysis

P=Treatment Plan or Recommendations

The doctor recognized a potential medical emergency and transferred Chole to the Emergency Department immediately. Last week, we learned what happened when Chloe first arrived in the Emergency Department. This week, we’ll let you know what some people have suggested as possible diagnoses. Next week, the doctor will reveal the actual diagnosis. Then we’ll begin a new riddle for the following month!

Some Guesses as to What the Diagnosis Will Be

“Chloe’s doctor said she had normal blood pressure and pulse, so I guess he’s not worried about what my doctor called ‘pre-stroke’. I had ‘malignant hypertension’, meaning extremely high blood pressure that came on suddenly. They lowered it slowly over a matter of a few hours and I ended up with no organ damage and no stroke. That said, I still wonder if Chloe could have had a little stroke, what they call a transient ischemic attack or TIA. ”

— Julie R.

“Maybe Chloe has an aneurysm. I hope not because that wouldn’t be good news! A brain aneurysm is a bulging area in the wall of a blood vessel. The reason I know is that my brother who is about Chloe’s age had a brain aneurysm. It ruptured and bled and was a life-threatening emergency. His wife got him to urgent care immediately and he pulled through, but it was very frightening. We did learn, though, that many aneurysms don’t rupture and that there are treatments to keep them from rupturing.”

— Kay L.

“Could Chloe have a brain tumor? I imagine that the CT scan would show that. If she does have a tumor, I pray it’s not cancer! Of course even benign brain tumors can be dangerous, but a friend of mine had one and she had surgery to remonve the tumor. She’s hale and hearty four years later, thank goodness!”

— Marlene G.

“Is Chloe positive she never had unequal pupil size before she hit her head? Maybe she never really studied her eyes in the mirror before the headchaes started. I had an enlarged pupil that my eye doctor noticed. She said it was called benign anisocoria and I probably got it from stress. I had just gone trhough a divorce and we were in the middle of a custody battle. I ended up getting the kids. Eventually the anaocoria went away.”

— Susan F.

“Meningitis seems like a possibility to me, although a pretty remote one. Meningitis is an inflammation of the membranes around the brain and the spinal cord. Usually the cause is a viral infection. My daughter had it her freshman year of college. The symptoms were a lot like what Chloe describes. My daughter doesn’t remember hitting her head, though, so Chloe’s problems probably aren’t from an infection. Also, meningitis is most common in young adults, especially those who live in communal settings such as dorms. ”

— Deirdre M.

To be continued . . .

Come back to ThirdAge.com next Thursday when the doctor will reveal the actual diagnosis and treatment plan.

Marie Savard, M.D., a former Medical Contributor for ABC News and a frequent keynote speaker around the world, is one of the most trusted voices on women’s health, wellness, and patient empowerment. She is the author of four books, including one that made the Wall Street Journal list of the best health books of 2009: “Ask Dr. Marie: What Women Need to Know about Hormones, Libido, and the Medical Problems No One Talks About.” Dr. Marie earned a B.S. in Nursing and an M.D. degree at the University of Pennsylvania. She has served as Director of the Center for Women’s Health at the Medical College of Pennsylvania, technical advisor to the United Nations’ Fourth World Conference on Women in Beijing, advisor to the American Board of Internal Medicine Subcommittee on Clinical Competency in Women’s Health, health columnist for Woman’s Day magazine, and senior medical consultant to Lifetime Television’s Strong Medicine. Please visit DrSavard.com.

Last week, the patient reported her symptoms. The doctor proceeded with the examination using the components of the classic S-O-A-P notes, which are as follows:

S=Symptoms or Chief Complaint

O=Objective Findings

A=Assessment or Analysis

P=Treatment Plan or Recommendations

The doctor recognized a potential medical emergency and transferred Chloe to the Emergency Department immediately. This week, we’ll learn what happened when Chloe first arrived in the Emergency Department.

When Chloe arrived at the Emergency Department, a neurosurgery consultant who had been alerted to her imminent arrival was already on call when she got there. He remained on standby while Chloe had a CT scan. A CT scan is sufficient and it’s usually done on an urgent basis for head trauma. It is the “gold standard”, and less costly than an MRI that may not be necessary or available as quickly or easily.

A non-contrast CT — no need for dye — showed a crescent shaped mass between the skull and surface of the cerebral hemisphere that extended beyond the suture line of the brain. There was minimal midline shift of about 5 mm consistent with mild swelling pushing brain slightly to one side.

To be continued . . .

Come back to ThirdAge.com next Thursday to find out what some people have guessed the diagnosis might be.