The acquired brain damage (DCA ) refers to an injury that occurs in a brain that had hitherto presented a normal or expected development and can result from different causes: traumatic brain injury (TBI), cerebrovascualres accidents (CVA), tumors Cerebral, anoxia, hypoxia, encephalitis, etc. (De Noreña et al., 2010).
In some cases, the scientific literature uses the term cerebral overhang ( DCS ) to refer to this same clinical concept of ACD.
Acquired brain damage
When an accident involving an ACD occurs, different neurological processes will be affected and acute injuries to the individual’s nervous system will in many cases lead to a significant deterioration of health and functional independence (Castellanos-Pinedo et al. , 2012).
This is one of the most important health problems in developed countries. This is due, on the one hand, to the magnitude of its incidence and the physical, cognitive and social impact that it causes to the people who suffer this type of lesions (García-Molína et al., 2015).
Statistics of acquired brain damage
In Spain there are no concrete and current data on the number of people affected by this type of pathologies, since they include or exclude different etiologies.
However, American literature shows that around 250 cases of head trauma occur every 10,000 inhabitants and in the case of Spain, approximately 100,000 people a year suffer from it . However, these statistics refer to accidents of a traumatic nature (CEADAC, 2015).
In Spain, in 2008, 420,064 people with acquired brain damage were registered . Among these, 52% are women and 48% are men . In relation to age, approximately 65% have an age that reaches or exceeds 65 years . It is estimated that 104,701 new cases of acquired brain damage occur every year (FEDACE, 2013).
As for the causes, those with a greater presence are: Ictus (53.36% in men and 46.64 in women), TBI (66.92% in men and 33.08% in women) and Anoxia (62 , 62% in men and 37.38% in women) (FEDACE, 2013).
A very important fact is that 113,132 people out of a total of over 420,000 with ACDs in Spain have been recognized by public services with different degrees of disability (73,584 with a grade higher than 65%, 31,272 with a grade higher than 33% And 8,276 people with a grade below 32%) (FEDACE, 2013).
Causes of acquired brain damage
Normally, ACD is associated with head trauma , in fact, in the English-language medical literature, the term brain injury is often used synonymously with traumatic brain injury (Castellanos-Pinedo Et al., 2012).
In addition, DCA may also have its origin in stroke , brain tumors or infectious diseases (De Noreña et al., 2010).
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Castellanos-Pinedo and collaborators (2012) show a broad list of the possible causes of brain damage due to the agent that causes them:
Injuries caused by external agents
- Cranioencephalic injury
- Toxic encephalopathy: drugs, drugs and other chemicals
- Encephalopathy by physical agents: ionizing radiation, electrocution, hyperthermia or hypothermia.
- Diseases of infectious type: meningoencephalitis
Injuries caused by endogenous causes
- Hemorrhagic or ischemic stroke
- Anoxic encephalopathy: due to diverse casings such as cardiorespiratory arrest.
- Primary or secondary neoplasms
- Autoimmune inflammatory diseases (connective tissue diseases-systemic lupus erythematosus, behçet’s disease, systemic vasculitis and demyelinating diseases-Multiple sclerosis or acute disseminated encephalomyelitis-).
Depending on their incidence, an order of importance of these causes can be established, being the most frequent the traumatic brain injury and stroke / cerebrovascular accident. Third, there would be anoxic encephalopathy. Less frequent would be the causes of the type infectious or derived from brain tumors (Castellanos-Pinedo et al., 2012).
Ardila & Otroski (2012), propose that the TCE occurs as a consequential impact of a blow on the skull. Generally, the impact on the skull is transmitted to both the meningeal layers and cortical structures.
In addition, different external agents can cause the impact: use of forceps at birth, bullet wound, blow-to-blow effect, extension of a mandibular blow, among many others.
Therefore, we can find open trauma ( ACT ) in which a skull bill is produced and penetration or exposure of brain tissue and closed head trauma , in which there is no fracture of the skull, but serious injury to the skull may occur. Brain tissue due to the development of edema , hypoxia , increased intracranial pressure or ischemic processes.
The term cerebrovascular accident (CVA) refers to an alteration of the blood supply of the brain. Within the VCA, we can find two groups: due to obstruction of the blood flow (obstructive or ischemic type accidents) and hemorrhages (hemorrhagic accidents) (Ropper & Samuels, 2009; Ardila & Otroski, 2012).
In the group of strokes caused by an obstruction of blood flow we can find the following causes described by Ardila & Otroski (2012):
- Accidents thrombotic: the cause of obstruction is an arteriosclerotic plaque that is placed in an arterial wall. This can impede blood flow, causing an ischemic area (which does not receive blood supply) and an infarct in the area that the obstructed artery irrigates.
- Cerebral embolism / embolic accidents: the cause of the obstruction is an embolus (blood, fatty, or gaseous clot) that obstructs the blood circulation of a brain vessel, causing an ischemic zone and an infarct in the area where the obstructed artery irrigates .
- Transient ischemic attack: occurs when the obstruction resolves in less than a 24-hour period. Norlmanelte, occur as a consequence of an arteriosclerotic plaque or thrombotic embolus.
On the other hand, hemorrhagic accidents are usually the consequence of rupture of a cerebral aneurysm (malformation of a blood vessel) that may be generating hemorrhagic blood flows at the intarcerebral, subarachnoid, subdural or epidural level (Ardila & Otroski, 2012).
The anoxic or hypoxic encephalopathy occurs when there is insufficient oxygen supply to the central nervous system (CNS) due to respiratory, cardiac or circulatory causes (Serrano et al., 2001).
There are different mechanisms through which the oxygen supply can be interrupted: Decreased cerebral blood flow (cardiac arrest, CAD, severe hypotension, etc.); By decreasing the amount of oxygen in the blood (polirradiculoneuritisa guda, myasthenia gravis, pulmonary diseases, thoracic trauma, drowning or inhalation of toxics); Reduction of the capacity to transport oxygen (carbon monoxide poisoning) or brain tissue inability to use oxygen (cyanide poisoning) (Serrano et al., 2001).
Consequences of acquired brain damage
When DCA occurs, most patients have serious consequences that affect multiple components: from the development of a vegetative state or minimal consciousness to major deficits in sensorimotor , cognitive or affective components .
The occurrence of aphasia , apraxia , motor limitations, visuo-spatial alterations, or heminelect has frequently been reported (Huertas-hoyas et al., 2015). On the other hand, cognitive deficits tend to appear as attention, memory and executive functions (Garcia-Molina et al., 2015).
Together, all these deficits will have a significant functional impact and will be an important source of dependency; Hampering social relations and job reintegration (García-Molina et al., 2015).
In addition, they will not only give consequences to the patient. At the family level the suffering of an ACD in one of its members will be the cause of a strong moral blow.
Generally, a single person, the primary caregiver , will take over most of the work, ie assume most of the care to the patient in a situation of dependency. Only in 20% of cases, care is assumed by more relatives (Mar et al., 2011)
Different authors emphasize that the care of one in a serious situation of dependence supposes an effort that can be compared to a working day. Thus, the primary caregiver supports an overload of work that negatively affects their quality of life in the form of stress or inability to tackle tasks.
It is estimated that the presence of psychiatric disorders in caregivers is 50%, among them are anxiety , depression , somatizations and insomnia (Mar et al., 2011).
Diagnosis of acquired brain damage
Due to the wide variety of causes and consequences of ACD, both the involvement of brain systems and the magnitude of this can vary considerably among individuals.
In spite of this, the working group headed by Castellanos-Pinedo (2012) proposes the following definition of DCA:
“Injury of any origin that occurs acutely in the brain, causing in the individual a permanent neurological deterioration, which conditions a deterioration of his functional capacity and his previous quality of life.”
In addition, they extract five criteria that must be present so that a case can be defined as DCA:
- Injury that affects part or all of the brain (brain, brain stem and cerebellum).
- The onset is acute (occurs in a range of a few seconds to days).
- There is a deficiency as a consequence of the lesion , directly objectifiable through clinical examination and the use of diagnostic tests.
- There is a deterioration of the functioning and quality of life premóbidos of the person.
- Hereditary and degenerative diseases and lesions that occur in the prenatal stage are excluded.
In the acute phase, therapeutic measures will be directed primarily at the physical sphere. At this stage the individuals are hospitalized and the objective will be to obtain control of the vital signs and and of the consequences of the ACD, such as hemorrhages, intracranial pressure, etc. At this stage, the treatment is developed from surgical and pharmacological approaches.
In the post-acute phase , we will intervene from a physiotherapeutic level to treat possible motor sequelae, such as at the neuropsychological level to address the cognitive sequelae: orientation deficit, amnesia , linguistic deficit, attention deficit, and so on.
In addition, in many cases psychological attention will be necessary since the event and its consequences can become a traumatic event for the individual and his environment.
Acquired brain damage has a strong personal and social impact. Depending on different factors such as the location and severity of the injuries, there will be a series of physical and cognitive consequences that can have a devastating impact on the social sphere of the individual.
Therefore, the developments of post-acute intervention protocols that attempt to restore the functional level of the patient to a point close to the premorbid level are essential.