(brain swelling) and a small right subdural hematoma (bleeding under the coverings of the brain). At the hospital, he was minimally responsive to pain, able to spontaneously move his extremities, but not able to communicate. Within a few hours of arrival at the hospital, he became totally unresponsive. His neurological exam showed a dilated pupil on the right eye. A dilated pupil that does not react to light especially on one side is usually indicative of compression of the third cranial nerve in the brain. The third cranial nerve is responsible for the contraction of the pupil when the eye is exposed to light. Further, a dilated pupil is generally an ominous sign of brain herniation from swelling or the effect of a mass, such as a subdural hematoma, causing the shifting of the brain from one side to the other. The effect of the edema and of the mass (subdural hematoma) also known as mass effect, caused the shift in Mario’s brain, which resulted in compression of the third nerve. Since this change was considered a neurological emergency, a follow-up CAT scan of the brain was carried out, which showed increased diffuse swelling of the brain with a shift of the brain from the right to the left, due to the massive expansion of the subdural hematoma on the right.
| Image # 1 – What Mario’s brain looked like before surgery |
Mario was taken into surgery, and a decompressive craniectomy (removal of a portion of the skull) was performed to drain the subdural hematoma and reduce the pressure in the brain. This gave the brain room to expand due to the swelling process, a sign of severe brain injury.
It was clear that Mario had SIS, a condition rarely diagnosed in TBI. But when diagnosed, SIS is most common in concussion and TBI due to sports-related injuries.
Despite having symptoms after the first injury, Mario was cleared by his neurologist to return to the sport. It was even more devastating that after a further review of the original CAT scan of the brain from his first injury, an area of contusion (brain bruise) in the right hemisphere of the brain was revealed. This area of contusion on the very first CAT scan was not picked up by the neurologist or the neuro-radiologist. As a result, he was cleared to return to the sport. Mario returned to wakeboarding before he had a chance to fully recover from the original injury, which along with the second injury caused his brain to suffer extreme swelling.
Mario’s brain injury was severe enough to result in a major disruption of his brain’s hierarchical organization, causing him to be in a comatose state for over one year. After six years of caring for Mario and observing the effects of TBI and concussion in many of my patients, while also; witnessing up close the natural history of how the nervous system recovers following injury, I was inspired to develop this work.
Imagine for one moment that the human brain has over 100 billion neurons (nerve cells) which create over 1,000 trillion connections. It is estimated that the brain, as a supercomputer, can process one trillion bits per second and has a memory capacity that can vary from one to one thousand terabytes of data. This extraordinary system has been compared with the Library of Congress, which has over 19 million volumes equivalent to 10 terabytes of data.
| Image # 2 – Neurons and their interconnections |
The complexity of such a system as it sits in our skull is unfathomable.
On a metaphysical level, it is an entire galaxy.
To paraphrase an expression, “It took years to build Rome, but it was destroyed in a day”. As a corollary, it took years for the human brain to evolve to its current state of sophistication and years following conception and birth to organize such a brain to perform what we now know as human behavior.
Yet, this highly organized structure can be destroyed in an instant!
From Head to Tail … What is the BHET Method?
WHEN CONSIDERING THE field of traumatic brain injury (TBI) and concussion, I am reminded of lyrics by Jimmy Cliff, a famous reggae artist who said, “There are more questions than answers, and the more I find out is the less I learn.” Despite years of scientific research on brain injuries, the experience of highly trained clinicians, and the support of families and foundations, we face the disadvantage of several unanswered questions.
According to Kenzie et al., TBI can be referred to as “the most complicated disease of the most complex organ of the body”.
The Brain Hierarchical Evaluation and Treatment (BHET) method challenges the current methods employed to evaluate and treat persons with TBI, while also providing an explanation for the hierarchical disorganization and subsequent reorganization that occurred in Mario’s brain and the over 50 million victims worldwide who are also affected by this condition each year.
BHET further provides the basis for carrying out treatment through various dimensions and domains to understand this very complex condition. The treatment and outcome will be covered in Volume II of this series.
Given the recent attention gained by the field of concussion and TBI, clinicians and patients are at a stage where they can no longer wait for answers to fundamental questions regarding how to properly evaluate and treat these conditions. The questions about the outcome of a specific health concern form the basis for what we believe subsequently and how we act: When will someone emerge from a coma? Can I overcome the phobia of going out in public? Is the dizziness and vertigo (spinning sensation) permanent? Why can’t I multitask and not be distracted? What about the problems pertaining to memory and anger management … will they ever go away? Will I ever be able to enjoy a good night of sleep? Should I stop this medication that I am using for seizures? Can I ever drive again? What about my sexuality? What about the restoration of my rights as an individual and will I ever be able to work again?
While the issues of concussion and TBI have been popularized in the modern media, there remains a lack of understanding among all stakeholders regarding the longitudinal issues in time and space that confront society related to this kind of injury. Brain injury as a concept is unlike any other condition, in that it impacts the computer-like processing system that directs the physiology of our bodies and how they operate, who we are, and what others perceive us to be. In fact, it is not merely about the health care provider and the patient; it involves a web of societal concerns, including the family unit, our policymakers, the legal system, funding sources, research interest, media, and our social organization. Those affected by this condition know very well the challenges it poses to our quality of life, economic stability, and social order.
Very few physicians have been interested in learning about TBI/concussions due to the limited understanding of the brain and the complexity of the science, the patients, and the issues. While extensive research has been done in the field, the results of TBI/concussion research have been “hampered by imprecise classification, methodological inconsistencies, measurement issues, and uncertainty about underlying pathophysiology” according to a paper published by Erin Kenzie and colleagues in 2017 (Kenzie 2017).
As of 2014, the total estimated cost incurred for failed clinical trials in TBI/concussion in the USA is over 1.1 billion dollars (ASPE 2014). In terms of the treatment, as of 2016, over 30 major clinical pharmaceutical trials to treat TBI have been conducted, and they have all been considered to have failed (Hack 2016).
As a treating neurologist for over three decades, I see a level of disorganization in our field, which has caused chaos among the stakeholders. I believe this disorganization is fundamentally due to our lack of
