Images of Brain Trauma

Wear a helmet, Avoid fights
No headers in soccer, Wear your seatbelt
Play golf instead of football

The impact of head trauma is often overlooked in psychiatry. Even minor head injuries to vulnerable parts of the brain can cause problems for years to come. SPECT is one of the best tools in evaluating functional deficits from brain trauma that are often not seen by other studies, leading to more understanding and effective treatments for patients. Typically, SPECT findings in brain trauma include focal areas of decreased activity, often in a contra-coup pattern (such as decreased activity in the left anterior prefrontal cortex and right occipital lobe or the anterior and posterior aspects of a temporal lobe) and, in some cases, marked hyperactivity over the site of the injury. In many cases we have seen increased "off center" cingulate gyrus activity after a head injury.

Documentation of head injuries is essential for several reasons. For school age children and teenagers it allows them to receive more specialized services. Knowledge of the injuries is often essential for legal/insurance reasons. Patient and family understanding of the effects of brain trauma of enhances treatment compliance and a deeper understanding from family and support systems. Here are several examples.

Brain Trauma Case Studies

Tim, age 15, was a high school sophomore at a high school in Connecticut. From the time he was young he exhibited severe conduct problems. He had already been arrested for shoplifting, he frequently cut school and was defiant and abusive toward his parents. He did not get along with other teens at school and seemed to "never fit in." He smoked a pack of cigarettes a day and frequently used both marijuana and cocaine. He had already been in one treatment program and was on his way to a second program when his parents brought him to our clinic. From an early age, Tim was hyperactive, impulsive, moody and frequently angry, especially whenever someone would tell him no. His temper flared quickly and often, often over minor or trivial incidences. He had tried numerous medications without success. His parents had heard about my clinic and decided to come across the country to see us.

His brain SPECT study showed severe damage to his left prefrontal cortex. It was one of the most severe cases I have ever seen. When he was 18 months old he fell down a flight of stairs. His mother said he was never quite the same since then. She could just tell there was a difference in his personality. Given the level of functional damage to Tim’s brain I decided to put him on a combination of an anticonvulsant medication and a stimulant. It helped lessen the rage and improve his impulse control. Given the level of damage, his chances for having full executive function are not very promising. The goal of treatment is to utilize every prescription available to help Tim develop auxiliary internal supervision mechanisms. Otherwise, legal authorities will have to impose external supervision in some form of a contained setting, basically through no fault of Tim. He doesn’t have the capacity for internal supervision that is housed in the prefrontal cortex.

top down surface view		front on surface view
underside surface view note the marked decreased left prefrontal, left hemisphere and left occipital lobe
left side surface view 16 y/o head trauma at age 7 school failure, substance abuse, impulsivity decreased left pfc		left side surface view 79 y/o car ran into a pole age 20 y/o long history of aggression and irritability decreased left pfc and anterior temporal lobe
underside surface view		left side surface view
48 y/o male, football injury age 16, significant problems expressing feelings (alexythymia) decreased left pfc and anterior left temporal lobe
underside surface view		underside active view
56 y/o male, fell off porch into pile of bricks age 6 significant problems with temper, illusions and depression decreased left pfc and left temporal lobe (left image), increased deep left temporal lobe activity (right image)
underside surface view		left side surface view

32 y/o female, rear ended by an 18 wheel semi-truck on the freeway, significant problems with irritability, depression and memory, decreased pfc and left temporal lobe (left image), decreased left anterior temporal lobe activity (right image).

Brain Trauma right anterior frontal pole

front on surface view
notice the dented area in the right anterior frontal pole

Betty was the most beautiful 88-year-old woman I had ever met. She was very proper and very proud. When she was a young woman she had emigrated from England after marrying a U.S. soldier. It was not her 90-year-old husband who brought her to the hospital to see me, however, it was her sister. Her husband, far from being supportive, angrily denied that his wife was suffering from serious cognitive problems. Yet during the evaluation process it was clear that Betty had severe memory problems; she did not know where she lived, her phone number, or her husband’s name. I ordered a SPECT study that showed a dent in the right side of Betty’s frontal lobe. It was obvious to me that she had, at some point in her life, suffered a significant head injury. When I asked her about it, all she could do was look down and cry; she could not give me details of the event. When I asked her sister, she reported that Betty and her husband had a stormy relationship and that he was abusive towards her. Sometimes he would grab her by the hair and slam her head into the wall. The sister wanted Betty to go to the police, but Betty said it would only make things worse.

Shortly after Betty was hospitalized, her husband began pressuring me to send her home. He kept protesting that there was nothing wrong with her, yet I knew that Betty needed to be removed from that environment so I contacted the Adult Protective Services. At Betty’s hearing, I used her SPECT studies to convince the judge that her home held potential danger. He then ordered her to have a conservator, and she went to live with her sister.

Here is another example. Zachary, age 10, was a fun loving, active boy who was loving, sweet and liked to please. He did well in kindergarten and was liked by the other children. One summer, between kindergarten and first grade, at dusk Zachary was riding in the front seat of a car with his mother on a trip to his grandparents house. All of a sudden a drunk driver swerved into their lane causing the mother to quickly jerk the car to the side of the road. She lost control and the car hit a tree. The mother broke her leg in the accident and Zachary, thankfully in a seat belt, hit his head against the side window. Zachary was unconscious, but only for about 10 minutes.

Initially, they were glad to just be alive and Zachary and his mother became even closer than before. About six weeks later, however, Zachary’s behavior began to change. He exhibited aggressive behavior, breaking his own toys and hurting his younger brother. He began swearing, which was a new behavior for him. He blurted out statements at inappropriate times and interrupted frequently. He became rude, contrary, argumentative and conflict seeking. He lost his friends at school the next year because he would say things that would hurt their feelings. He started to tease the two cats at home, so much so that they started to avoid him whenever he came into the house. Six months after the accident his mother knew that there was something seriously the matter. She brought him to a counselor who thought the problem was psychological, as a result of the accident. The counselor thought that Zachary and his mother were too close and developed strategies to help Zachary become more independent. That only seemed to make things worse. After two years of counseling, which didn’t seem to help much, the mother consulted Zachary’s her pediatrician. He diagnosed Zachary with ADD and put him on Ritalin. But it didn’t help very much. In fact, it only seemed to make him more aggressive. When Zachary was brought to see me at age 9, I thought he might have a chronic post concussive syndrome, secondary to the accident. His brain SPECT study revealed marked decreased activity in the left pfc and decreased activity in the left occipital cortex, indicating both a front and back injury (common in head injuries). In addition, he had decreased activity in his left temporal lobe. Given this constellation of findings I put him on a combination of medication (an anticonvulsant, to stabilize his aggressiveness and help his temporal lobe function, and amantadine [Symmetrel] to help with focus, concentration and impulse control). He was also placed in a special class at school and given cognitive retraining exercises. Over the next several months his behavior began to improve and he was able to live at home.

front on surface view notice the dented area in the left anterior frontal pole
top down surface view notice marked overall decreased activity 43 year male, motorcycle accident
top down surface view 28 y/o male bicycle accident, no helmet problems with impulsivity and concentration		top down surface view 26 y/o rollerblade accident, no helmet executive function problems, suicidal ideas
underside surface view 15 y/o horseback riding accident memory, concentration and school problems		top down surface view 26 y/o bar fight, hit with large mirror executive function problems, note contra coup injury to frontal and occipital lobes
underside surface view		underside surface view
62 y/o fall from a ladder severe memory problems underside surface view 22 y/o diving accident memory, concentration and mood problems		36 y/o car accident memory and temper problems top down surface view 16 y/o fell down stairs at age 3 school failure, aggression, in jail for rape
top down surface view 21 y/o tackle football concussion aggression problems		underside surface view 10 y/o fell off jungle gym school failure, temper problems

top down surface view
note large defect left parietal area

left side surface view
note large defect left parietal and temporal lobe area

48 year old male roofer who fell 25 feet off a roof. Subsequently, he had problems with speech, listening, memory, concentration and temper problems. His wife divorced him.

Fall from Ramp Onto Concrete

top down surface view note marked decreased prefrontal activity		underside surface view marked overall decreased activity
underside surface view marked decreased prefrontal area