brain power and recovery from TBI

This past Sunday, there was a very interesting article in the New York Times about recovery from a Traumatic Brain Injury (TBI).  This is the latest in a series of articles titled Brain Power.

The focus was a 19 year old guy named Adam Lepak, who survived a serious motorcycle accident in late 2007.  Adam spent about six months in a near-vegetative state, only minimally responsive.  His diagnosis was Diffuse Axonal Injury (DAI).  This is a condition in which the connections between the “white matter” (axonal tracts in the brain appear white due to myelination) and the “gray matter” of the brain are disrupted due to the traumatic shearing forces that occur when areas of varying density in the brain are subject to very sudden acceleration through the less dense brain tissue.

Over 90% of patients with DAI never wake up.  I believe that my friend Peter Ostertag, who died as a result of brain injuries received in a bicycle accident in 2005 had DAI, owing to the description we received from the neurologist who worked with him.  The axonal injury can be widespread over many areas of the brain, governing executive function, personality, and logic.  In Peter’s case, the diagnosis was that in the unlikely event that he were to awake from his coma, the damage was widespread enough that he would never be able to live independently or even interact with those around him.

The young man whose injury was detailed in the article was quite a bit more fortunate.  Despite having extensive injury, Adam Lepak did awake from his coma.  He has made much progress, although the injury has affected him significantly.  He is able to interact with friends and family, and recalls some of the circumstances of his injury (“I think I was in a motorcycle accident”).

One of the more intriguing aftereffects has been that Adam sometimes becomes suspicious of his closest relationships – believing that the people close to him are “imposters”.  Apparently, this is also common in schizophrenic patients as well as some trauma patients.  Doctors have hypothesized that this may be due to the nature and location of the damage to the brain. 

In Adam’s case, he sustained damage to his cortical midline structures.  This is a thick trunk of neural pathways that traverse the brain from the frontal lobes to a number of other regions, some of which are the “identity centers”.  These are the diffuse areas that piece together different bits of information that permit us to associate the beings and objects in front of us with the aspects of memory that help us identify them. 

Delusions of identity suggest that the conduit between acquisition of the raw information (in this case the cortical midline structures) and the regions of the brain that interpret them has been disrupted.  The medical data suggests that this is also related to disruption of connection between the logical, linear reasoning areas (left hemisphere) and holistic judgment and emotional processing areas (right hemisphere).  Often the patients have sustained more damage to their right hemisphere, affecting their ability to associate the images with what those images mean to them personally.

The delusions seem to result from the absence or incompleteness of true holistic judgment (“this is my mother”) with the resultant logical judgment (“she looks familiar, but she must be an impostor”).

One key to recovery is to facilitate remapping of the neural function ordinarily occurring between the cortical midline structures and the areas governing holistic judgment.  The brain is definitely capable of doing this.  Naturally it requires concerted effort and therapy.

The most important theme in the article with respect to this therapy is that the patient needs to be surrounded by familiar people and images.  They also need to be continually cued to and reminded of the associations between them.  In Adam’s case, being constantly around family and friends who sound very loving and supportive is exactly what the doctors ordered.  And while it can’t always be easy when the patient accuses his loved ones of “being fake people”, I’d posit that remaining close and working through the problems together feels a lot better than giving up.

While not directly relevant to my specific form of TBI, I find articles like this to be illuminating and somewhat inspiring.  They teach us what’s possible with respect to recovery from profound injury.

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