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CHAPTER 6 - IMAGES OF BRAIN TRAUMA
Select a chapter from the list
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.
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underside surface view
note the marked decreased left prefrontal, left hemisphere and left occipital
lobe
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16 y/o head trauma at age 7
school failure, substance abuse, impulsivity
decreased left pfc
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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
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48 y/o male, football injury age 16, significant problems expressing feelings
(alexythymia)
decreased left pfc and anterior left temporal lobe
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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)
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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).
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
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top down surface view
notice marked overall decreased activity
43 year male, motorcycle accident
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top down surface view
28 y/o male bicycle accident, no helmet
problems with impulsivity and concentration
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top down surface view
26 y/o rollerblade accident, no helmet
executive function problems, suicidal ideas
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underside surface view
15 y/o horseback riding accident
memory, concentration and school problems
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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
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62 y/o fall from a ladder
severe memory problems
underside surface view
22 y/o diving accident
memory, concentration and mood problems
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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
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top down surface view
21 y/o tackle football concussion
aggression problems
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underside surface view
10 y/o fell off jungle gym
school failure, temper problems
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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
22 year old female fell down a ramp head first onto the concrete. Subsequently, she had
problems with impulse control, concentration and motivation.
Brain Trauma, Ways We Can Help
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