Craniocerebral trauma: Symptoms, consequences and a new diagnostic method

At the weekend there were two accidents in the Bikepark Winterberg and one in the Bikepark in Schmallenberg-Gellinghausen. One woman and two men were seriously injured: A 20-year-old Dutch woman, a 51-year-old man from Lemgo and a 61-year-old man from Werneuchen. According to the police, all of the injured had to be flown to hospitals by rescue helicopter. Last weekend, a 12-year-old boy was seriously injured in an accident at the Winterberg bike park. - radiosauerland.de

Unfortunately, there are always reports of this or similar incidents - from bike parks, but also from bike trails - not to mention accidents in urban traffic. Thanks to protectors and crash helmets, we are much better protected these days. A superficial graze or a broken bone usually heals quickly with more or less medical intervention. Falls on the head can be quite different. We all remember with horror the serious accident suffered by Formula 1 driver Michael Schumacher in 2013. These so-called traumatic brain injuries (TBI) are common. In Germany, around 270,000 people suffer a TBI every year (data from the German Social Accident Insurance) - in Switzerland, there are over 25,000 such accidents (Swiss Neurological Society). However, not all accidents are reported or documented, so the actual number is probably much higher.

Every fall on a bike is unique in terms of the course of events, the mechanism of damage and the force exerted, but the principle of abrupt acceleration or deceleration is the same for these injuries, the energy of which can be lost despite Crash helmet, MIPS and co and the patient's own skull bones to the brain.

Symptoms of craniocerebral trauma

In medicine, the Glasgow Coma Scale (GCS) is used to assess the severity of a head injury. During the initial examination, points are awarded for the impact of the symptoms. It is analysed whether the injured person opens their eyes spontaneously, for minor restrictions in mobility ("best motor response") and adequate answers to questions ("best verbal response").

13-15 points characterise a mild craniocerebral traumawhich generally requires neither neurosurgical nor intensive medical care. If the patient is nevertheless admitted to an emergency department as part of the accident investigation, a computerised tomography (CT) scan is often ordered to rule out accident-related injuries (e.g. minor bleeding) even in the case of mild TBI (the doctor speaks of complicated mild trauma).

Other terms used in medicine for head injuries are

1. Contusio capitis (head / skull contusion), as the mildest form of injury in which the impact of the accident is completely absorbed by the (helmet and) skull bone.
   
2. Commotio cerebri (concussion), which is characterised by a brief loss of consciousness, a memory gap for the accident, often nausea and usually (delayed) headaches.
   
3. Contusio cerebri (brain contusion) with a disturbance of consciousness / loss of consciousness lasting longer than 10 minutes and correspondingly more pronounced symptoms. Here it is good to have a buddy or at least one crash sensor who can then provide further details about the course of the accident and the immediate symptoms. As the treatments differ depending on the severity of the injury, any information is of course helpful.

Headaches to memory impairment - even mild TBI should be taken seriously

A "mild TBI" after a mountain bike crash is not automatically without symptoms for those affected. Long-lasting or even daily headaches, sleep disorders, dizziness, reduced performance, concentration and / or memory disorders are typical complaints reported by accident victims. As the original diagnosis and clinical examination of these minor head injuries is often not very conspicuous, "only" the information provided by the accident victim themselves remains. This can become a problem if the ability to work has still not been restored after an accident that occurred some time ago. Specialist doctors - not only for professional athletes - can help here.

Craniocerebral trauma - a field report

Thomas crashed on his MTB on the trail of his home circuit. He didn't break anything. His shoulder and hip hurt a little. He couldn't say how it happened. He only remembers sitting on the ground and wondering how he had ended up here! Then at least he remembered: he was on the trail that he had ridden countless times before. Even today, he still has a "film tear" about the event, which happened six months ago. Thomas has often had headaches since then. His concentration has also diminished and he feels less powerful than before the bike accident. Subjectively, his strength in his right leg is somewhat weaker and he occasionally has visual disturbances.

Various symptoms, but no conclusive diagnosis of TBI

However, the doctors found no abnormalities. He had a computerised tomography (CT) scan of his head immediately after the accident - and then a magnetic resonance imaging (MRI) scan due to persistent headaches, both of which were without any abnormal findings. The doctors had mentioned "post-traumatic stress disorder" and "depression"... that was completely out of the question for the active cyclist. Fortunately, a friend of Thomas works in the healthcare sector. She had heard about a certain MRI method that can recognise brain injuries in TBI better than the so-called "conventional imaging" that had already been carried out on Thomas.

A Craniocerebral trauma is very individual - a new diagnostic method takes this into account

Two different techniques are used, which are primarily used in research, but are now also used for pre-operative planning in neurosurgery. Diffusion Tensor Imaging (DTI) measures microstructural damage, the second, Functional Magnetic Resonance Imaging (fMRI) measures the functionality of the brain via its ability to absorb oxygen from the blood. Professor Mike Noseworthy (Vice Director of Radiology in Hamilton, Canada) and his team have been using this new method for some time, particularly for injuries to ice hockey players or after road accidents. "For over 20 years, there have been studies and data on mainly (semi-)professional athletes in contact sports such as American football, boxing or ice hockey who have suffered brain damage after a fall (body check or knock-out). We know that classic conventional imaging is not sensitive enough for this," says Prof Noseworthy. "However, the data from these young professional athletes cannot simply be transferred 1:1 to the accident victim in middle age. We compare the individual brain with an MRI image database of healthy people of the same age. This is because our brains change over the course of our lives, and there are differences between men and women.

Over the years, he and his team have therefore collected a constantly growing database consisting of MRI data from currently over 17,000 healthy people in order to be able to compare the individual brain of the affected person with the corresponding group of healthy people. Prof. Noseworthy calls his approach "individualised personal medicine". Together with Prof Stephan Ulmer, a specialist in brain imaging (neuroradiology) in Zurich, they have developed the platform 0800Brain was founded to help injured people, like Thomas in our case. He actually showed changes that could explain his complaints.

New diagnostic method shows brain injuries on a colour scale

The highly sensitive magnetic resonance imaging (MRI) was without findings in Thomas. It was only with this new method that Thomas was found to have injuries in the posterior region of the brain (visual fields, so-called visual cortex). The motor system (movement) was also affected. Higher resolution in the evaluation allows the exact localisation in the respective system to be displayed. A disorder was found precisely in the area of the brain that controls the movements of the leg - matching his subjective reduction in strength in the leg. In addition to his great relief at finally having a diagnosis and being taken seriously, his physiotherapy can now be adapted accordingly.

Whether the health insurance company will pay is unfortunately uncertain

This specific diagnostic method for suspected traumatic brain injury is also available to people from Austria or Germany. However, it is questionable whether the costs will be covered by health insurance, especially for those with statutory health insurance. Professor Ulmer and his team of doctors in Zurich always submit an individual enquiry to the relevant health insurance company regarding the assumption of costs. They can often only charge the health insurance company for part of the examination and the patient has to pay a co-payment - similar to dental treatment. Unfortunately, this makes it very difficult for some accident victims to obtain such a diagnosis for cost reasons. However, if someone has unexplained complaints for months, such as headaches, memory or sleep disorders, it is worth investing in a visit to the Swiss neuroradiology centre.