Section 2 New Perspectives

#### **Chapter 7**

## Perspective Chapter: The Complex Architecture of a Traumatic Brain Injury

*Leighton J. Reynolds*

#### **Abstract**

This is a perspective chapter that explores the crucial importance of understanding the full impact and architecture of a traumatic brain injury, beginning with the conception of a "Shock Trauma." This architecture is followed by the brain/mind architecture of "electrical and chemical disruptions in the brain," the brain/mind architecture of "homeostasis, allostasis, and allostatic load causing further disruptions in brain and mind functioning," and the brain/mind architecture of the "perfect storm" in the brain. Each architecture represents a stage in the toxic, cascading progression of a traumatic brain injury. It is generally not understood that traumatic brain injuries are not static events and that they can quickly become neurodegenerative disease processes, especially if they are not treated. Over time, these Four Architectures fold into one another creating huge challenges for the healing process. The conception of the Four Architectures is well illustrated through the case of a 20 year-old female who suffered a brain hemorrhage at age 7. Unfortunately, no follow-up was considered after a year of treatment. Her case identifies the importance of understanding the toxic, cascading progression of a traumatic brain injury through the Four Architectures, and how serious a condition this can become. Finally, the author discusses how brain injuries are different from all other types of injuries to a person, because of their neurodegenerative nature. And that these injuries need to be understood in a very different light, with a great deal more follow-up.

**Keywords:** TBI, PTSD, shock trauma, neurovascular coupling, homeostasis, allostasis, allostatic load, CTE, AD, PD, dementia

#### **1. Introduction**

A number of authors and articles [1–5] have addressed the conception that "head trauma is the beginning of an ongoing, perhaps lifelong, process that impacts multiple organ systems and may be both disease causative and accelerative (1)." This posttraumatic mortality can include neurological disorders (epilepsy and sleep disorders), neurological diseases (AD, CTE, ALS, PD, and dementia), neuroendocrine disorders (post-traumatic hypopituitarism), psychiatric disorders (schizophrenia and manic/

depression), and non-neurological disorders (sexual dysfunction, incontinence, musculoskeletal dysfunction, and metabolic dysfunction) [1]. This chapter agrees with this conception of the major consequences of a TBI and explains why and how this occurs through an understanding of the Four Architectures of a TBI. I introduce the case of S. as a demonstration of how devastating the consequences of a TBI can be for an individual's life without this understanding.

#### **2. The case of MS. S**

S. began working with me when she was 20 years old. At that time, her mother was desperate to find some answers that would explain her daughter's deteriorating condition and her defiant behavior. S. could not sleep at night. And she could not wake up in the morning with any energy or motivation. She was chronically fatigued and would frequently lash out at her mother over "small stuff." She had difficulties with concentration, focus, and attention. Reading and writing for any length of time were out of the question because she became exhausted when attempting either reading or writing for very long. She could barely remain on a computer for 15 minutes. Regarding work and school, S. could not hold down a job, because of the above and she was failing out of school. And probably the worst for her: she was in constant physical pain day in and day out. Later we discovered through a 72-hour EEG, that she was having multiple absence seizures throughout the day. This was not good news! In the meantime, her mother had struggled for years to find answers to what was wrong with her daughter. And no answers were available.

Finally, one June afternoon her mother brought S. in to see me. After sharing her daughter's long list of symptoms, she asked:

"Could her symptoms have anything to do with the accident that happened to her when she was 7-years-old?"

When S. was 7 years old she was thrown off the back of a horse when the horse bolted, and she hit the back of her head on a rock. Her mother explained that she heard screaming and ran back out of the ranch house where she had gone to pick up an item. By the time she reached S. she was lying motionless on the ground, and her eyes had rolled back into her head.

As her mother explained it: "No one wants to see their child like this!"

With the help of their neighbors, S. was airlifted to a nearby trauma center where she underwent emergency surgery for a brain hematoma and a depressed skull fracture. The neurosurgery included the placement of two mental plates. One year later, S. had a second surgery to remove the screws holding the metal plates. During this period, she appeared to have recovered quite nicely.

"Was there any follow-up from there," I asked?

Her Mother replied: "No, not really. No one was paying much attention after that. And our lives moved on."

S.'s mother related she was told that they were lucky the injury was on the occipital lobe and that part of the brain managed mostly vision. She was told that her daughter would be able to have a normal life, but to keep an eye on her vision. Nothing was ever mentioned about looking out for problems with CPS (post-concussion syndrome).

Everything appeared to be normal for S. except for issues around concentrating and organization in school. However, early on S. did express having intense, overwhelming

#### *Perspective Chapter: The Complex Architecture of a Traumatic Brain Injury DOI: http://dx.doi.org/10.5772/intechopen.108554*

feelings with her friends during grade school, and often experienced stomach upsets. Unfortunately, her mother did not associate these difficulties with her head injury because of the "good news" prognosis given by S.'s neurologist and the.

supporting medical staff treating her case. But when S. entered her teenage years, she began to display further obvious and more intense behaviors: acting out, impulsive and dangerous behaviors, cutting, threatening suicide, defiance, severe difficulties in school (socially), could not follow a normal sleep pattern, had difficulties with math, reading, and writing, and could not focus for very long on anything. Her mother brought her into treatment where she was labeled severely depressed and ADHD and medicated. But nothing changed. And S. continued to be seen as a "problem child."

S.'s psychological evaluation, done when she was age 15, addressed the fact that S. was performing poorly in school, had difficulty paying attention in school, reported feeling highly anxious and was hearing voices, and had difficulties keeping up with her classmates. She was diagnosed then with: persistent depressive disorder, generalized anxiety disorder, and attention deficit hyperactivity disorder, combined type. Again, there was no mention of any possible connection to her TBI at age 7.

Sadly, this pattern continued into high school and S. ended up not graduating from high school. As her mother looked back on those years, she explained to me that: "This wasn't my child anymore. Where did she go? I didn't know who she was anymore."

What lies ahead in this chapter is the story of S. in the context of the Four Architectures I understand that occur with all traumatic brain injuries. My goal is to "paint the picture" of these Four Architectures as they played out in S.'s case and present the perspective that after a TBI, there is much more that needs to be done. Much more, because a traumatic brain injury is really the beginning of a neurodegenerative disease process in the brain/mind [1–5]. In not following through the progression of a TBI, persons end up in the same situation R. did when she first came to see me. And this is a very difficult place to be as you can see from the above symptomatology R. presented with.

Against this background, S.'s original injury was the following: depressed right parietal skull fracture with underlying parenchymal contusion, subarachnoid hemorrhage, pneumocephalus, and overlying scalp laceration. She received excellent medical care for her injury. However, again, there was no follow-up. The concept of the Four Architectures argues that there is much more to an original traumatic brain injury and that not following through with continued treatment leads to serious consequences. Exactly as S. has been experiencing since elementary school.

#### **3. The Four Architectures**

In my experience, all blows to the head follow a similar architecture that, again, does not lead to a good place. Especially, if not recognized, addressed, and treated. Too often, trauma to the brain/mind ends up as Alzheimer's Disease, Parkinson's Disease, MS, ALS, CTE, or dementia in general following the path of the Four Architectures I describe here. And as research is now informing us, trauma to the brain/mind can also lead to serious mental disorders, most notably schizophrenia and manic/depression (bipolar I & II) [4, 5].

S.'s symptomatology unfortunately fits an injury pattern I am seeing too often because of misunderstandings and misconceptions of the cascading course of a traumatic brain injury. Her Spect Scan, done when she was age 20, demonstrated small scattered focal areas of predominately mild hypoperfusion in five different areas of her brain (September 18, 2020). Again, her case illustrates so well the consequences of not treating this cascading progression of a TBI. Her Spect Scan is proof that her original injury at age 7 was not a static event. Rather, it was the beginning of a serious neurodegenerative disease process.

Why am I using the word "architecture" to describe this cascading, neurodegenerative process in the brain/mind/body? One of the definitions of the word architecture (in addition to the standard definition of the word as the art and practice of designing and constructing building) is "the complex or carefully designed structure of something." An example would be: "The chemical or electrical structure of the brain." I will be exploring this conceptualization with the outline of Architecture Two. For now, I am referring to the complex architecture (structure and design) that follows trauma to the entire brain/mind/body.

**Architecture One** following a TBI can best be described and understood as a "Shock Trauma." A Shock Trauma is an automatic defense mechanism that helps protect the brain and the body from further damage. This protection process is accompanied by a range of physical and psychological symptoms that include [6]:


In the literature I explored, this "alarm response" (see the work of Hans Seyle dating back to the 1930s) usually lasts for seconds to minutes. But in my experience, if this architecture is not adequately addressed, it continues to proceed in the brain/ mind/body as the person's homeostatic balance attempts to restore itself, too often unsuccessfully. What I have yet to find in the literature is any widespread recognition that this recovery process in the brain does not in fact come to a quick halt. Instead, there are many factors influencing the individual's recovery from a shock trauma. Not the least of which is the patient's personality, character, developmental history, and prior illnesses and diseases. And over time, this rebalancing attempt, if uncorrected, will result in a further deterioration process in the mind/brain/body [7].

The specifics of the physical process of a Shock Trauma include [6]:


*Perspective Chapter: The Complex Architecture of a Traumatic Brain Injury DOI: http://dx.doi.org/10.5772/intechopen.108554*


Again, these symptoms are all related to the body's attempts to rebalance itself but are seldom viewed this way. All the patients I have worked with over the past 6 years who have immediately gone to the ER have received an MRI (which did not show any damage to the brain), and they were sent home and told to rest for at least a week before returning to their "regular" lives. The perceptive that something is already going on in their brain/mind, which is potentially very dangerous, is totally missing.

One could logically suspect that this initial shock to the brain/mind/body would be a short-term process. The brain/mind/body restores itself and the person's life appears to have gone back to normal. After all, the person does appear to be normal in every respect. However, this is not what I have witnessed on too many occasions. In S.'s case, she appeared to be developmentally fine moving forward with her life as a normal kid would. But in fact, this was not to be the case for her. As her mother later shared with me looking back, by her teenage years S. was already becoming problematic. But no one really.

understood why. I note that the evaluations done for S. at that time were only psychological. There was no consideration of what might be going on in her brain as a result of the accident that occurred when she was 7 years old.

Note that all brain trauma (including a TBI, a stroke, infections, disease processes, and tumors) is traumatic to an individual. And further, we cannot separate the individual person from their injury. Trauma is always subjective in part and is often less indicative about the actual event and more about the ways a person interprets the experience and makes meaning of their traumatic experience. I note that mental

processing will affect the person's physical recovery [8, 9]. And that this fact will influence the course of all Four Architectures. And yes, these psychological factors will show up on evaluations. But they are not the entire story of what a patient (like S.) is dealing with.

Looking further into Architecture One, there are basically two overarching kinds of shock traumas. Dissociative shock traumas occur when a person disconnects from themselves and others around them to reduce the amount of stimulation they must deal with daily [6]. This is an automatic, unconscious process, during which the person often feels disconnected from reality, often develops memory loss for the event (or events over time), and can manifest as a long-term dissociative disorder.

The other variation of a shock trauma is medical (although I believe that the physical and the mental interact as one). With hypovolemic shock traumas, there can be severe blood and fluid loss making it difficult for the heart to pump blood causing vital organs in the body to lose functionality. With distributive shock traumas, the.

result is abnormalities with the blood vessels that interfere with the distribution of blood in the body, possibly leading to low blood pressure and collapse. With cardiac shock traumas, there is a heart attack, and the heart is unable to pump blood to the body. And finally, there are neurogenic shock traumas when the brain and spinal cord are injured. Damage to the nervous system will also interfere with and block normal blood flow [6]. None of this is good and puts the person's life at risk for brain/mind problems in the future. And again, especially if not addressed.

In my experience, all of this occurs as the mind/body attempts to, again, rebalance itself in the face of huge disruptions to its homeostatic balance. I note that the most important function of our brains is not thinking, but rather survival [10]. Hence any trauma to the brain threatens our very survival. Nor, in my experience, does this rebalancing process necessarily subside in a short period of time. It can literally go on for years, especially if not addressed.

Finally, note that work is being done to better understand the immediate effects of a "shock trauma," through an understanding of the concept of Neurovascular Coupling [11–14]. I will be exploring neurovascular coupling further in Architecture Two as a major cause of disruptions to brain/mind functioning following a TBI. And I note the authors' statement that: "Given the difficulty of rapid detection, mTBI poses a particular challenge to public health because repeated injuries such as concussions have a cumulative effect on brain health" [11] (045007–1). The use of the phrase "cumulative effect on brain health" is why I believe understanding and treating the Four Architectures is so important, illustrated so well through S.'s case.

**Architecture Two** addresses disruptions to the electrical and chemical signals in the brain/mind. Literally, that makes us human! As TBI research is demonstrating, "There is increasing evidence that TBIs promotes the accumulation, misfolding, and aggregation of multiple abnormal proteins associated with neurodegeneration including tau, B-amyloid, a-synuclein, and tar DNA binding 43 proteins" [2] (p.9). And "A single moderate to severe TBI with LOC is associated with a two-to-fourfold increased risk of dementia in later life" [2, 15]. Note here that: "It is increasingly clear that TBI is a process and not a static injury, and that prolonged symptoms in TBI survivors represent functional and structural damage in the brain" ([2], p. 21). One of the brain systems most affected by this architecture is the neurovascular coupling system in the brain. NVC refers to the important connection between the nerve cells in the brain (the neurons) and their vascular (blood) supply. This is the source of energy that allows the brain/mind to both work and function properly. This coupling between the neurons and their vascular supply controls blood flow in the brain giving the neurons their energy to send and receive messages. Without the nutrients and oxygen regulated by NVC, the brain/mind cannot function adequately. And once the brain/mind has been damaged through a TBI (or other insults), it is very difficult to re-establish this important coupling. This results in the wide variety of symptoms we see with a TBI.

I have no information that would indicate S. was treated for a "shock trauma" following her accident. Although she did recover reasonably quickly following her neurosurgery. My concern is that by not fully addressing the effects of a "shock trauma" and doing long-term follow-up appointments, something very important is being missed.

"And what kinds of symptoms are you experiencing now, S.?"

"I don't function at all anymore. I mostly stay in my room all day, because I just don't have any energy anymore."

"And you're in constant pain?"

"Yes, I don't even want to get out of bed in the morning."

"Because of the pain?"

"What's the point if you're in constant pain!"

In S.'s case, this is all a result of long-term PCS (post-concussion syndrome) that had gone unrecognized and untreated. When the brain/mind is injured and unable to regulate blood flow to the neurons through NVC, the result is chronic fatigue and exhaustion, daily headaches, slow thinking, heavy brain fog, confusion, disorientation, memory loss, chronic sleep deprivation, and an inability to concentrate or focus on much of anything. This was unfortunately S. to a "T."

Too often this entire process goes unrecognized (and hence untreated) because vascular damage to the brain does not show up on an MRI (which is looking at structural issues in the brain). Standard structural clinical neuroimaging studies show no abnormal findings for the majority of PCS patients. For these patients, the damage is caused by cerebrovascular dysregulation and neuronal dysfunction [12]. Brain imaging studies using fMRI or Spect Scan technology are far more useful in demonstrating this kind of damage in the brain. "In short, it is becoming increasingly clear that NVC alterations, along with cerebrovascular reactivity (CVR) disruptions and autonomic nervous system (ANS) dysregulation play a significant role in PCS sequelae" ([10], p.1).

Sadly, there is more damage done to the brain beyond disruptions with neurovascular coupling (as damaging as this is). The mechanical forces involved in brain trauma (acceleration and deceleration linear, rotational, forces associated with blast injuries, blunt impact, and penetration by a projectile) cause direct damage to the neurons, dendrites, glia, and blood vessels in focal, multifocal, and/or diffuse patterns in the brain, and initiate a dynamic series of complex cellular, inflammatory, mitochondrial, neurochemical, and metabolic alterations ([2], pp. 2–3). While the immediate neurologic damage from primary traumatic forces is usually not alterable, the secondary damage produced by a cascading series of events does have the potential to be reversed. It is this cascading series of events that result in Architecture Two. For more information about reversing the secondary damage from a TBI see my forthcoming "Listening To The Brain" with Cambridge Scholars Publishing (2023).

Within Architecture Two of a TBI, I reiterate what I have stated above, because I believe this is so important to recognize that a TBI is not a static neurological insult to the brain/mind. It is now clear that a TBI can trigger progressive neurodegenerative damage leading to various forms of dementia (Alzheimer's Disease, Parkinson's Disease, ALS, Lewy body disease, CTE, and MS). Cognitive impairments with these diseases include memory loss, speed processing problems (which I find with all my

TBI patients), and executive functioning decline proceed long after the initial injury. Increasing epidemiological evidence demonstrates the links between head injury and an increased risk of dementia [16]. And exactly what is the link involved here between a TBI and an increasing path toward dementia of some type?

In a rather unusual manner (the brain is a different animal), the flow of the brain (the interactions between the various networks in the brain) begins to break down as literally broken pieces of the nerve cells (the neurons) and the supporting glia cells begin to clump together in a toxic process that cascades through the brain/mind. This leads to a host of symptoms that are at once invisible and very damaging. I believe this process is what is currently considered to be PCS. The culprits most identified in this cascading, degenerative processes are abnormal tau amyloid beta, and TDP-43. "The neurotoxicity of these pathogenic proteins (e.g., cis-P-tau) contributing directly to neuronal loss seen after injury is a potential link between acute and chronic of post-TBI changes" ([4], p. 1221). In my experience, there is a direct link here demonstrated so clearly in [4] (see Open Access: Understanding Neurodegeneration, p. 1225).

Architecture Two, then, addresses many factors all leading in the direction that the normal functioning of the brain/mind has now become toxic. And if not recognized and treated, will continue toward some form of dementia. I note that a person's entire existence is at risk when there are severe disruptions to the brain's electrical and chemical systems. This is how neurons talk to one another and give us our life force! But now, due to unrecognized and untreated "shock trauma" that the body/mind experienced, there is a cascading process of toxic build-up in the brain/mind. This is the concern of Architecture Two, which was initiated through a "shock trauma" that has gone unrecognized and hence untreated.

Architecture Three involves the following:

In my experience, medicine, psychology, and the legal system do not pay enough attention to the very important concept of Homeostasis. Homeostasis references the constant need our bodies, and our minds have, to maintain the balance of our physiology, our biochemistry, our neurology, and our psychology. Homeostasis is how we sustain our lives! The related concept of Allostasis addresses the moment-by-moment changes our bodies and our minds are constantly creating to keep us in the range of homeostatic balance. And where is the master switch for this crucial process to every individual on the planet? Yes, our brains accomplish this feat every moment of our existence. But again, our question is what happens when the brain is injured? When there are huge disruptions in a person's ability to function effectively in their everyday lives because their homeostatic balance is in question. Then, these individuals cannot function normally!

As noted in Architecture Two, the toxic processes cascading through the brain/ mind following the disruptions in brain functions from a TBI are not just isolated aspects of the brain. The person's entire being is affected. Why? Because when the Master Switch (the brain) of everyone's existence is damaged, the processes of Homeostasis and Allostasis are affected on a very large scale. And this is what accounts for the wide range of symptoms that brain-injured persons experience. We are now in the midst of Architecture Three, when the brain/mind/body is working overtime to maintain homeostatic balance, and the allostatic resources to do so are simply not there. The energy necessary (driven by processes in the brain) to restore homeostatic balance and maintain body budgeting is not available because the master switch in the brain has been damaged [17]. This is what causes the pervasive symptomatology we encounter with all brain injuries (especially when not treated). Consider that there are no other medical problems that are so pervasive in an

#### *Perspective Chapter: The Complex Architecture of a Traumatic Brain Injury DOI: http://dx.doi.org/10.5772/intechopen.108554*

individual's life. Broken arms, broken legs, kidney infections, IBS problems, and skin disorders for example do not affect the entire body in the manner that an injury to the brain will do. Yet we recognize so little about this!

The third consideration we need to pay attention to here as part of Architecture Three is allostatic load [17]. The primary hormonal mediators of the stress response in the body are glucocorticoids and catecholamines. They have both protective and damaging effects on the body. In the short run sphere, they are essential for adaptation, the maintenance of Homeostasis, and the survival of the mind/body/brain through Allostasis. But over time, these managing processes exact a cost (Allostatic Load) that can begin and accelerate disease processes. The paradox here is the systems that automatically respond to stressful episodes in all of us, the autonomic nervous system and adrenocortical system in the body, are indeed protectors of the body in the short run. But over time, they cause damage and accelerate diseases in the mind/brain/ body. Specifically, allostatic load refers to the price the mind/body/brain pays for being forced to adapt to adverse physical, psychological, and/or environmental situations. Allostatic load represents both the presence of too much stress and/or the inefficient operation of the stress hormonal response system ([17], p. 114).

An additional (and major) concern of Architecture Three is the role of increasing demands on the brain/mind/body following a TBI.

Demands on the brain, for any reason (no matter how small), demand energy, and as a consequence take energy away from the healing process and increase allostatic load [17]. And as noted above, increases in allostatic load led to further damage and injury to the person struggling with a TBI. I note that for all my patients, as they begin to resume their normal activities, they begin to experience continuing episodes of chronic fatigue. Thus, it is very difficult to "get ahead" with an injury to the brain unless there are major opportunities for rest and healing.

And finally, not to further complicate the cascading, progression of a TBI, there is Architecture Four, the "perfect storm" in the brain [18, 19]. We know that brain injuries slow down the processing of this person's world, internal and external. I have had to learn in working with TBI patients, to give them plenty of "room" and time to process their thoughts and feelings and respond during sessions. I likened this experience for the patient to the running of a slow computer. Because either something is wrong with the computer or it is out of date with its processing speed and power. Does this cause problems for persons experiencing a TBI, in a modern culture that is now always moving exponentially? Yes! At the same time, all brain injuries are traumatizing experiences for that individual and therefore cases of PTSD. What does PTSD do in the brain? It speeds things up as the HPA axis works to cope with a mind/body/brain that is under seize (Howard Weiner). In my experience, trauma is at the root of all PTSD issues. And what could be more traumatizing than "losing your brain/mind," because it will affect every aspect of your life.

PTSD is the brain/mind/body's response to being traumatized (when the event overwhelms the person's ability to cope). The symptomatology of PTSD includes [19]:


hatred, self-destructive behavior with drugs and ETOH, difficulties with sleep, and an inability to concentrate and focus in all aspects of daily life.


"What's your day-to-day life like S.?"

"I don't really do much. I'm always tired and in pain, which is really no fun!" "Are you able to read, write, watch TV, see a movie?"

"Not really, I mostly veg every day. I don't have any energy, and if I do something, I always pay for it and end up sleeping a lot."

"Do you feel hopeless about all of this?"

"I don't see anything getting any better. What do you expect. And yes, I do feel suicidal from time to time, because nothing ever seems to get better!"

Architecture Four addresses the fact that there are now clashing forces operating in the brain/mind/body. A TBI slows things down while PTSD speeds things up. Where is the good news here? No wonder so many TBI patients feel like they are going crazy. Then how does anyone cope with a brain/mind/body that is experiencing these clashing events?

See the following references for further details describing the neurodegenerative disease processes that catalyze the development of the Four Architectures. And note that the Four Architectures are the brain/mind's complex response to a traumatic injury [20–26].

#### **4. Discussion**

Why am I using the concept of "Architectures" to explain the cascading progression of a TBI? Because these "Architectures" represent the brain's responses to damage, and over time they fold into one another. Further, this damage, over time, will cause huge disruptions in the active flow of the brain/mind/body. It is a neurodegenerative disease process that is causing a cascading, toxic effect in the brain, and by connecting the mind and the body. Since our brains are built to control and ensure our survival (not just thinking which is of course a major part of our survival), damage to the brain is a threat to the person's very day-to-day survival [10]. In my private practice over the past 6 years, I have seen the clear results of how damaging this cascading, neurodegenerative process can be.

Here is a summary of the information supporting the conception of a neurodegenerative disease process in S.'s brain. Her original accident occurred in October of 2007 when she was 7 years old.

S.'s psychological evaluation was done in 2015 (noted above) to address her ongoing behavioral problems. Sadly, nothing about the brain was included, and despite efforts to help S. nothing changed.

Her MRI brain without contrast (July 13, 2020) concluded that there was a focus of cortical and adjacent white matter encephalomalacia [27] that involved the parietal occipital lobe. And that this may represent a focus on cortical contusional injury, or previous intraparenchymal hemorrhage in view of the patient's history.

*Perspective Chapter: The Complex Architecture of a Traumatic Brain Injury DOI: http://dx.doi.org/10.5772/intechopen.108554*

Her EEG report of 7/21/2020 concluded that her EEG was abnormal and that this abnormal activity was suggestive of a generalized seizure disorder.

Her qSPECT (Spect Scan) of 9/18/2020 concluded that this was an abnormal brain SPECT demonstrating scattered, small focal areas of predominately mild hypoperfusion in five different areas of the brain. I believe these five areas of hypoperfusion are what account for the wide range of symptoms S. is experiencing that are so disabling in her life.

The current list of symptoms that S. lists are quite pervasive indicating huge disruptions in her attempts at Homeostatic Balance (see Architecture Three above). These include:

Difficulties with anger management, blurred vision, confusion and disorientation, following instructions, integrating information, learning new things, concentration and focus, short and long-term memory, and decreased judgment.

Balance problems, increased irritability, low frustration tolerance, mood swings, insomnia, nightmares and sleep paralysis, increased depression and anxiety including suicidal ideation, panic attacks, and paranoia.

Chronic fatigue, headaches, pain, racing thoughts, sensitivity to light, sound, and touch, ringing in the ears, and trauma flashbacks.

Among the patients I have worked with over the past 6 years, this huge range of symptoms is the norm. And when you look at the Four Architectures that fold into one another it is easier to understand how this is happening.

My goal in writing this chapter is to open the door to a more complete understanding of this very complex and complicated process that follows from an injury to the brain. My hope is that this chapter will help to initiate further research, understanding, and treatment of traumatic brain injuries.

I close this chapter with two quotes I believe resonate with my conception of the Four Architectures and points us in the direction of the research, understanding, and TBI treatment we need to focus on:

"Previously, TBI has generally been viewed as producing a static neurological insult. However, it is now clear that it can trigger progressive neurodegeneration and dementia. Cognitive impairments such as memory loss, processing speed problems and executive dysfunction are common, and some survivors experience cognitive decline long after injury, in part due to the development of dementia" ([4], p. 1221).

"Advances in the understanding of the neuropathophysiology of TBI suggest that these forces initiate an elaborate and complex array of cellular and subcellular events related to alterations in Ca++ homeostasis and signaling. Furthermore, there is a fairly predictable profile of brain regions that are impacted by neurotrauma and the related events. This profile of brain damage accurately predicts the.

acute and chronic sequelae that TBI survivors suffer from, although there is enough variation to suggest that individual differences such as genetic polymorphisms and factors governing resiliency play a role in modulating outcome" ([28], p. 1).

In my experience, all blows to the head are in some manner insults and disruptions to neurological functioning on some (sometimes many) levels. Accordingly, we need to research this subject in much more depth! (See the research on 12-year-old hockey players in Canada who were asymptomatic following a concussion, but brain damage was clearly visible on follow-up brain imaging.) [29, 30].

*Topics in Trauma Surgery*

#### **Author details**

Leighton J. Reynolds Treatment and Tools for Trauma, Greater Los Angeles, CA, USA

\*Address all correspondence to: leightonj@sbcglobal.net

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Masel BE, DeWitt DS. Traumatic brain Injury: A disease process, not an event. Journal of Neurotrauma. 2010;**27**:1529-1540

[2] McKee AC, Daneshvar DH. The neuropathology of traumatic brain Injury. Handbook of Clinical Neurology. 2015;**127**:45-66

[3] Kemp S, Goulding P, Spencer J, Mitchell AJ. Case study: Unusually rapid and severe cognitive deterioration after mild traumatic brain Injury. Brain Injury. 2005;**19**(14):1269-1276

[4] Graham NSN, Sharp DJ. Understanding neurodegeneration after traumatic brain Injury: From mechanisms to clinical trials in dementia. Neurology, Neurosurgery & Psychiatry. 2019;**90**:1221-1233

[5] Ashman TA, Gordon WA, Cantor JB, Hibbard MR. Neurobehavioral consequences traumatic brain Injury. The Mount Sinai Journal of Medicine. 2006;**73**(7):999-1005

[6] Sanjana Gupta. What is Traumatic Shock. 2022. Available from: https:// www.VeryWellMind.com/Traumatic-Shock-Definition-Symptoms-Causesand-Treatment (5242269)

[7] Williams R. Tau pathology present decades after a single brain Injury. Science Transitional Medicine. 2019;**11**:eaaw1993

[8] Molaie AM, Maguire J.

Neuroendocrine abnormalities following traumatic brain Injury: An important contributor to neuropsychiatric sequelae. Frontiers in Endocrinology. 2018;**9**:176

[9] Ashman TA, Gordon WA, Cantor JB, Hibbard MR. Neurobehavioral consequences of traumatic brain Injury. The Mount Sinai Journal of Medicine. 2006;**73**(7):999-1005

[10] Lisa Feldman Barrett. 7 ½ Lessons about the Brain. Boston: Houghton Mifflin Harcourt; 2020

[11] Jang H, Huang S, Hammer DX, Wang L, Rafi H, Ye M, et al. Alterations in neurovascular Coupling following acute traumatic brain Injury. Neurophotonics. 2017;**4**(4): 045007

[12] Allen MD, Epps CT. Neurovascular coupling: A unifying theory for postconcussion syndrome treatment and functional neuroimaging. Journal of Neurology and Neurophysiology. 2017;**8**(6):1000454

[13] Watts ME, Pocock R, Claudianos C. Brain energy and oxygen metabolism: Emerging role in Normal function and disease. Frontiers in Molecular Neuroscience. 2018;**11**:216

[14] Falkowska A, Gutowska I, Goschorska M, Nowacki P, Chlubek D, Baranowska-Bosiacka I. Energy metabolism of the brain, including the cooperation between astrocytes and neurons, especially in the context of glycogen metabolism. International Journal of Molecular Sciences. 2015;**16**:25959-25981

[15] Ryback R. Traumatic Brain Injury: The Invisible Illness (a Single Concussion Can Change your Life). Psychology Today; 2016

[16] Camandola S, Mattson MP. Brain metabolism in health, aging, and neurodegeneration. The EMBO Journal. 2017;**36**:1474-1492

[17] McEwen BS. Allostasis and Allostatic load: Implications for Neuropsychopharmacology. Neuropsychopharmacology. 2000;**22**(2):108-124

[18] Marilyn Lash MSW, TBI and PTSD: Navigating the Perfect Storm, Brain Injury Journey Magazine, Issue #1, 2013

[19] Bryan R. Post-traumatic stress disorder vs traumatic brain Injury. Dialogues in Clinical Neuroscience. 2011;**13**(3):251-262

[20] Mike McRae. Just One Head Injury Could Be Enough to Tangle Proteins in Your Brain. 2019. Available from: https:// www.sciencealert.com/one-head-injurycould-be-enough-to-create-the-proteintangles-in-your-brain

[21] Do Carmo S, Spillantini MG, Cuello AC. Tau pathology in neurological disorders. Frontiers in Neurology. 2021;**12**:754669

[22] Faden AI, Loane DJ, Injury CNATB. Alzheimer disease, chronic traumatic encephalopathy, or persistent Neuroinflammation? Neurotherapeutics. 2015;**12**:143-150

[23] Emily Lunardo. Encephalomalacia: Definition, causes, types, symptoms, and treatment. 2017. Available from: https:// belmarrahealth.com/encephalomalaciacauses-types-treatment

[24] Roman Hlatky MD, Alex B, Valadka MD, Claudia S. Intracranial hypertension and cerebral ischemia after severe traumatic brain Injury. Neurosurgical Focus. 2003;**14**(4):2

[25] Pasley BN, Freeman RD, Coupling N. Scholarpedia. 2008;**3**(3):5340

[26] Alina Fong. What You Need to Know About TBI Symptoms and Treatment.

2020. Available from: https://www. cognitivefxusa.com/traumatic-braininjury-long-term-effect-and-treatment

[27] Encephalomalacia: Definition, Causes, Types, Symptoms, and Treatment. Available from: https://www. belmarrahealth.com/encephalomalaciacauses-types-treatment

[28] Thomas W. McAllister, Neurobiological consequences of traumatic brain Injury, dialogues Clinical Neuroscience. 2011;**13**(3):287-300

[29] Emery C. Concussions Affect 1 in 10 Youth Athletes every Year. Here's What Needs to Change. Calgary, Canada: University of Calgary; 2020

[30] Charles T, Victoria B, Jin Ma. Persisting concussion symptoms from bodychecking: Unrecognized toll in boys ice hockey. Published online. Cambridge University Press; 2022. pp. 1-9

### *Edited by Selim Sözen*

Early treatment is of the utmost importance for traumatic injuries. The patient's vital signs, abdominal examination and hematocrit should be checked at frequent intervals. Using ultrasound allows the examiner to make a better clinical diagnosis of the patient. This book discusses different types of trauma surgery for abdominal injuries, bone fractures, injuries sustained from animal attacks, and traumatic brain injuries.

Published in London, UK © 2023 IntechOpen © oceandigital / iStock

Topics in Trauma Surgery

Topics in Trauma Surgery

*Edited by Selim Sözen*