A Rehab Doc's Take on Brain Injury

As posted to Our-Kids on May 20, 2000

Date: Sat, 20 May 2000 09:36:11 -0500
From: "Vikki A. Stefans" <vstefans@care.ach.uams.edu>
Subject: Re: [OK] Brain Damaged

OK , you asked for it, you got it...a rehab doc's take on brain
injury. :-)

My answer to this is basically that kids all have an underlying and
incredibly powerful drive to grow, develop, and learn. They will use
whatever brain tissue they have and do as much as possible with it. All
of us know kids with severe progressive neurodegenerative diseases who for
years went undiagnosed because they were making as much progress as they
did despite it for so long. And we all know that even kids with
hydranencephaly, having just a little basal and gangliar tissue, will use
it to connect with and recognize caregivers, enjoy some music, etc...I
guess they save what they've got for the truly important things in life!!
A bad looking CT or MRI is just a picture of an injured brain, and does
not in itself tell you exactly how much that brain can still do, or
predict lifespan.

The other, related part of this answer is "plasticity". The younger the
brain the less committed certain parts are to doing certain specialized
functions. Plasticity is not infinite and it is not a free lunch. For
example, kids with right hemiparetic cerebral palsy don't have aphasia
like an adult with a left sided cortical stroke and right hemiparesis most
often does. But the child with CP is more likely to have some
spatial-perceptual and learning or milder language problems. For the
amount of brain tissue lost, the child's hemiparesis will also be a lot
milder than the adult's, but there will generally be at least a
little. This is why people in general are amazed at what a child who has
a hemispherectomy can do and how "normal" they look...but some parents,
who were expecting totally normal, have been disappointed with their real

So there's not a lot of white matter. So what there is works a little
overtime to get through what messages it can. When not enough messages
that control excess tone are getting through (when it comes to motor
functions especially, the cortex is largely inhibitory in function) we see
a lot of spasticity and basically we try various ways to send the message
to relax with the various medications and such we use. Then whatever
messages to move a certain part a certain way can get through will better
be able to accomplish something. White matter also has some function in
learning, connecting the different areas of gray matter together and
connecting the hemispheres with each other. The "diffuse axonal
injury" seen after head trauma is largely a white matter injury,
disrupting lots of connections, and generally results in overall
inefficiency of operation of the brain. Exactly how new connections get
established and how brain function continues to improve over months to
years afterwards is still more than a little mysterious.

Remember that the resolution of even the best neuroimaging is still a
little limited. There are many things we could not see on CT scans that
we can see now on MRIs but you can't see down to the level of an
individual nerve cell by any means. The famous cases where the person was
thought to have hydranencephaly but actually had severe hydrocephalus with
enough cortex to learn algebra would be less likely to be mistaken today;
these were recently brought up in an ethics discussion for a baby with
hydranencephaly (Barb- you'll be pleased to know that the neurosurgeon
finally DID do the shunt after all!) and the question was brought up
whether the shunt should be done just to see if in fact this was the case
instead. This is no longer at all likely; and in a way, that was the
wrong reason to do the shunt. The point is that the child obviously had
capability to have a quality of life despite the obvious limitations and
needed the shunt to live and to avoid having a huge head that would have
limited mobility and care. (That's what persuaded the neurosurgeon to do

So remember that every brain is designed to grow and develop, and even an
injured brain will grow and develop to whatever extent is possible. Your
child's abilities and potential to maximize them matter more that the
picture of how the brain looks. Also, this has come up before on this
list- but if someone is diagnosed with mental retardation (about 50% of
people with CP have some degree of MR) it does not mean they cannot learn.
It means that they may learn more slowly, require more repetitions, may
have to be more explicitly taught things that others just learn
"naturally". We all face the challenge of pointing out that the cup is
3/4 full instead of empty- there is a world out there that tends to see it
as either 100% full or nothing.

Vikki Stefans, pediatric physiatrist (rehab doc for kids), e-mail junkie,
working Mom of Sarah T. and Michael C., and wife of Henry "My Travel Agent",
Arkansas Children's Hospital/ U of A for Medical Sciences, Little Rock, aka
  ...and EVERY mom is a working mom! (OK, dads too.)

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