D. Lindsay McLellan

The impact of traumatic brain injury on family members living with patients: a preliminary study in Japan and the UK

PURPOSE To ascertain the views of families living with TBI patients about the nature of the problems experienced as a result of TBI, and to compare the views of Japanese family members (J-FM) and British family members (B-FM) in order to find out whether there were cultural differences in family response to TBI. METHODS Family members involved in providing care were identified by the patients. Face to face interviews were conducted with all 18 carers in B-FM and four carers in J-FM. The remaining eight carers in J-FM participated in the postal questionnaire. Questionnaires were developed to explore the nature of problems and the involvement of family such as social embarrassment. RESULTS Problems arising in families were almost the same reported from both groups. However families in B-FM were likely to know more about how to cope with these problems. Family members in J-FM reported more statistically significant increases in social embarrassment than those in B-FM. CONCLUSION The preliminary results showed that family members living with TBI patients in both groups had experienced problems. Appropriate rehabilitation services should be developed to help families as well as TBI patients in Japan.Purpose: To ascertain the views of families living with TBI patients about the nature of the problems experienced as a result of TBI, and to compare the views of Japanese family members (J-FM) and British family members (B-FM) in order to find out whether there were cultural differences in family response to TBI. Methods: Family members involved in providing care were identified by the patients. Face to face interviews were conducted with all 18 carers in B-FM and four carers in J-FM. The remaining eight carers in J-FM participated in the postal questionnaire. Questionnaires were developed to explore the nature of problems and the involvement of family such as social embarrassment. Results: Problems arising in families were almost the same reported from both groups. However families in B-FM were likely to know more about how to cope with these problems. Family members in J-FM reported more statistically significant increases in social embarrassment than those in B-FM. Conclusion: The preliminary results showed that family members living with TBI patients in both groups had experienced problems. Appropriate rehabilitation services should be developed to help families as well as TBI patients in Japan.

Diseases of Muscle

The development of new techniques for the histological study of muscle has led to fresh concepts of the pathogenesis and classification of neuromuscular disorders. In this chapter a general account of the pathological reactions of muscle will be given, particularly in relation to biopsy material, although some attention will also be given to autopsy findings. The features of individual disorders will be summarised.

General Pathology of the Central Nervous System

Many parallels can be drawn between pathological reactions in the CNS and those occurring elsewhere in the body. Acute pyogenic and granulomatous inflammation are both seen in the brain as in other organs and atherosclerosis affects the cerebral blood vessels as it involves the medium-sized arteries in other parts of the body. Occlusion of arteries will result in infarction both in the brain and in systemic organs like the heart and kidney. As in other organs, viruses, bacteria, fungi, protozoan and metazoan parasites, may affect the CNS, although these organisms may show some specificity for the brain or spinal cord. The CNS is a common site for metastatic tumours and both well- and poorly differentiated primary tumours occur in the brain. Metabolic disorders and ageing processes also have well-recognised effects upon CNS structure and function.

Intracranial and Spinal Tumours

Diagnosis and treatment of intracranial and spinal tumours form an important part of the workload of neurosurgical, neuroradiological and neuropathological services. Therapy for many of the malignant brain tumours is still far from satisfactory but accurate diagnosis, and especially the detection of meningiomas and other benign tumours is an essential part of good clinical management.

Virus Infections of the Nervous System

Viruses cause neurological disease either as the result of cytopathic effects from direct invasion of the nervous system, or as a consequence of an accompanying or delayed immunological response to virus invasion of the nervous system (post-viral encephalitis or polyneuropathy). Viruses may enter the nervous system by one of a number of routes, but it is uncommon for there to be clinical evidence of the mode of entry. During viraemia, viruses may penetrate the CNS, usually causing viral meningitis or viral encephalitis. Invasion of the nervous system through the nasopharynx and the olfactory nerves, or by passage of viral particles along peripheral nerves, e.g. the trigeminal nerve, is also recognised. Furthermore, some viruses such as rabies virus may enter the nervous system after inoculation through a bite on an extremity and subsequent passage along periperhal nerves. Invasion during viraemia is probably the commonest of these routes of infection.

Bacterial, Fungal and Parasitic Infections of the Central Nervous System

There are acute and chronic forms of bacterial infections of the CNS. The infection may be primarily localised in the subarachnoid space and ventricular system, i.e. bacterial meningitis and ventriculitis, or may involve the parenchyma of the brain itself leading to the formation of a cerebral abscess. On rare occasions, infections may cause subdural abscesses or involve the epidural spaces with secondary spread to the subarachnoid space or to the parenchyma of the brain. Bacterial infections may spread to the brain and spinal cord either by haematogenous routes or by direct spread from surrounding tissue. Thus bacterial meningitis or cerebral abscess may occur as complications of head injury when fractures at the base of the skull perforate the meninges or even perforate the brain itself. Furthermore, infection in the bones of the skull, as in chronic otitis media or chronic petrositis may lead to secondary invasion of the brain. Infection may also spread to the subarachnoid space from a primary site of infection in the paranasal air sinuses. In some cases, bacterial infections of the CNS are a complication of malignant disease in which erosion of the bones of the skull or spine has occurred; the infection thus enters the brain through a break in the meninges.

Developmental and Neonatal Neuropathology

The morphological expression of abnormalities of development in the CNS is varied. The abnormality may be anatomical, i.e. structural, presenting as a developmental malformation or biochemical, presenting as a functional abnormality without structural change. Abnormal fetal development may thus result in a non-viable conceptus, leading to spontaneous abortion or stillbirth, to a dysraphic state, or to motor and behavioural retardation without specific clinical features. The viability of a conception depends on the nature and severity of the defect in the CNS and of any associated defects. Abnormalities of development of the CNS may be associated with defects in other organ systems. Gross defects result in spontaneous abortion, but some less severe anomalies may not become evident until late infancy or even adult life.

Hereditary and System Disorders of the Nervous System

The hereditary system disorders of the nervous system form a large group of diseases in which the characteristic feature is degeneration of one or more systems of neurons, and of their interconnecting projections. In some the pathogenesis is relatively well understood, for example subacute combined degeneration of the spinal cord, but in others, for example motor neuron disease, the cause is obscure. The term ‘system degeneration’, which is often used to describe these degenerative disorders, indicates that certain functional groups of neurons and their axons are selectively affected, resulting in clearly recognisable patterns of abnormality.

The Interpretation of Neurological Symptoms and Signs

The clinical diagnosis of neurological disease requires a particularly detailed analysis of patients’ symptoms. This is partly because the nervous system is a communications system with direct access to consciousness, so that the patient is in a unique position to monitor his own disorder. Clinical diagnosis becomes very difficult in the presence of dysphasia, confusion or dementia. Another reason is that useful biochemical and histological information about the function of neurons is rarely available, in contrast to the wealth of data used in the assessment of diseases of other organs, such as the lungs, liver or kidneys. The failure of neurons in the CNS to regenerate means that delay in making a precise diagnosis can worsen the eventual outcome; the clinician often cannot afford to watch how an illness progresses before intervening.

Inborn Lysosomal Storage Disorders Affecting the Nervous System

Lysosomes are membrane-bound cytoplasmic bodies involved in the degradation of material or debris resulting from autolysis, phagocytosis or other metabolic processes. They contain numerous degradative enzymes which are most active in an acid environment such as that found within the lysosome. Lysosomal enzymes are classified according to their functions; for instance, glycosidases remove specific sugar residues from complex carbohydrates or glycolipids, cathepsins (proteinases) degrade protein and the sulphatases remove ester sulphate groups which are covalently linked to organic residues (e.g. sugars).