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Neurological Examination
Nerve Damage
Toolkits > Istanbul Protocol Model Medical Curriculum > Module 5: Physical Evidence of Torture and Ill-Treatment > Neurological Examination > Head Trauma and Post-traumatic Epilepsy

Head Trauma and Post-traumatic Epilepsy

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Head trauma is among the most common forms of torture. Even repeated minor head trauma can cause permanent damage to brain tissues. This can in turn cause permanent physical handicap. Lacerations and abrasions of the head and their late consequences should be documented as above. Scalp bruises are frequently not visible externally acutely unless there is swelling. Bruises also may be difficult to see in dark skinned individuals, but will be tender to palpation.

Survivors of torture often report that they were unconscious at times, but it is impossible for them to know what happened unless they were with a reliable witness. It is necessary to try to differentiate between loss of consciousness following blows to the head, post-traumatic epilepsy (see below), asphyxiation, pain and exhaustion, or any combination of these.

Many victims of torture have suffered blows to the head, and many complain of persistent or recurrent headaches, whether or not they have sustained any head injury. Generally the headaches are psychosomatic or due to tension headache. In some cases with a history of repeated blows to the head, it is possible to feel areas of hyperaesthesia (extreme sensitivity of neurological sensation) and some thickening of the scalp from scar tissue.

Headache may also be the initial symptom of an expanding subdural haematoma. There may be associated psychological changes of acute onset, and a CT scan or MRI must be arranged urgently, if one is available. It may also be appropriate to arrange psychological or neuropsychological assessment. Soft tissue swelling and/or haemorrhage will usually be detected with CT or MRI. In cases of trauma caused by falls, contracoup lesions (on the opposite side to the point of impact) of the brain may be observed on investigation, whereas following direct trauma, the main damage to the brain may be seen directly under the point of impact.

Violent shaking of the upper body has been reported as a form of torture (as it has as a form of child abuse). Survivors complain of severe headaches and persistent changes in cognitive function. In these cases no injuries are visible. Shaking can lead to death due to cerebral oedema and subdural bleeding. Retinal haemorrhages have been noted on post-mortem examination and, when seen in children, are very suggestive of shaking injuries.

Immediately after severe head injury there may be concussive convulsions, but these do not necessarily lead to epilepsy. Convulsions (or seizures) in the first week or so after a severe head injury tend to be tonic-clonic. They may recur for a year or more, but are not generally lifelong. Severe head injuries leading to brain lesions, specifically in the temporal lobe, can cause convulsions that start months or years after the incident. The latter are complex partial seizures.

Typically (>90% of cases), complex partial seizures start with an aura (a strange feeling that precedes the convulsion). This is followed by an absence that can last up to two minutes. Concurrent automatic movements, particularly lip smacking have been reported. After these episodes there is usually a period of a few minutes of disorientation. Often the aura is described as a strange feeling in the stomach, but it may involve bizarre smells or tastes. These must be differentiated from the re-experiencing phenomena of PTSD where the person is always capable of being roused and never completely loses consciousness.

In most countries the prevalence of epilepsy in the population is 2%. About 65% of epilepsy is due to complex partial seizures. The cause of complex partial seizures is unknown in 45% of cases. Traumatic events including birth events account for 3% of it. The likelihood of acquiring epilepsy after a head injury depends on the severity of the injury (see table).

Degree of head injury Loss of consciousness Relative risk of epilepsy Duration of increased risk
Minor < 30 minutes 1.5 5 years
Moderate < 24 hours 2.9 (three times) —
Severe > 24 hours 17.2 (17 times) 20 years

Survivors of torture rarely have an accurate account of their head injuries, and unless they have an external reference, they cannot know for certain how long they were unconscious. One problem with attributing epilepsy to head trauma is that there is rarely any information about the individual’s neurological state prior to the incident.

Neurological Examination
Nerve Damage
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  • Istanbul Protocol Model Medical Curriculum

    • Preface
      • Copyright and Acknowledgements
      • Resources
      • Glossary
    • Introduction
      • Curriculum Materials
      • Summary of Content
      • How to Use These Educational Resources
    • Module 1: International Legal Standards (Overview)
      • Torture
        • What is Torture
        • Purpose of Torture
        • History of Torture
        • Other Definitions
        • Cruel Inhuman & Degrading Treatment & Punishment (CID)
        • Prohibition of Torture in International Law
        • The United Nations Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment 1984
        • Torture in the World Today
        • Country-Specific Legal Standards and Torture Practices
        • The Perpetrators
        • Common Situations for Torture Allegations
        • Where Does Torture and Ill-treatment Occur?
        • Obligation to Investigate and Bring Justice
        • Formal Inspection of Detention Facilities
        • Official Complaints to Human Rights Bodies and Other Organizations
        • Recently Released Detainees
        • NGO Information Gathering
        • Late Allegations
      • Prevention and Accountability
        • Prevention
        • Accountability
        • Reparation
      • International Supervisory Machinery and Complaints Procedures
        • The Human Rights Committee
        • The UN Committee against Torture
        • Regional Mechanisms
        • Other monitoring mechanisms
        • The UN Special Rapporteur on Torture and other Cruel, Inhuman and Degrading Treatment or Punishment
        • International criminal courts and tribunals
        • The International Committee of the Red Cross (ICRC)
      • Safeguards Against Torture for Those Deprived of Their Liberty
        • Notifying people of their rights
        • Use of officially recognized places of detention and the maintenance of effective custody records
        • Avoiding incommunicado detention
        • Humane conditions of detention
        • Limits on interrogation
        • Access to a lawyer and respect for the functions of a lawyer
        • Access to a doctor
        • The right to challenge the lawfulness of detention
        • Safeguards for special categories of detainees
      • Module 1 Presentation: International Legal Standards
      • Self-Assessment and Quiz
        • Module 1 Answers
    • Module 2: Istanbul Protocol Standards for Medical Documentation of Torture and Medical Ethics
      • The Istanbul Protocol
        • About the Istanbul Protocol
        • Brief History
        • International Recognition of the Istanbul Protocol
      • An Overview of the Istanbul Protocol
        • Legal Investigation of Torture
        • General Considerations for Interviews
        • Physical Evidence of Torture
        • Psychological Evidence of Torture
        • Interpretation of Findings and Referrals
        • Misuse of the Istanbul Protocol
        • Procedural Safeguards for Detainees
      • Medical Ethics
        • Introduction
        • Duties of the health professional
        • International Codes
        • Ethical rules directly prohibiting involvement in torture
        • Primary loyalty to the patient
        • Dual Obligations
        • The treatment of prisoners and detainees
        • Issues surrounding examinations of individuals in the presence of security forces
        • Abusive medical treatment
        • Consent and confidentiality
        • Security
        • Involvement of other health professionals in torture
        • Seeking further information and support
        • Country-specific legal responsibilities of health professionals for forensic documentation of torture and ill-treatment
      • General Guidelines for Gathering Evidence and Documenting Findings
        • The aims and goals of investigation
        • Multidisciplinary approach to documentation
        • Role of the health professional in the team
        • Role of the lawyer in the team
        • Role of the NGO member in the team
        • Role of judges and prosecutors
      • Documenting the allegations
        • The aim of medical documentation
        • Types of evidence
        • Medical evidence
        • Gathering of evidence
        • Essential information
        • Quality of information
        • Comparing records
      • Module 2 Presentation: Istanbul Protocol Standards for Medical Documentation of Torture and Medical Ethics
      • Self-Assessment and Quiz
        • Module 2 Answers
    • Module 3: Interview Considerations
      • Preliminary Considerations
        • Purpose of Medical Evaluations
        • Interview Settings
        • Trust
        • Informed Consent
        • Confidentiality
        • Privacy
        • Empathy
        • Objectivity
        • Safety and Security
        • Procedural Safeguards for Detainees
        • Risk of Re-traumatisation
        • Gender Considerations
        • Interviewing Children
        • Cultural and Religious Awareness
        • Working with Interpreters
        • Transference and Counter-Transference Reactions
      • Conducting Interviews
        • Types of questions
        • Cognitive Techniques
        • Summarising and clarifying
        • Difficulties Recalling and Recounting
        • Assessing Inconsistencies
      • Interview Content
        • Identification and Introduction
        • Psychosocial History (Pre-Arrest)
        • Past Medical History
        • Summary of Detention(s) and Abuse
        • Circumstances of Detention(s)
        • Prison/Detention Place Conditions
        • Allegations of Torture and Ill-treatment
        • Review of Symptoms
        • Psychosocial History (post-arrest)
        • Assessments of Physical and Psychological Evidence
        • Physical Examination
        • Closing
        • Indications for Referral
      • Module 3 Presentation: Interview Considerations
      • Self-Assessment and Quiz
        • Module 3 Answers
    • Module 4: Torture Methods and their Medical Consequences
      • Introduction
      • Torture Methods
        • Beatings/Falanga
        • Ear Trauma
        • Eye Trauma
        • Restraint, Shackling and Positional Torture
        • Suspension
        • Crushing and Stretching Injuries
        • Burning
        • Electrical injuries
        • Asphyxiation
        • Violent Shaking
        • Sexual Assault
        • Sexual Humiliation
        • Prolonged Isolation and Sensory Deprivation
        • Sleep Deprivation
        • Temperature Manipulation
        • Sensory Bombardment
        • Threats of Harm
      • Psychological Consequences of Torture
        • Introduction
        • The Paradox of Psychological Consequences of Torture
        • The Psychological Consequences of Torture
        • Social, Political and Cultural Context
        • Risk factors for Trauma and Torture-Related Disorders
        • Psychological Symptoms
      • Module 4 Presentation: Torture Methods and their Medical Consequences
      • Self-Assessment and Quiz
        • Module 4 Answers
    • Module 5: Physical Evidence of Torture and Ill-Treatment
      • Physical Evidence of Torture
        • Medical history
      • The Physical Examination
        • Dermatologic Evaluation
        • Head and Neck
        • Chest and Abdomen
        • Musculoskeletal System
      • Neurological Examination
        • Head Trauma and Post-traumatic Epilepsy
        • Nerve Damage
      • Examination of Women
        • Examination Following a Recent Assault
        • Examination After the Immediate Phase
        • Follow-up
        • Genital Examination of Women
      • Genital Examination of Men
      • Perianal Examination
      • Medical Photography
        • Assessment for Referral
      • Diagnostic Tests
      • Module 5 Presentation: Physical Evidence of Torture and Ill-Treatment
      • Self-Assessment and Quiz
        • Module 5 Answers
    • Module 6: Psychological Evidence of Torture and Ill-Treatment
      • The Central Role of the Psychological Evaluation
        • Conducting the Psychological Evaluation
        • Psychological Findings and Diagnostic Considerations
        • Components of the Psychological/Psychiatric Evaluation
      • Children and Torture
        • Introduction
        • Developmental Considerations
        • Clinical Considerations
        • Role of the Family
      • Apendix I: Sample Psychological Evaluations
        • Psychological Evaluation #1
        • Psychological Evaluation #2
      • Apendix II: ICD-10
      • Module 6 Presentation: Psychological Evidence of Torture and Ill-Treatment
      • Self-Assessment and Quiz
        • Module 6 Answers
    • Module 7: Case Example #01
      • Introduction
      • Preliminary Considerations
      • Materials
      • Module 7 Presentation: Case Example #01
      • Self-Assessment and Quiz
        • Module 7 Answers
    • Module 8: Case Example #02
      • Introduction
      • Preliminary Considerations
      • Materials
      • Module 8 Presentation: Case Example #02
      • Self-Assessment and Quiz
        • Module 8 Answers
    • Module 9: Report Writing and Testifying in Court
      • Written Reports
        • General Considerations
        • Content of Written Reports
        • Conclusions
        • Inconsistencies
      • Providing Testimony in Court
      • Appendix: Court Testimony Guidelines and Maxims
      • Module 9 Presentation: Report Writing and Testifying in Court
      • Self-Assessment and Quiz
        • Module 9 Answers
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