Traumatic Brain Injury

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Traumatic Brain Injury

• Galen V. Henderson, M.D.
• Brigham and Womens Hospital
• Harvard Medical School

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Outline

• Epidemiology
• Concussion
• Types of hemorrhages with TBI
• Treatment of intracranial HTN
• Penetrating injuries
• Surgical decompression
• Intracranial monitoring vs. neuro exam and
  cerebraling

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TBI in the United States
At least 1.7 million TBIs occur in the United
States each year.
52,000 Deaths
275,000 Hospitalizations
1,365,000 Emergency Department Visits
??? Receiving Other Medical Care or No Care
Average annual numbers, 1995-2001
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Causes of Death in US, 2012
(37/100,000)
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Causes of Death in US, 2012
Age gt 65 Accidents are 9 cause of death rate
94.5/100,000
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Classification of Head (Brain) Injury

• Minimal
• GCS 15
• Mild
• GCS 14-15
• Moderate
• GCS 9-13
• Severe
• GCS lt 8

• Glasgow Coma Scale
• Best Motor Response
• Obeys 6
• Localizes pain 5
• Flexion withdrawal 4
• Flexion abnormal (decorticate rigidity) 3
• Extension (decerebrate rigidity) 2
• No response 1
• Best Verbal Response
• Oriented and converses 5
• Disoriented and converses 4
• Inappropriate words 3
• Incomprehensible sounds 2
• No response 1
• Eye Opening
• Spontaneously 4
• To verbal stimuli 3
• To pain 2
• Never 1

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Concussion

• Immediate and transient loss of consciousness
  accompanied by a brief period of amnesia after a
  blow to the head.
• 128/100,000 population in the US
• The clinical status of the momentary sensation of
  being "starstruck," or dazed, after head injury
  without a brief period of loss of consciousness
  is uncertain, but it is generally considered the
  mildest form of concussion.
• Young children have the highest rates.
• Sports and bicycle accidents account for the
  majority of cases among 5- to 14-year-olds
• Falls and vehicular accidents are the most common
  causes of concussion in adults.

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Mechanism of Concussion
Ropper A, Gorson K. N Engl J Med 2007356166-172
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Symptoms of post-concussive syndrome

• Somatic Symptoms
• Persistent low
• grade headache
• Dizziness
• Vertigo
• Fatigability
• Insomnia
• Nausea/vomiting

• Mood
• Anxiety
• Depression
• Irritability

• Cognitive Deficits
• Slow thinking
• Poor attention and
• concentration
• Impaired memory

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fMRI and symptom severity
Chen JK, Johnston KM, Collie A, McCrory P, Ptito
A. J Neurol Neurosurg Psychiatry  2007 78(11)
1231-1238.
Control
Low PCS
Moderate PCS
High PCS
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Spectrum of Pathologic Features and Outcomes of
Traumatic Brain Injury
DeKosky ST et al. N Engl J Med 20103631293-1296.
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Epidural Hemorrhage

• Occurs in about 3 of head injuries
• Acute presentation 40 have lucid interval with
  delayed (hrs) LOC
• 90 have skull fx 85 of these are temporal
• Children get EDHs without fx
• Elderly rarely get EDHs dura firmly adherent
• Amount of blood seen in fatal EDHs is 100-150ml

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• Source of blood
• Torn meningeal vessels
• Torn dural sinus
• Diploic veins
• Marrow sinusoids

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Epidural Hemorrhage

• Hyperdense Bi-Concave
• Limited by sutures (unless fracture crossed
  suture line)

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Subdural Hemorrhage

• Acute to subacute presentation
• Associated with severe trauma (except in elderly
  and especially those with coagulopathy)
• Associated with non-traumatic events
  (hypertensive hemorrhage or ruptured AVM with
  SAH/SDH
• Source of blood
• Torn bridging veins
• Laceration of cortical vessels
• Expanding contusion hematoma

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Acute SDH

• 50 associated with a skull fx (not always at
  site of SDH)
• Most lethal form of SDH 40-60 mortality rate
• Frequently associated with other forms of injury
  (DAI, contusions etc.)

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Acute SDH

• Amount of blood which is significant depends on
  pt age and rate of accumulation
• Infants few mls
• Toddlers 30-50 ml
• Children and adults 150-200 ml

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Subarachnoid Hemorrhage

• Traumatic
• Most common cause
• Seen in almost any significant injury (/-
  impact)
• In areas of contusions, lacerations, penetrating
  injuries
• Under SDHs where traction on bridging veins tears
  arachnoid vessels
• Non-traumatic
• Ruptured aneurysm/vascular malformation
• Torn/dissection of vertebral artery

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Acceleration/Deceleration

• Brain
• SDH
• Diffuse vascular injury
• Traumatic axonal injury
• Contusional Tears
• Eye
• Retinal hemorrhages, Optic nerve sheath
  hemorrhage
• Spine
• Stretching

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Gunshot Wounds

• Damage is dependent on energy of missile which is
  dependent on the velocity
• Tissue damage
• Permanent track of bullet
• Temporary cavity which follows bullet
• Low-velocity bullet 4-5 x bullet size
• Hi-velocity bullet up to 15 times bullet size
• Secondary missiles (bone fragments)

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Gunshot Wounds

• Low Velocity Bullets (most civilian handguns)
• Most often do not exit skull
• Ricochet off inner table to form secondary track
• Exhaust energy and come to rest in brain
• High Velocity Bullets or Shotgun at close/contact
  range
• Most often exit skull producing massive fractures
• Large temporary cavity
• Often thrusts much of brain out of head

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DONT FORGET TO PROTECT THE C-SPINE !!

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Liver lacerations
Hemopericardium
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FACTORS CAUSING SECONDARY BRAIN INJURY

• THE 4 Hs
• HYPERCAPNEA
• HYPOXIA ( PaO2 lt 60 mmHg SpO2 lt 90)
• SYSTEMIC HYPOTENSION ( lt 90 mmHg )
• INTRACRANIAL HYPERTENSION

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OTHER FACTORS CAUSING SECONDARY BRAIN INJURY

• ISCHEMIA
• VASOSPASM
• SEIZURES
• LOSS OF AUTOREGULATION

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Intracranial HTN Treatment Modalities

• Insert ICP monitor
• General goals Maintain ICP lt 20 mm Hg and CPP gt
  70 mm Hg
• For ICP gt 20-25 mm Hg for gt 5 minutes
• Drain CSF via ventriculostomy
• Elevate head of bed
• Osmotherapy
• Sedation, agitation and fever control
• Hyperventilation
• Pressor therapy to maintain MAP and ensure CPP
• For refractory intracranial HTN
• Phenobarbital/Hypothermia/Decompressive craniotomy

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Osmolality of IV fluids
Fluid Osmolality (mOsm/kg)
5 Dextrose 252
Lactated ringers 250-260
Plasma 285
5 Albumin 290
Normal Saline 0.9 308
25 Albumin 310
6 Hetastarch 310
2 Normal Saline 682
3 Normal Saline 1025
25 Mannitol 1375
7.5 Normal Saline 23.4 Normal Saline 2400 8008
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Surgical Treatment of Intracranial HTN
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Original Article Decompressive Craniectomy in
Diffuse Traumatic Brain Injury
D. James Cooper, M.D., Jeffrey V.
Rosenfeld, M.D., Lynnette Murray, B.App.Sci.,
Yaseen M. Arabi, M.D., Andrew R. Davies, M.B.,
B.S., Paul D'Urso, Ph.D., Thomas Kossmann, M.D.,
Jennie Ponsford, Ph.D., Ian Seppelt, M.B., B.S.,
Peter Reilly, M.D., Rory Wolfe, Ph.D., for the
DECRA Trial Investigators and the Australian and
New Zealand Intensive Care Society Clinical
Trials Group
N Engl J Med Volume 364(16)1493-1502 April 21,
2011
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Study Overview

• Patients with severe traumatic brain injury and
  refractory intracranial hypertension were
  randomly assigned to either decompressive
  craniectomy or standard care.
• Craniectomy was associated with a significant
  reduction in intracranial pressure but worse
  outcomes.

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Cooper DJ et al. N Engl J Med 20113641493-1502
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Cooper DJ et al. N Engl J Med 20113641493-1502
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Original Article A Trial of Intracranial-Pressure
Monitoring in Traumatic Brain Injury
Randall M. Chesnut, M.D., Nancy Temkin, Ph.D.,
Nancy Carney, Ph.D., Sureyya Dikmen, Ph.D.,
Carlos Rondina, M.D., Walter Videtta, M.D.,
Gustavo Petroni, M.D., Silvia Lujan, M.D., Jim
Pridgeon, M.H.A., Jason Barber, M.S., Joan
Machamer, M.A., Kelley Chaddock, B.A., Juanita M.
Celix, M.D., Marianna Cherner, Ph.D., and Terence
Hendrix, B.A.
N Engl J Med Volume 367(26)2471-2481 December
27, 2012
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Study Overview

• In this randomized trial involving 324 patients
  with severe traumatic brain injury in Bolivia and
  Ecuador, guideline-based management with
  intracranial pressure monitoring was not superior
  to management based on imaging and clinical
  assessments.

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Cumulative Survival Rate According to Study Group.
Chesnut RM et al. N Engl J Med 20123672471-2481
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ICP
CPP
Exam
MAP
TCD
EEG
Cellular Metabolism
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Summary

• Epidemiology
• Concussion
• Types of hemorrhages with TBI
• Treatment of intracranial HTN
• Penetrating injuries
• Surgical decompression
• Intracranial monitoring vs. neuro exam and
  cerebral imaging

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Thank You For Your Attention