Introduction to Traumatic Brain Injury

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Introduction to Traumatic Brain Injury

• Joe Rosenthal, MD
• Clinical Assistant Professor
• TBI Fellow
• 11/1/10

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Objectives

• Definition
• Epidemiology
• Severity of injury
• Mechanisms/Types of Brain Injury
• Symptoms/Treatment
• Return to work and driving

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Definition

• Nondegenerative, noncongenital insult to the
  brain from an external mechanical force, possibly
  leading to permanent or temporary impairments of
  cognitive, physical, and psychosocial functions
  with an associated diminished or altered state of
  consciousness

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www.cdc.gov/features/dsTBI_BrainInjury/
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National Center for Injury Prevention and Control
at the Center for Disease Control
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Survival in the USA

• Mild (80 of all TBIs)
• 100 (nearly) survive
• Moderate (10 of all TBIs)
• 93 survive
• Severe (10 of all TBIs)
• 42 survive

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Risk Factors

• Young (15-24 year olds Highest Risk)
• Low income
• Unmarried
• Minority
• Inner city
• Male (2x more likely)
• Substance abuse
• Previous TBI

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Common Causes in the United States

• 1 MVA
• 50
• 2.41 Male
• 2 Falls
• 20-30 (most common gt 75 yo)
• 3 Firearms
• 12 (age 25-34)
• 61 Male

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What is the Most Common INDIRECT Cause of TBI?
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Most Common INDIRECT Cause

• ALCOHOL

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TBI Spectrum
Mild/Concussion
Moderate
Severe
Death
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Determining Severity

• Loss of Consciousness Duration
• Post Traumatic Amnesia Confusion
• Wounds, Bruising, Swelling
• Tools
• Glascow Coma Scale (GCS)
• Radiographic Imaging

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Mild TBI

• Traumatically induced physiologic disruption of
  brain function, as manifested by one of the
  following
• LOC up to 30 minutes
• Anterograde or retrograde amnesia not greater
  than 24 hours
• Altered mental status
• Focal neurologic deficits
• Headaches, nausea, wooziness, etc.

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Other Mild TBI Criteria

• GCS 13-15
• No Head CT abnormalities
• Hospital stay lt 48 hrs
• No operative lesions

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Complicated Mild TBI

• Mild TBI with small amount of bleed, bruising,
  swelling, or skull fracture seen on imaging
• Higher risk of more chronic symptoms

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Moderate TBI

• GCS 9-12
• PTAgt24hrs
• Coma duration 20 minutes to 6 hours
• Abnormalities on CT
• Operative intracranial lesion
• Hospital stay at least 48 hrs

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Severe TBI

• GCS 3-8
• Coma duration 6 hours

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Why is the Brain so Vulnerable?
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Brain Injury Types

• Contusion
• DAI
• Penetrating Injuries
• Intracranial Hemorrhage
• Secondary Injuries (including Hypoxia)

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Contusion

• Low velocity impact
• Often symmetric (coup-countercoup)
• Not responsible for coma
• Focal deficits
• Recovery dependent on size and location
• Occasionally require resection

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Injury Not Always Just atImpact Site
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Diffuse Axonal Impact

• High velocity impact
• Almost always has some time of unconsciousness
• Diffuse pattern of deficits
• Recovery gradual

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Diffuse Axonal Injury

• Widespread stretching of axons
• Rotation on axis
• Acceleration-deceleration
• Mild force - external
• Severe force - internal
• Often imaging is normal

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http//braininjury.blogs.com/photos/uncategorized/
closedheadinjury.jpg
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Penetrating Injuries

• Missile (Gun shot wound)
• Non-missile (ice pick)
• Only primary mechanism on the rise

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Penetrating Injuries

• GSW
• Damage along track of bullet and embedded bone
  fragments
• Usually lead to focal deficits
• Energy ½ mass x velocity squared
• High velocity missiles cause most damage

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Intracranial Hemorrhage

• Epidural Hematoma
• Impact loading with laceration of dural arteries
• Often with fracture of temporal bone and tear of
  middle meningeal artery.
• RAPID neurologic deterioration

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Intracranial Hemorrhage

• Subdural Hematoma
• Injury to cortical bridging veins most common
• Slow collection of blood
• Lucid interval
• Actress Natasha Richardson
• High mortality rate
• Often need evacuation

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Intracranial Hemorrhage

• Intraparenchymal hemorrhage
• Cerebral parenchyma
• Injury to deeper, larger cerebral vessels
• Different mechanism and often more diffuse
  deficits compared to CVA bleed

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Intraventricular Hemorrhage

• Occur with very severe TBI
• Unfavorable prognosis due to severity of injury

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Anoxic/Hypoxic Brain Injury

• Caused by lack of oxygen to brain
• Most common cause Cardiac Arrest
• Other causes near drowning, infection,
  respiratory arrest, choking, Carbon Monoxide
  poisoning, etc.

Wijdicks EFM, Campeau NG, Miller GM (2001)
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Secondary Injuries

• CNS
• Brain swelling (Inc ICP)
• Hemorrhage/Hematoma
• Brain herniation
• Seizures
• Hydrocephalus
• Ischemia
• Infection

• Systemic
• Hypoxia/Anoxia
• Hypotension
• Anemia
• Hyperthermia
• Hyper/hypocarbia
• Fluid imbalance
• Sepsis

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Journey to Recovery
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Immediate Treatment

• Observation alertness, confusion, Headache,
  nausea, etc.
• Blood Pressure other vitals monitoring
• Imaging
• Surgery
• Intracranial Pressure Monitoring

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Traumatic Brain Injury Sequela

• Agitation
• Mood Disorder
• Sleep Disturbance
• Motor Dysfunction
• Cognitive Deficits
• Headaches
• Decreased Arousal
• Bowel Bladder Dysfunction
• Pain Syndromes
• Seizures
• Denial of Disability

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Amnesia
http//braininjuryrx.com/2009/06/misconceptions-ma
de-by-nursing-students-about-amnesia-in-tbi/
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Posttraumatic AmnesiaDefinitions

• period of impaired consciousness after brain
  injury
• ending at the time the patient can give a
  clear, consecutive account of what is happening
  around them
• absence of continuous memory or inability to
  retain new information
• broader syndrome of disorientation, confusion,
  diminished memory, reduced capabilities to attend
  to and respond to environmental issues

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Post- Traumatic Headaches

• Very common, especially after Mild-Mod TBI
• Different Types
• Migraine
• Tension
• Related to Neck injury/pain
• Treatment
• Time
• Medications

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Sleep Disorders

• Trouble Falling Asleep
• Common after TBI
• Often treated with good sleep hygiene and/or meds
• Trouble Staying Awake
• Decreased arousal during the day
• Tx good sleep hygiene, medications
• Nightmares
• Associated with PTSD

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Cognitive Changes
http//www.braybray.co.uk/cms/photo/misc/head_inju
ries.gif
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Other Cognitive Deficits

• Short Term and Working Memory Problems
• Decreased Attention
• Cognitive Fatigue
• Problem Solving difficulties

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Emotional/Personality Changes

• Depression
• Anxiety
• Irritability
• Anger/Aggression
• Obsessive/Compulsive
• Often pre-injury psychiatric conditions are
  exacerbated after injury

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Incidence of Anxiety and Depression
afterTraumatic Brain injury

• Depression 61
• Anxiety 17
• Anxiety and depression 60

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Frequent Complaints with TBI related Depression

• Frustration 81
• Restlessness 73
• Boredom 66
• Sadness 66

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Treatment

• For the most part, same as non-injured pts
• Counseling
• Anti-depressants
• Other medications
• Monitor for other conditions that can cause
  Depression (i.e. low thyroid)

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Movement Disorders

• Weakness
• Spasticity
• Abnormal movements
• Difficulty coordinating movements

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Visual Deficits

• Blurry Vision
• Double Vision
• Trouble opening and closing eyelids
• Blindness

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Dizziness Vertigo

• Inner ear damage -- ringing in ears
• Lightheadedness from blood pressure problems
• Injury directly to brain resulting in these
  symptoms
• Tx

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Other Senses

• Taste change
• Loss of smell
• Numbness/tingling

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Post Concussive Syndrome

• Persistent, chronic symptoms after the expected
  time of recovery
• -Headache, dizziness, fatigue, irritability,
  sleep disturbance, mood changes, etc.
• Controversial
• -Definition
• -Timing (1 month vs 3 months)
• - of symptoms

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RehabilitationMulti-Disciplinary Approach

• Physicians
• Medication
• Monitoring labs
• Managing therapies
• Clearance for return to work/drive
• Nursing (in-patient)
• Bowel and bladder
• Wound Care
• Family education

• Therapists
• PT/OT/ST/Rec Therapy
• Community re-entry, assist with return to
  work/driving
• Neuropsychologist
• Testing
• Counseling
• FAMILY/FRIENDS

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Return To Work

• Dependent on multiple factors
• Severity of injury
• Cognitive functioning
• Type of job
• Symptoms
• Physical limitations

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Return to Work

• Tools to assess readiness
• Physician visits
• Therapy reports
• Neuropsychological testing

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Epidemiology of Traumatic Brain Injuryin the
United StatesReturn to Work

• mild 90-100
• moderate poor data
• severe 10-25

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Return to WorkPossible Accommodations

• New position (less demanding, safer)
• Frequent rest breaks
• Return Part Time
• Work Conditioning/Hardening with therapy
• Vocational Training (BVR)
• Memory Aids

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Return to Driving

• Again, dependent on multiple factors
• Severity of injury
• Cognitive functioning
• Symptoms
• Physical limitations
• Seizures
• Tools to assess readiness
• Therapy results
• Vision evaluation
• Drivers Evaluation

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Questions
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References

• Brain injury medicine. Principles and Practice.
  2007.
• Physical medicine and rehabilitation Principles
  and practice. Fourth edition.2005.
• Physical medicine and rehabilitation board
  review. 2004.
• Pharmacologic enhancement of cognitive and
  behavioral deficits after traumatic brain injury.
  Olli Tenovuo. Current Opinion in Neurology
  2006, 19528-533.
• High-Yield Neuroanatomy. Second Edition. 2000
• Traumatic brain injury diagnosis and outcome. W.
  Jerry Mysiw, M.D.
• eMedicine Traumatic brain injury Definition,
  epidemiology, pathophysiology. http//www.emedicin
  e.com/pmr/topic212.htm
• Sleep disturbances following Traumatic Brain
  Injury. Rao V Rollings P. Current Treatment
  Options in Neurology. 2002, 477-87.

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