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Introduction to Traumatic
Brain Injury
Joe Rosenthal, MD
Clinical Assistant Professor
TBI Fellow
11/1/10
Objectives
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Definition
Epidemiology
Severity of injury
Mechanisms/Types of Brain Injury
Symptoms/Treatment
Return to work and driving
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
www.cdc.gov/features/dsTBI_BrainInjury/
National Center for Injury Prevention and Control at the Center for Disease Control
Survival in the USA
• Mild (80% of all TBI’s)
– 100% (nearly) survive
• Moderate (10% of all TBI’s)
– 93% survive
• Severe (10% of all TBI’s)
– 42% survive
Risk Factors
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Young (15-24 year olds – Highest Risk)
Low income
Unmarried
Minority
Inner city
Male (2x more likely)
Substance abuse
Previous TBI
Common Causes in the United
States
• #1 MVA
– 50%
– 2.4:1 Male
• #2 Falls
– 20-30% (most common > 75 yo)
• #3 Firearms
– 12% (age 25-34)
– 6:1 Male
What is the Most Common
INDIRECT Cause of TBI?
Most Common INDIRECT Cause
ALCOHOL
TBI Spectrum
Mild/Concussion
Moderate
Severe
Death
Determining Severity
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Loss of Consciousness Duration
Post Traumatic Amnesia & Confusion
Wounds, Bruising, Swelling
Tools:
– Glascow Coma Scale (GCS)
– Radiographic Imaging
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.
Other Mild TBI Criteria
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GCS 13-15
No Head CT abnormalities
Hospital stay < 48 hrs
No operative lesions
Complicated Mild TBI
• Mild TBI with small amount of bleed,
bruising, swelling, or skull fracture seen on
imaging
• Higher risk of more chronic symptoms
Moderate TBI
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GCS 9-12
PTA>24hrs
Coma duration 20 minutes to 6 hours
Abnormalities on CT
Operative intracranial lesion
Hospital stay at least 48 hrs
Severe TBI
• GCS 3-8
• Coma duration 6+ hours
Why is the Brain so
Vulnerable?
Brain Injury Types
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Contusion
DAI
Penetrating Injuries
Intracranial Hemorrhage
Secondary Injuries (including Hypoxia)
Contusion
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Low velocity impact
Often symmetric (coup-countercoup)
Not responsible for coma
Focal deficits
Recovery dependent on size and location
Occasionally require resection
Injury Not Always Just at
Impact Site
Diffuse Axonal Impact
• High velocity impact
• Almost always has some time of
unconsciousness
• Diffuse pattern of deficits
• Recovery gradual
Diffuse Axonal Injury
• Widespread stretching of axons
– Rotation on axis
– Acceleration-deceleration
• Mild force - external
• Severe force - internal
• Often imaging is normal
http://braininjury.blogs.com/photos/uncategorized/closedheadinjury.jpg
Penetrating Injuries
• Missile (Gun shot wound)
• Non-missile (ice pick)
• Only primary mechanism on the rise
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
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
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
Intracranial Hemorrhage
• Intraparenchymal hemorrhage
– Cerebral parenchyma
– Injury to deeper, larger cerebral vessels
– Different mechanism and often more diffuse
deficits compared to CVA bleed
Intraventricular Hemorrhage
– Occur with very severe TBI
– Unfavorable prognosis due to severity of
injury
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)
Secondary Injuries
• Systemic
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Hypoxia/Anoxia
Hypotension
Anemia
Hyperthermia
Hyper/hypocarbia
Fluid imbalance
Sepsis
• CNS
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Brain swelling (Inc ICP)
Hemorrhage/Hematoma
Brain herniation
Seizures
Hydrocephalus
Ischemia
Infection
Journey to Recovery
Immediate Treatment
• Observation – alertness, confusion,
Headache, nausea, etc.
• Blood Pressure & other vitals monitoring
• Imaging
• Surgery
• Intracranial Pressure Monitoring
Traumatic Brain Injury Sequela
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Agitation
Mood Disorder
Sleep Disturbance
Motor Dysfunction
Cognitive Deficits
Headaches
Decreased Arousal
Bowel & Bladder Dysfunction
Pain Syndromes
Seizures
Denial of Disability
Amnesia
http://braininjuryrx.com/2009/06/misconceptions-made-by-nursing-students-about-amnesia-in-tbi/
Posttraumatic Amnesia
Definitions
• 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
Post- Traumatic Headaches
• Very common, especially after Mild-Mod TBI
• Different Types:
– Migraine
– Tension
– Related to Neck injury/pain
• Treatment
– Time
– Medications
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
Cognitive Changes
http://www.braybray.co.uk/cms/photo/misc/head_injuries.gif
Other Cognitive Deficits
• Short Term and Working Memory
Problems
• Decreased Attention
• Cognitive Fatigue
• Problem Solving difficulties
Emotional/Personality Changes
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Depression
Anxiety
Irritability
Anger/Aggression
Obsessive/Compulsive
• Often pre-injury psychiatric conditions are
exacerbated after injury
Incidence of Anxiety and
Depression after
Traumatic Brain injury
• Depression
• Anxiety
• Anxiety and depression
61%
17%
60%
Frequent Complaints with TBI
related Depression
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Frustration
Restlessness
Boredom
Sadness
81%
73%
66%
66%
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)
Movement Disorders
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Weakness
Spasticity
Abnormal movements
Difficulty coordinating movements
Visual Deficits
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Blurry Vision
Double Vision
Trouble opening and closing eyelids
Blindness
Dizziness & Vertigo
• Inner ear damage -- ringing in ears
• Lightheadedness from blood pressure
problems
• Injury directly to brain resulting in these
symptoms
• Tx
Other Senses
• Taste change
• Loss of smell
• Numbness/tingling
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
Rehabilitation
Multi-Disciplinary Approach
• Physicians
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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
Return To Work
• Dependent on multiple factors
– Severity of injury
– Cognitive functioning
– Type of job
– Symptoms
– Physical limitations
Return to Work
• Tools to assess readiness
– Physician visits
– Therapy reports
– Neuropsychological testing
Epidemiology of Traumatic Brain Injury
in the United States
Return to Work
• mild
• moderate
• severe
90-100%
poor data
10-25%
Return to Work
Possible Accommodations
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New position (less demanding, safer)
Frequent rest breaks
Return Part Time
Work Conditioning/Hardening with therapy
Vocational Training (BVR)
Memory Aids
Return to Driving
• Again, dependent on multiple factors
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Severity of injury
Cognitive functioning
Symptoms
Physical limitations
Seizures
• Tools to assess readiness
– Therapy results
– Vision evaluation
– Driver’s Evaluation
Questions
References
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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,
19:528-533.
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.emedicine.com/pmr/topic212.htm
Sleep disturbances following Traumatic Brain Injury. Rao V & Rollings P.
Current Treatment Options in Neurology. 2002, 4:77-87.