Download Mild Traumatic Brain Injury

Mild Traumatic Brain Injury:
Issues Related to Evaluation and
Diagnosis
Traumatic Brain Injury
• Insult to the brain caused by an external physical
force
• Produces a diminished or altered state of
consciousness
▫ Dazed and confused
▫ Loss of consciousness
• Post traumatic amnesia (PTA) may be present
Mild/Concuss
Severity of
ion
LOC less then
30 minutes with
normal
imagining
Moderate
TBI
Severe
LOC greater
then 6 hours
with abnormal
imaging
GCS 13-15
LOC greater the
30 minutes, less
then six hours
with abnormal
imaging
GCS 9-12
PTA less then
24 hours
PTA less then 7
days
PTA greater
then 7days
GCS<9
TBI Prognosis
• Injury severity is the strongest predictor of
recovery
• Recovery after moderate and severe TBI may not
be as complete as recovery from mild TBI
• Pre and post injury medical and MH issues place
people at risk for poorer outcome
Acute Phase
• The development of post concussive
symptomology (PCS) is normal and expected
Alves et al., 1986)
• Initial symptom development is related to
organic and neuropathological processes
McCrea, 2008
• Symptoms develop within minutes to hours to
days after the injury
▫ Delayed symptom development is rare
Post Concussive Symptomology (PCS)
▫ Physical: Headache, dizziness, fatigue, noise/light
intolerance, insomnia, sleep disturbances,
tinnitus, balance and visual problems
▫ Cognitive: Memory complaints, poor
concentration
▫ Emotional: Depression, anxiety, irritability, mood
lability
Acute Phase
• Research suggests a period of metabolic dysfunction
within hours to days of injury
• Metabolic disarray explains resulting cognitive
impairment and post concussive symptomology
• mTBI subjects show an abnormal profile of cerebral
activation in response to cognitive demands
• fMRI shows decreased activation of select neuronal
circuits in the frontal lobes
• Effect is most evident in mTBI subjects with LOC
McCrea, et al., 2002
Acute Phase
• Cognitive and physical symptoms are most
common
• Emotional symptoms are difficult to link to
concussion verses other stressors in the combat
zone
• Anxiety, depression, combat stress, PTSD, grief
Recovery
• Recovery following mTBI/concussion is normal
and expected
• Research has repeatedly demonstrated that in
the civilian population, the vast majority of
individuals who sustain a concussion completely
recover in a matter of days to weeks.
▫ 80-90% recover in 7-10 days
▫ 3% experience persistent symptoms beyond one to
three months
Belanger et al., 2005; McCrea, 2008; Ivins et al., 2009
Cognitive Recovery After mTBI
McCrea et al., 2003
Symptom Recovery After mTBI
McCrea et al., 2003
Recovery
• Return to normal metabolic function is expected
within several days
• fMRI studies show no cerebral activation deficits
in the injured subjects after a few weeks
McCrea, et al., 2002
Recovery
• Recovery follows a progressive course
▫ Symptomology usually improves as time goes on;
symptoms usually do not get worse over time
▫ If they do, secondary etiologies should be considered
• Delayed symptom onset is rare
• Headache is the symptom that tends to linger
the longest and to be most problematic in terms
for clinical management
“Complicated” verses Uncomplicated
• “The unfortunate few”-approximately 3%
• mTBI with structure damage on imaging may
have a more complicated recovery course
▫ Outcome may be more consistent with moderate TBI
• Individuals with multiple mTBIs within a short
period of time are also at risk for more persistent
problems
Guskiewicz et al., 2003
Persistent symptoms
• Symptoms persisting beyond the expected
recovery course after mTBI are highly nonspecific to MTBI and are often attributable to
non-injury related factors Mittenberg, 1996; McCrea, 2008
• PCS-like symptoms are common in “normal”
people
Post Concussive Symptoms
Symptom
MTBI/PCS
General
Population
Poor Concentration
71%
14%
Irritability
66%
16%
Fatigue
64%
13%
Depression
63%
20%
Memory Problems
59%
20%
Headaches
59%
13%
Anxiety
58%
24%
Dizziness
52%
7%
Blurry vision
45%
8%
Light sensitivity
40%
14%
Mittenberg, 1996
Effect Size of mTBI on
Neuropsychological Functioning
Iverson, 2005
Effect Size of mTBI on
Memory Functioning
Iverson, 2005
Diagnosis Issues
• Two questions:
▫ Did the person have a concussion?
▫ Are their current symptoms related to their
history of concussion or better explained by other
etiologies?
• Just because a person has a history of
concussion does not mean that they have
current brain injury.
Question 1:
• Did the patient experience a concussion?
▫ This is the easy question
▫ Assess injury event
▫ Change in consciousness
 Alteration in consciousness is different from a posttraumatic stress reaction
▫ Development of post concussive symptomology
Question 2
• Are their current symptoms related to their history
of concussion or better explained by other
etiologies?
▫ This is the hard question
▫ Emphasis must be on the temporal proximity of
symptom development
▫ Must assess other co-morbid medical and MH issues
that may explain their current symptomology
VA/DOD Guidelines
• Training from central office has stressed the
importance of assessing the temporal proximity
of symptom development to the injury event
▫ In order for the symptoms to be related to the
concussion, they must have developed within
hours to days after the injury
▫ Symptoms that develop months to years later are
most likely related to other causes
mTBI Evaluation
• Consider other in-theater factors that might explain
symptom development
▫ Combat stress, PTSD, sleep deprivation, dehydration
• Assess symptoms present prior to the concussion
▫ Complete resolution would not be expected and
ongoing problems may not be attributed to concussion
▫ Patient will return to their baseline which is not the
same as being symptom free
 Patients with headaches before their concussion, will
likely continue to experience headaches after
mTBI evaluation
• No symptom checklist can diagnose brain injury
• No physical or neurological test can diagnose
brain injury
• Differential diagnosis relies on an in-depth
clinical interview focusing on the temporal
development of symptoms
▫ Knowledge and assessment of other conditions
that may be contributing is necessary
PTSD
Re-experiencing
Avoidance
Social withdrawal
Memory gaps
Apathy
mTBI
Sequela
Difficulty with decisions
Mental slowness
Concentration
Headaches
Dizzy
Appetite changes
Fatigue
Sadness
Depression
Arousal
Sensitive to noise
Concentration
Insomnia
Irritability
PTSD
Pain
Medications
Depression
Mild TBI
Sequela
Medical
Issues
Substance
Abuse
Post Traumatic Headaches
• Trauma event and headache start must correlate
in time
▫ How much time?
• International Headache Society (IHS)
▫ Headache must develop within 7 days of the injury
• Other standards have been applied
▫ Up to 30 days post injury
Summary
• History of concussion does not mean a current
diagnosis of brain injury
• Most people completely recovery following a
concussion
• Of the estimated 3% of remain symptomatic a
portion of those are symptomatic for reasons
other then brain injury
Summary
• Other etiologies of their current difficulties must
be considered (i.e., PTSD, depression, medical
issues, pain, medications, etc.)
• The timeline of symptom development is very
important
• Secondary etiologies should be considered
symptoms that develop much later
Additional Training Material
• VA Polytrauma training
▫ Video with Dr. David Cifu
• mTBI research overview
▫ Video with Dr. Michael McCrea
• Readings
▫ Mild Traumatic Brain Injury and Post Concussive
Syndrome-Michael McCrea
References
• Alves WM, Cohohan AR, O'Leary TJ, Rimel, RW and Jane JA.
Understanding post-concussice symptoms after minor head injury.
Journal of Head Injury Trauma Rehabilitation,1986; 1: 1-12.
• Belenger HG, Curtiss G, Demery, JA, Lebowski BK and Vanderploeg
RD. Factors moderating neuropsychological outcomes following
mild traumatic brain injury: A meta-analysis. Journal of the
International Neuropsychological Society; 2005; 11, 215-227.
• Guskiewicz KM, McCrea M, Marshall SW et al. Cumulative effects
associated with recurrent concussion in collegiate football players:
the NCAA Concussion Study , JAMA, 2003; 290: 2549-55.
• Iverson GL. Outcome from mild brain injury. Curr Opin Psychiatry,
2005; 18: 301-7.
References continued
• Ivins BJ, Kane R and Schwab KA. Performance on the automated
neuropsychological assessment metrics in a non-clinical sample of
soldiers screened for mild TBI after returning from Iraq and
Afghanistan: A descriptive analysis. Journal of Head Trauma
Rehabilitation; 2009: 24(1) 24-31.
• McCrea, M. Mild Traumatic Brain Injury and Postconcussion
Syndrome: The New Evidence Base for Diagnosis and Treatment.
New York: Oxford University Press, 2008.
• McCrea M, Kelly JP, Randolph C, Cisler R, Berger L. Immediate
neurocognitive effects of concussion. Neurosurgery 2002; 50: 103242.
• McCrea M, Guskiewicz KMm Marshall SW, et al. Acute effects and
recovery time following concussion in collegiate football players:
the NCAA concussion study. JAMA, 2003; 290:2556-63.
• Mittenberg W, Tremont G, Zielinski R, Fichera S, Rayls, K.
Cognitive behavioral prevention of post concussion syndrome.
Archive of Clinical Neuropsychology; 1996; 11:139-145.