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The following lecture has been approved for
University Undergraduate Students
This lecture may contain information, ideas, concepts and discursive anecdotes that may be thought provoking and challenging
It is not intended for the content or delivery to cause offence
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Introduction to Introduction to Brain InjuryBrain Injury
Dr. Craig JacksonSenior Lecturer in Health Psychology
School of Health and Policy StudiesFaculty of Health & Community Care
University of Central England
[email protected]@uce.ac.uk
What was Michael Angelo’s Hidden Message? What was Michael Angelo’s Hidden Message?
Michelangelo. Michelangelo. The Creation of Adam The Creation of Adam (detail, Sistine Chapel). (detail, Sistine Chapel).
1510. Fresco. Sistine Chapel, Vatican, Rome.1510. Fresco. Sistine Chapel, Vatican, Rome.
ObjectivesObjectives
List major structures and function of nervous systemList major structures and function of nervous system
Name types of head and spine injuries; describe clinical featuresName types of head and spine injuries; describe clinical features
Describe mechanisms of neurological Describe mechanisms of neurological
injuryinjury
Describe assessment of head injuriesDescribe assessment of head injuries
Describe functional affects and symptomsDescribe functional affects and symptoms
Describe imaging techniquesDescribe imaging techniques
Neurological InjuriesNeurological Injuries
Responsible for 50+% of trauma deathsResponsible for 50+% of trauma deaths
Approx. 1,000,000 patients in UK attend A&E with head injury per yearApprox. 1,000,000 patients in UK attend A&E with head injury per year
Can be prevented (some extent) by helmets and PPECan be prevented (some extent) by helmets and PPE
Major cause of chronic disabilityMajor cause of chronic disability
Mostly from Falls, RTAs and AssaultsMostly from Falls, RTAs and Assaults
Flannery & Buxton, 2001Flannery & Buxton, 2001
Anatomy PrinciplesAnatomy Principles
NeuronNeuronspecialized nerve cellspecialized nerve cell
Dendrites and Axons Dendrites and Axons short and long processes of neuronsshort and long processes of neurons
Peripheral neurons sheathed with myelinPeripheral neurons sheathed with myelin
Impulses transmitted from synapses to dendritesImpulses transmitted from synapses to dendrites
Anatomy Principles 2Anatomy Principles 2
Central Nervous System = brain, spinal cordCentral Nervous System = brain, spinal cord
Peripheral Nervous System = nerves, branchesPeripheral Nervous System = nerves, branches
Meninges = protective triple layer coverMeninges = protective triple layer cover
Dura matter Dura matter = = outer layerouter layerArachnoidArachnoid == middle layermiddle layerPia matterPia matter == inner layerinner layer
Cerebral Spinal Fuid (CSF) circulates in middle layerCerebral Spinal Fuid (CSF) circulates in middle layer
Anatomy Principles 3Anatomy Principles 3
Cerebrum (hemispheres)Cerebrum (hemispheres)Cerebellum, brainstemCerebellum, brainstem
Cranial nerves Cranial nerves originate at base of brainoriginate at base of brain
Sensory / motor supply to head and faceSensory / motor supply to head and face
Motor nerves = brain to muscle unitsMotor nerves = brain to muscle units
Sensory nerves = skin back to brainSensory nerves = skin back to brain
Somatic Nervous System = voluntary actionSomatic Nervous System = voluntary action
Automatic Nervous System = involuntary actionAutomatic Nervous System = involuntary action
Anatomy Principles 4Anatomy Principles 4
Traumatic Brain InjuryTraumatic Brain Injury
Physical force causes nerve cells to stretch, tear and pull apartPhysical force causes nerve cells to stretch, tear and pull apart
Unable to relay messages through brainUnable to relay messages through brain
Force causes brain to slam against skull interior: “Traumatic Brain Injury” Force causes brain to slam against skull interior: “Traumatic Brain Injury”
Injury to brain cells affects processing:Injury to brain cells affects processing:
thinkingthinkingrememberingrememberingseeingseeingcontrol & coordinationcontrol & coordinationmoodmood
Traumatic Brain InjuryTraumatic Brain Injury
TBI ranges from mild to severe:TBI ranges from mild to severe:
degree of forcedegree of force
multiple traumamultiple trauma
neurological complicationsneurological complications
speed of assistancespeed of assistance
Head InjuriesHead Injuries
Severity depends on amount of Primary and Secondary brain injurySeverity depends on amount of Primary and Secondary brain injury
Main cause of Secondary injury = hypoxiaMain cause of Secondary injury = hypoxia
Categories: Open or ClosedCategories: Open or Closed
Forces: Shearing and CompressionForces: Shearing and Compression
Non Loss of FunctionNon Loss of Function
41 yr old Mike Hill41 yr old Mike Hill
Attacked from behindAttacked from behind
Full recovery after removalFull recovery after removal
No infectionNo infection
Left hospital 1 week after removalLeft hospital 1 week after removal
Epileptic medication and some memory problemsEpileptic medication and some memory problems
Functional StatusFunctional Status
SPECT image with Technetium (T99)SPECT image with Technetium (T99)
Pathophysiological DisturbancePathophysiological Disturbance
Involve scalp, cranium, or underlying brainInvolve scalp, cranium, or underlying brain
Depends on mechanism of injuryDepends on mechanism of injury
Scalp:Scalp: lacerations, contusions, abrasionslacerations, contusions, abrasions
Skull fractures: Skull fractures: vault / base, simple or compound, depressed or planarvault / base, simple or compound, depressed or planar
Primary Brain Injury:Primary Brain Injury: Focal (intra-cranial haematoma, contusion)Focal (intra-cranial haematoma, contusion)
Diffuse (diffuse axonal injury)Diffuse (diffuse axonal injury)
Categories: Open or ClosedCategories: Open or Closed
Forces: Shearing and CompressionForces: Shearing and Compression
““Closed” or “Open” Head InjuryClosed” or “Open” Head Injury
Closed Head Injury (CHI): Closed Head Injury (CHI): No penetration of the skullNo penetration of the skullUsually a TBIUsually a TBINot always thoughNot always though
Open head Injury (OHI): Open head Injury (OHI): Bullet, Knife, or Fracture Bullet, Knife, or Fracture Skull breechedSkull breeched
Brain injury depends on power of physical force injuryBrain injury depends on power of physical force injury
If great enough, forces radiates through skull, causes sudden brain movementIf great enough, forces radiates through skull, causes sudden brain movement
Results in damaged nerve cellsResults in damaged nerve cells
May result in “soft tissue” injuryMay result in “soft tissue” injury -- cervical straincervical strainmyofascial traumamyofascial trauma
““Mild” Traumatic Brain InjuryMild” Traumatic Brain Injury
Head injury graded on:Head injury graded on: (i) length of unconsciousness(i) length of unconsciousness(ii) length of amnesia(ii) length of amnesia
Both caused by sudden trauma and nerve cell tearingBoth caused by sudden trauma and nerve cell tearing
Brain cannot maintain functioning and shuts down either:Brain cannot maintain functioning and shuts down either:
fully (unconsciousness)fully (unconsciousness) oror partially (dazed)partially (dazed)
MBI refers to loss of consciousness for 30 mins or lessMBI refers to loss of consciousness for 30 mins or less
UnconsciousUnconsciousAmnesiaAmnesia Any of these Any of these Diffuse AxonalDiffuse AxonalAltered consciousnessAltered consciousness indicates MBIindicates MBI InjuryInjuryneurological deficitsneurological deficits
MBI can result in life changing consequencesMBI can result in life changing consequences
Diffuse Axonal InjuryDiffuse Axonal Injury
Thinking slows downThinking slows down
Memory poorMemory poor Mild Brain InjuryMild Brain Injury Processing slowerProcessing slower
Concentration haphazardConcentration haphazard
““Roadblocks of damaged unconnected neurons”Roadblocks of damaged unconnected neurons”
Individual feels:Individual feels:
IncompleteIncomplete emotional problemsemotional problemsUnconfidentUnconfidentFrustratedFrustrated Described as “ mental fog”Described as “ mental fog”IrritableIrritableStrugglingStruggling cognitive problemscognitive problems
Brain Injury without Direct TraumaBrain Injury without Direct Trauma
Whiplash & ShakingWhiplash & Shaking
Sudden movement inside cranium damages neuronsSudden movement inside cranium damages neurons
Acceleration – DecelerationAcceleration – Deceleration
RTAs – even with airbag deployment –can cause brain injuryRTAs – even with airbag deployment –can cause brain injury
Brain is torn, squashed, bruisedBrain is torn, squashed, bruised
RollercoastersRollercoasters
Types of Head InjuriesTypes of Head Injuries
Concussion: Temporary alteration in neurological function or LORConcussion: Temporary alteration in neurological function or LOR
Cerebral Contusion: Bruised brainCerebral Contusion: Bruised brain
Cerebral Haemotoma or bleedCerebral Haemotoma or bleed
epiduralepidural
sub-duralsub-dural
sub-arachnoidsub-arachnoid
intra-cerebralintra-cerebral
Signs and SymptomsSigns and Symptoms
HeadacheHeadache
DizzinessDizziness
Nausea / VomitingNausea / Vomiting
AmnesiaAmnesia
Decreased responsivenessDecreased responsiveness
ConfusionConfusion
CombativenessCombativeness
Loss of responsivenessLoss of responsiveness
AssessmentAssessment
First impression: Responsive or UnresponsiveFirst impression: Responsive or Unresponsive
Urgent Survey:Urgent Survey: LORLOR ABC’sABC’s
Open airway with C-spineOpen airway with C-spine
Check breathing: Ventilate; Oral airway; OCheck breathing: Ventilate; Oral airway; O22 when available when available
Check carotid artery pulse – CPR if indicatedCheck carotid artery pulse – CPR if indicated
Control any major bleedingControl any major bleeding
Assessment continuedAssessment continued
Rapid Body SurveyRapid Body Survey Sample, DCAP-BTLSSample, DCAP-BTLS
Stabilize head between kneesStabilize head between knees
Call for equipment, assistance, transportCall for equipment, assistance, transport
Maintain body temp.Maintain body temp.
Transport (head uphill)Transport (head uphill)
Non-Urgent SurveyNon-Urgent Survey
Ongoing Survey – seizures, vomiting, change in LOROngoing Survey – seizures, vomiting, change in LOR
Assessment continuedAssessment continued
Brain SwellingBrain Swelling
Increased Intracranial Pressure (ICP)Increased Intracranial Pressure (ICP)
HypoxiaHypoxia
Further Secondary Brain InjuryFurther Secondary Brain Injury
More SwellingMore Swelling
Increased ICPIncreased ICP
Localised Neurological Signs (ICP)Localised Neurological Signs (ICP)
GENERAL SIGNS + PLUS +GENERAL SIGNS + PLUS +
Change in pupil size / light reactivityChange in pupil size / light reactivity
Slowing pulseSlowing pulse
Rising BP.Rising BP.
Change in respirationChange in respiration
Unilateral weaknessUnilateral weakness
IncontinenceIncontinence
SeizureSeizure
Urgent Interventions - ATLSUrgent Interventions - ATLS
Presume C-Spine injuryPresume C-Spine injury
Immobilize neckImmobilize neck
Open airway: administer oxygenOpen airway: administer oxygen
Treat bleeding and shockTreat bleeding and shock
Prevent aspiration of vomit / secretionsPrevent aspiration of vomit / secretions
Transport immediatelyTransport immediately
Elevate head 6”Elevate head 6”
Transport head uphillTransport head uphill
ImagingImaging
Xray, MRI and CT cannot show traumatic Xray, MRI and CT cannot show traumatic brain injurybrain injury
Techniques rely on Techniques rely on tissue densitytissue density
Diffuse damage will not show on these Diffuse damage will not show on these techniquestechniques
SPECT or PET measure brain cell SPECT or PET measure brain cell metabolismmetabolism
Can detect changes in function due brain injuryCan detect changes in function due brain injury
Behavioural ChangesBehavioural Changes
SpeechSpeech
CognitionCognition
MemoryMemory
MoodMood
Mental healthMental health
psychosespsychoses
deliriumdelirium
TremorTremor
GaitGait
Symmetry of functionSymmetry of function Gross over-simplificationGross over-simplification
VisualVisual
AuditoryAuditory
Positive and negative symptomsPositive and negative symptoms
Other Causes of Brain InjuryOther Causes of Brain Injury
Drug effectsDrug effects
TumorTumor
MetastasesMetastases
Physical assaultPhysical assault
SurgerySurgery
Traumatic birthTraumatic birth
HypoxiaHypoxia
Glasgow Coma ScaleGlasgow Coma Scale
Scores 8 or less = needs urgent anaesthetic assessment. Scores 8 or less = needs urgent anaesthetic assessment. Danger of airway compromiseDanger of airway compromise13-15 = mild13-15 = mild 9-12 = moderate 9-12 = moderate 3-8 = severe3-8 = severe
Queen’s Medical CentreQueen’s Medical Centre
Cerebral Asymmetry of FunctionCerebral Asymmetry of Function
Hemispheric asymmetry of function is relativeHemispheric asymmetry of function is relative
Asymmetries have been overblown by popular media into fads Asymmetries have been overblown by popular media into fads (e.g. golf with your right brain)(e.g. golf with your right brain)
Anterior-posterior differences far outweigh left-right differences Anterior-posterior differences far outweigh left-right differences
Asymmetry is not uniquely human Asymmetry is not uniquely human
Cerebral Asymmetry of FunctionCerebral Asymmetry of Function
LEFT HEMISPHERELEFT HEMISPHERE
Convolutions mature more rapidly Convolutions mature more rapidly
Extends further posteriorlyExtends further posteriorly
Higher in density (more gray matter; more neurons) Higher in density (more gray matter; more neurons)
Planum temporale larger on left (in 60-90%) of cases Planum temporale larger on left (in 60-90%) of cases
Larger insula Larger insula
Longer Sylvian fissure (gentler slope) Longer Sylvian fissure (gentler slope)
Double cingulate gyrus Double cingulate gyrus
Larger lateral posterior nucleus (to parietal cortex) Larger lateral posterior nucleus (to parietal cortex)
Wider occipital lobe Wider occipital lobe
Larger total area of frontal operculum (much buried in sulci)Larger total area of frontal operculum (much buried in sulci)
Larger inferior parietal lobule Larger inferior parietal lobule
Cerebral Asymmetry of FunctionCerebral Asymmetry of Function
RIGHT HEMISPHERERIGHT HEMISPHERE
Convolutions mature less rapidly Convolutions mature less rapidly
Extends further anteriorly Extends further anteriorly
Larger and heavier Larger and heavier
Primary auditory (Heshl's gyrus) larger on rightPrimary auditory (Heshl's gyrus) larger on right
Shorter (steeper slope) Shorter (steeper slope)
Single Single
Larger medial geniculate nucleus Larger medial geniculate nucleus
Narrower Narrower
Larger area of convexity in frontal lobe; wider frontal lobe Larger area of convexity in frontal lobe; wider frontal lobe
Cortical LesionsCortical Lesions
Human cognitive and sensory dysfunction different following lesions Human cognitive and sensory dysfunction different following lesions
(due to strokes, surgery, accident, etc.) (due to strokes, surgery, accident, etc.)
Differences noted in lesions to left and right hemispheresDifferences noted in lesions to left and right hemispheres
Lesions can provide clues about brain organizationLesions can provide clues about brain organization
Do specific areas possess special unique functions?Do specific areas possess special unique functions?
Does a lesion to a specific area demonstrate a dysfunctionDoes a lesion to a specific area demonstrate a dysfunction
++
Lesions to other brain locations Lesions to other brain locations do notdo not cause a similar dysfunction cause a similar dysfunction
DissociationDissociation
Lesion siteLesion site ReadingReading WritingWriting Speaking Speaking
100100 normalnormal normal normal impairedimpaired
102102 impairedimpaired normalnormal normalnormal
104104 normalnormal impairedimpaired normal normal
Allows understanding of specific sites and impairmentsAllows understanding of specific sites and impairments
Hemispherical FunctionHemispherical Function
LeftLeft RightRight
VisionVision linguistic stimulilinguistic stimuli patternspatterns faces facessteropsissteropsis
AuditionAudition language soundslanguage soundsrhythm rhythm
SomatosensationSomatosensation tactile recognitiontactile recognition
MotorMotor complex movementcomplex movement spatial movementspatial movement
MemoryMemory verbal memoryverbal memory non-verbal memorynon-verbal memory
LanguageLanguage speech readingspeech reading prosodyprosodywriting arithmeticwriting arithmetic
EmotionEmotion social emotionssocial emotions primary emotionsprimary emotions
Spatial processesSpatial processes geometrygeometry spatial images orientationspatial images orientation
Split Brain and Commissurotomy Split Brain and Commissurotomy
Corpus Callosum joins hemispheresCorpus Callosum joins hemispheres
Sever corpus callosumSever corpus callosum
Two hemispheres cannot communicateTwo hemispheres cannot communicate
Brain Injury - SummaryBrain Injury - Summary
1. The main cause of secondary damage to the brain is _ _ _ _ _ _ _ ?1. The main cause of secondary damage to the brain is _ _ _ _ _ _ _ ?
2. Head injury alone rarely causes damage. T / F?2. Head injury alone rarely causes damage. T / F?
3. Temporary loss of consciousness or function from a head trauma is a 3. Temporary loss of consciousness or function from a head trauma is a _ _ _ _ _ _ _ _ _ _ ?_ _ _ _ _ _ _ _ _ _ ?
4. Brain injury can occur without any impact trauma. T / F4. Brain injury can occur without any impact trauma. T / F
5. Axons being damaged / shredded is the simple reason for cognitive 5. Axons being damaged / shredded is the simple reason for cognitive problems in head injury patients. T / Fproblems in head injury patients. T / F
Hemispherical testHemispherical test
I always wear a watch
1
Hemispherical test
I keep a journal
2
Hemispherical test
I believe there is a right and wrong way to do everything
3
Hemispherical test
I hate following directions
4
Hemispherical test
The expression "Life is just a bowl of cherries" makes no sense to me
5
Hemispherical test
I find that sticking to a schedule is boring
6
Hemispherical test
I'd rather draw someone a map the tell them how to get somewhere
7
Hemispherical test
If I lost something, I'd try to remember where I saw last
8
Hemispherical test
If I don't know which way to turn, I let my emotions guide me
9
Hemispherical test
I'm pretty good at math
10
Hemispherical test
If I had to assemble something, I'd read the directions first
11
Hemispherical test
I'm always late getting places
12
Hemispherical test
Some people think I'm psychic
13
Hemispherical test
Setting goals for myself helps keep me from slacking off
14
Hemispherical test
When somebody asks me a question, I turn my head to the left
15
Hemispherical test
If I have a tough decision to make, I write down the pros and the cons
16
Hemispherical test
I'd make a good detective
17
Hemispherical test
I am musically inclined
18
Hemispherical test
If I have a problem, I try to work it out by relating it to one I've had in the past
19
Hemispherical test
When I talk, I gesture a lot
20
Hemispherical test
If someone asks me a question, I turn my head to the right
21
Hemispherical test
I believe there are two sides to every story
22
Hemispherical test
I can tell if someone is guilty just by looking at them
23
Hemispherical test
I keep a to do list
24
Hemispherical test
I feel comfortable expressing myself with words
25
Hemispherical test
Before I take a stand on an issue, I get all the facts
26
Hemispherical test
I've considered becoming a poet, a politician, an architect, or a dancer
27
Hemispherical test
I lose track of time easily
28
Hemispherical test
If I forgot someone's name, I'd go through the alphabet until I remembered it
29
Hemispherical test
I like to draw
30
Hemispherical test
When I'm confused, I usually go with my gut instinct
31
Hemispherical test
I have considered becoming a lawyer, journalist, or doctor
32
Hemispherical test
1. L 1. L
2. L2. L
3. L 3. L
4. R 4. R
5. L 5. L
6. R 6. R
7. R 7. R
8. L 8. L
9. R 9. R
10. L 10. L
11. L 11. L
12. R12. R
Hemispherical test
13. R 13. R
14. L 14. L
15. R 15. R
16. L 16. L
17. L 17. L
18. R 18. R
19. R 19. R
20. R 20. R
21. L 21. L
22. R 22. R
23. R 23. R
24. L 24. L
Hemispherical test
25. L 25. L
26. L 26. L
27. R 27. R
28. R 28. R
29. L 29. L
30. R 30. R
31. R 31. R
32. L32. L