TRAUMATIC & ACQUIRED BRAIN
INJURY
James F. Malec, PhD, ABPP-Cn, RpProfessor & Research Director
PM&R, Indiana University School of Medicine& Rehabilitation Hospital of Indiana
Emeritus Professor of Psychology, Mayo Clinic
Overview1. What is traumatic brain injury?
2. What sorts of injuries or events can cause TBI?
3. What behaviors should lawyers be looking for that might be red flags for TBI?
4. What questions should we be asking our clients to verify TBI (other than seeking medical records)?
5. How is TBI diagnosed? Is imaging necessary or helpful? Are there other ways to diagnose?
6. What are the symptoms of TBI?7. How can TBI impact cognition?8. Can TBI be cured or ameliorated and if so, how? What is the long term
prognosis for persons with TBI?
What is traumatic brain injury?
Definitions TBI Model System (moderate-severe): TBI is defined as
damage to brain tissue caused by an external mechanical force as evidenced by medically documented loss of consciousness or post traumatic amnesia (PTA) due to brain trauma or by objective neurological findings that can be reasonably attributed to TBI on physical examination or mental status examination.
CDC: A TBI is caused by a bump, blow, or jolt to the head or a penetrating head injury that disrupts the normal function of the brain. Not all blows or jolts to the head result in a TBI.
TBI Severity Ranges from “mild” (i.e., a brief change
in mental status or consciousness) to “severe” (i.e., an extended period of unconsciousness or memory loss after the injury)
Concussion = mild TBI Severity based on initial injury
NOT severity of sequelaeThese are associated but not perfectly
TBI Severity Severity based on initial injury
Glasgow Coma Scale (GCS)Duration of loss of consciousness (LOC)Duration of post-traumatic amnesia (PTA)Time to follow commands
Severity NOT based on severity of sequelae or symptoms
Severity of injury and sequelae are associated but not perfectly
Glasgow Coma Scale
Eye Opening Response Spontaneous; eyes open with blinking
at baseline: 4 points To verbal stimuli, command, speech: 3
points To pain only (not applied to face): 2
points No response: 1 point
Glasgow Coma Scale Motor Response
Obeys commands for movement: 6 points Purposeful movement to painful stimulus: 5
points Withdraws in response to pain: 4 points Flexion in response to pain (decorticate
posturing): 3 points Extension response in response to pain
(decerebrate posturing): 2 points No response: 1 point
Glasgow Coma Scale
Verbal ResponseOriented: 5 points Confused conversation, but able to
answer questions: 4 points Inappropriate words: 3 points Incomprehensible speech: 2
points No response: 1 point
Glasgow Coma Scale GCS = sum of three components Usually worst within first 24 hours Motor score alone is good proxy for
entire scale In current practice, often invalidated by
emergency intubation/sedation
Post-traumatic Amnesia (PTA) Time between injury and recovery of
continuous anterograde memoryUsually signified by orientation to person,
time, placeScales used in research, eg, O-LOG,
Galveston Orientation and Amnesia Test (GOAT)
Memory loss may also be retrogradeRetrograde < anterograde
Post-traumatic Confusional State (Delirium) PTA or memory loss is one component Disturbance of awareness/attention Behavior disturbance
Agitation vs. abulia Sleep cycle disturbance
TBI severity Mild (Concussion)
GCS >13LOC < 30 minPTA <24 hrsmay include no LOC or PTA and normal GCS
(15) with disruption of consciousness, ie, dazed or confused
Complicated mildAbove criteria + positive neuroimagingSequelae similar to moderate
TBI severity Moderate
GCS = 9-12LOC = 30 min-24 hrsPTA = 24 hrs-1 wk
SevereGCS < 9LOC > 24 hrsPTA > 1 wk
Systems with finer grades exist Others differentiate only mild vs.
moderate/severe
ABI: Acquired brain injury Brain damage from other causes, eg,
anoxia, cerebrovascular event, electrocution, poisoning or metabolic imbalance
Not congenital or developmental Not progressive (eg, dementia, MS,
Huntingtons, Parkinsons) Stroke
With vs. without hemiplegia
What sorts of injuries or events can cause TBI?
Causes of TBI Any injury to the brain resulting from an
external forceMost common: car accidents, falls, fights,
blast injuries Penetrating or nonpenetating Usually results from a blow to the head May result from acceleration-
deceleration or blast injury without direct head trauma
What behaviors should lawyers be looking for that might be red flags for TBI?
Most Common TBI/ABI Sequelae Impaired attention or memory Limited behavioral or emotional control
Impulsivity vs. lack of initiation Above may also result from many other
causes including personality, psychiatric disorder, sleep disorder, other medical illness
TBI/ABI requires documentation of an event that abruptly disrupted consciousness and resulted in identifiable brain damage or sequelae attributable to brain damage
What questions should we be asking our clients to verify TBI (other than seeking medical records)?
OSU-TBI-ID Systematic method for discovering a
history of significant TBI as suggested by:Hospitalization, ER visits, car accident, falls,
fights, blast injuriesLoss or alteration of consciousnessMultiple injuries
Only for TBI Form, information and training at:
http://www.ohiovalley.org/tbi-id-method/
How is TBI diagnosed? Is imaging necessary or helpful? Are there other ways to diagnose?
Mayo Criteria: Moderate-Severe (DEFINITE)One or more of the following criteria apply:1. Death due to this TBI2. Loss of consciousness of 30 minutes or more3. Post-traumatic anterograde amnesia of 24 hours or more4. Worst Glasgow Coma Scale full score in first 24 hours
(unless invalidataed upon review, e.g., attributable to intoxication, sedation, systemic shock)
5. One or more of the following present: intracerebral, subdural, or epidural hematoma, cerebral contusion, hemorrhagic contusion, penetrating TBI (dura penetrated), subarachnoid hemorrhage, brain stem injury
Mayo Criteria: Mild (PROBABLE)Not moderate-severe and one or more of the following criteria apply:1. Loss of consciousness of momentary to
less than 30minutes2. Post-traumatic anterograde amnesia of
momentary to less than 24 hours3. Depressed, basilar or linear skull
fracture (dura intact)
Mayo Criteria: Symptomatic (POSSIBLE)Not moderate-severe or mild and one or more of the following symptoms are present: Blurred vision Confusion (mental state changes) Dazed Dizziness Focal neurologic symptoms Headache Nausea
Imaging Intracranial damage attributable to
trauma is clear evidence of TBIAlthough subdural hematoma will be
challenged MRI more sensitive than CT TBI can also be present with normal
neuroimaging
Diagnosis with normal imaging History of injury and sequelae are critical Medical diagnosis by brain injury
specialist, ie, neurosurgeon, neurologist, neuropsychiatrist, physiatrist (PM&R)Not all in these specialties are brain injury
experts Neuropsychology evaluation and testing
“consistent with” TBI/ABINeuropsychologists = clinical psychologists
○ May diagnose within DSM
What are the symptoms of TBI?
Symptoms of Mild TBI[from Rivermead Postconcussion Symptoms Questionnaire]
Headaches Dizziness Nausea and/or Vomiting Noise Sensitivity, easily
upset by loud noise Sleep Disturbance Fatigue, tiring more
easily Being Irritable, easily
angered Feeling Depressed or
Tearful
Feeling Frustrated or Impatient
Forgetfulness, poor memory
Poor Concentration Taking Longer to Think Blurred Vision Light Sensitivity, Easily
upset by bright light Double Vision Restlessness
Symptoms of Moderate-Severe TBI Similar to mild but more severe More often include impairments of
higher order abilitiesReasoning and judgmentPlanningSelf-awareness
No symptoms are specific to TBI or ABI
How can TBI impact cognition?
Effects on Cognition Neurotransmitter disruption
Often transient in mild TBI Structural damage
Neural damage to brain areas that are critical for specific types of cognition○ Frontal lobes: reasoning, judgment, self-regulation○ Left hemisphere: language○ Right hemisphere: spatial abilities○ Temporal lobe, hippocampus: memory
Diffuse axonal injury: disconnection syndromes, impaired attention
Can TBI be cured or ameliorated and if so, how? What is the long term prognosis for persons with TBI?
Only Cure is PreventionAnd prevention of secondary complications/ injuries
Rehab Works• Inpatient• Outpatient/
Community-based• Medical and
behavioral interventions
• Ideally: early, focused, lifelong follow-along
Long term PrognosisMuch better than it is…