Introduction to Traumatic Brain InjuryJoe Rosenthal, MD
Clinical Assistant ProfessorTBI Fellow
11/1/10
Objectives
• 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
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
• 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
• 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
• 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
• 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
• Contusion
• DAI
• Penetrating Injuries
• Intracranial Hemorrhage
• Secondary Injuries (including Hypoxia)
Contusion
• 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 atImpact 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– Hypoxia/Anoxia– Hypotension– Anemia– Hyperthermia– Hyper/hypocarbia– Fluid imbalance– Sepsis
• CNS– 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• 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 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
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
• 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 61%
• Anxiety 17%
• Anxiety and depression 60%
Frequent Complaints with TBI related Depression
• Frustration 81%
• Restlessness 73%
• Boredom 66%
• Sadness 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
• Weakness
• Spasticity
• Abnormal movements
• Difficulty coordinating movements
Visual Deficits
• 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
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
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 Injuryin the United States
Return to Work
• mild 90-100%
• moderate poor data
• severe 10-25%
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
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– Driver’s Evaluation
Questions
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, 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.