1. TBI and Stroke: What is the Same? What is Different?
Carol Ann Smith, RN, CNRN
Program Coordinator - Traumatic Brain Injury Center
Donna Lindsay, MN, RN, SCRN
Program Coordinator - Hennepin Stroke Center

2. Objectives
At the end of this presentation the learner will be able to:
Define traumatic brain injury (TBI) and stroke
Describe similarities in TBI and stroke neurological & functional impairments
Identify differences in TBI and stroke prevention

3. Definition TBI and Stroke are both types of acquired brain injury
TBI and Stroke are both types of acquired brain injury
Acquired brain injury is damage to the brain that occurs after birth
The two main types of acquired brain injury are:
Traumatic brain injury
Direct or indirect trauma to the brain
Non-traumatic brain injury
Includes brain damage from stroke, brain tumors,
infection, hypoxia or substance abuse
Just a high level overview of stroke to start with
Of note, In the US, stroke has gone from the 3rd leading cause of death to the 4th and in Minnesota, it has dropped to the 5th. The work you are doing IS making a difference!!
Unfortunately, the incidence of stroke has not declined so rapid recognition and treatment continues to be very important.

4. Definition
 In both TBI and Stroke, brain injury is often categorized as primary or secondary
Primary brain injury occurs at the time of the initial insult to the brain (trauma, hemorrhage or infarct)
Secondary injury occurs over hours to days and involves an array of cellular processes that may be the result or independent of the primary insult
Common causes of secondary brain injury are impaired cerebral perfusion, altered brain metabolism & oxygen utilization, increased intracranial pressure, cerebral edema, seizure activity, electrolyte abnormalities and hypoxemia
Just a high level overview of stroke to start with
Of note, In the US, stroke has gone from the 3rd leading cause of death to the 4th and in Minnesota, it has dropped to the 5th. The work you are doing IS making a difference!!
Unfortunately, the incidence of stroke has not declined so rapid recognition and treatment continues to be very important.

5. Stroke Definitions
The rapid loss of brain function due to disturbance in the blood supply to the brain
Stoppage of blood flow to brain: a sudden blockage or rupture of a blood vessel in the brain
A stroke or "brain attack" occurs when a blood clot blocks an artery or a blood vessel breaks, interrupting blood flow to an area of the brain

6. Traumatic Brain Injury Definitions
Traumatic Brain Injury (TBI) is caused by a blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain
Mild TBI
a pathophysiological process affecting the brain induced by direct or indirect biomechanical forces
GCS 14-15
Severe TBI
CT scan shows bleeding, bruising, shear injury, swelling
Major changes in blood flow & how the brain uses oxygen
Unconscious, GCS score 3-8

7. Stroke Statistics
Approximately 795,000 Americans suffer a stroke each year
Stroke is the 4th leading cause of death and the leading cause of serious, long-term disability in the US.
The cost of stroke in the US is approximately $28.6 billion annually.
On average in the US, every 40 seconds someone has a stroke and every 4 minutes someone dies.
87 % of all strokes are ischemic, 10 % are intracerebral hemorrhage, and 3 % are subarachnoid hemorrhage.
Just a high level overview of stroke to start with
Of note, In the US, stroke has gone from the 3rd leading cause of death to the 4th and in Minnesota, it has dropped to the 5th. The work you are doing IS making a difference!!
Unfortunately, the incidence of stroke has not declined so rapid recognition and treatment continues to be very important.

8. Stroke Statistics in Minnesota
Over 97,000 Minnesotans have had a stroke
Approximately 11,500 new strokes occur each year
Stroke is the 5th leading cause of death and the leading cause of long-term disability
In 2011, $414 million was spent on hospital care for stroke

9. TBI Statistics
According to research from CDC, approximately 3.5 million persons have a TBI in the United States each year.
2.1 million receive care in emergency departments,
300,000 are hospitalized,
84,000 are seen in outpatient departments,
1.1 million receive care from office-based physicians,
53,000 die
TBI is a contributing factor to a third (30.5%) of all injury-related deaths
An Estimated $76.5 billion in direct medical costs and indirect costs such as lost productivity due to TBI each year
5.3 million Americans living with long term disability

10. TBI Statistics in Minnesota
14,548 Minnesotans sustained traumatic brain injury in 2012: (MDH - MIDAS)
10,310 were discharged from the emergency department
3.960 were hospitalized
278 died
58% male and 42% female
This only counts people who present to the ED
Over 100,000 Minnesotans live with a disability as a result of a brain injury
83% of offenders entering the Minnesota prison system have a history of TBI

11. Non-fatal TBI in Minnesota

12. Types of Stroke Hemorrhagic Ischemic Intracerebral Hemorrhage
Atherothrombotic
Embolic
Transient Ischemic Attack
Hemorrhagic
Intracerebral Hemorrhage
Subarachnoid Hemorrhage

13. Types of Traumatic Brain Injury
Brain injuries can be classified as:
Mild, moderate or severe
As determined by the Glasgow Coma Scale
Open or Closed
Skull fracture or no skull fracture
Linear, depressed, basilar
Penetrating wound (knife, bullet or other object)
Focal or diffuse
The injury is localized to one area (focal)
Hematoma, contusion
The injury is throughout the entire brain (diffuse)
Concussion, shear injury

14. Types of TBI Concussion Contusion Epidural Hematoma Subdural Hematoma
Intraparenchymal Bleed
Subarachnoid Hemorrhage
Intraventricular Hemorrhage
Diffuse Axonal Injury (Shear)

15. What Causes Stroke? Controllable Risk Factors
High blood pressure (> 140/85 or if diabetic > 130/80)*
High cholesterol (LDL > 130 if no other risk factors, > 100 if other risk factors present)
Smoking*
Atrial Fibrillation
Heart Disease ( dilated cardiomyopathy, heart valve disease, artificial heart valve, heart failure)
Carotid Artery Disease
Diabetes*

16. What Causes Stroke? Controllable Risk Factors (cont.)
Alcohol and Substance Abuse*
Physical Inactivity
Sleep Apnea
Clotting Disorders*
Vasculitis*
Uncontrollable Risk Factors
Age (every decade over age 55 the risk of ischemic stroke doubles)
Gender (men are at slightly higher risk)
Race/Ethnicity*
Family History*
Vascular Abnormality*
* Risk factor for both hemorrhagic and ischemic stroke

17. How Do You Prevent Stroke?
It is believed that 80 – 85% of ischemic strokes could be prevented if risk factors were identified and controlled
Challenges to stroke prevention
Lack of healthcare screening (risk factors not identified)
Failure of patients to adhere to risk reduction measures
Failure of healthcare providers to implement aggressive risk reduction measures

18. How Do You Get a TBI? Etiologies: Falls (35.2%) Leading cause of TBI
Rates highest in children 0-4 & elderly > 75
Motor Vehicle Collision (17.3%)
Results in greatest # of hospitalizations
Rate highest in age group
Struck by/fell against (16.5%)

19. How Do You Get a TBI? Assault (10%)
Firearm use leading cause of death related to TBI
Blasts leading cause of TBI for active duty military personnel in a war zone
Unknown (0%)
Other (7%)
Bicycle/non-MV (3%)
Suicide (1%
(Source CDC)

20. How Do You Prevent a TBI?
The only known cure for brain injury is prevention!!
Protect your brain - always wear a helmet for sports and recreational activities
Purchase only consumer product safety commission (CPSC) certified helmets
Concentrate on driving - never talk on a cell phone or text while driving
Everyone buckle up every time – infant car seats, booster seats for children under 8 or under 40 lbs, then seat belts
Stay focused & have a clear mind, do not drive impaired by drugs or alcohol
Stay steady - prevent falls from ladders and steps.
Never shake a baby, never
Keep small children away from open/screened windows and stairs
Prevent falls in the elderly
Home safety evaluations, medication & vision checks

21. How Do You Manage Ischemic Stroke?
Recanalization Therapy
0 – 4.5 hours after last known well
IV rtPA
0 – 6 hours after last known well
Mechanical Thrombectomy
Intra-arterial Thrombolysis

22. IV rtPA 0–3 hours – Outcome Data
Favorable outcome (complete or nearly complete recovery 3 months after stroke):
50% in treated group
38% in placebo group
For a favorable outcome, NNT = 8.3
For an improved outcome, NNT = 3.1
National Institute of Neurologic Disorders and Stroke (NINDS) Acute Stroke Trial - December 1995

23. IV rtPA 0-3 hours – Outcome Data
Symptomatic intracerebral hemorrhage
6.4% in treated group
0.6% in placebo group
Mortality rate at 3 months and 1 year
17% and 24% in treatment group
20% and 28% in placebo group
National Institute of Neurologic Disorders and Stroke (NINDS) Acute Stroke Trial - December 1995

24. IV rtPA 3-4.5 hours – Outcome Data
Favorable outcome (complete or nearly complete recovery 3 months after stroke):
52.4% in treated group
45.2% in placebo group
This is a modest but statistically significant difference
For a favorable outcome, NNT = 14
For an improved outcome, NNT = 8
European Cooperative Acute Stroke Study (ECASS - 3)

25. IV rtPA 3-4.5 hours – Outcome Data
Symptomatic intracerebral hemorrhage
7.9% in treated group
3.5% in placebo group
Mortality rate at 3 months
7.7% in treatment group
8.4% in placebo group
European Cooperative Acute Stroke Study (ECASS - 3)

26. IV rtPA – Timing of Treatment
Odds ratios for favorable outcome by time of drug initiation from onset of symptoms:
0 – 90 minutes 2.81†
91 – 180 minutes 1.55 †
181 – 270 minutes 1.3 
†Alteplase Thrombolysis for Acute Non-interventional Treatment of Stroke (ATLANTIS) - IV rtPA 0.9 mg/Kg 0–5 hours from stroke onset. U.S. based, industry funded trial
Pooled data from ECASS-1, ECASS-2, ECASS-3 and ATLANTIS

27. How Do You Manage Ischemic Stroke?
Acute Stroke Treatment
Minimize secondary brain injury
Allow “permissive hypertension” for first hours
Maintain Normothermia
Decompressive craniotomy/ICP management if edema is severe
Avoid complications (swallow screening and if needed modified diet, VTE prophylaxis, early mobilization, fall prevention)
Initiate rehabilitation therapies
Diagnostic work-up to identify cause of stroke and stroke risk factors
Implement stroke risk factor reduction measures

28. How Do You Manage Hemorrhagic Strokes?
Intracerebral Hemorrhage
Most common type of hemorrhagic stroke
Mortality rate is 35 – 55%
Emergent reversal of INR if anticoagulated
Decompressive craniotomy, hematoma evacuation
Minimize secondary brain injury (similar to TBI)
Avoid complications
Initiate rehabilitation therapies

29. How Do You Manage Hemorrhagic Strokes?
Subarachnoid Hemorrhage (non-traumatic)
Mortality rate is approximately 50% (15% die prior to reaching medical attention)
Treat the underlying cause
80% of SAH is caused by ruptured aneurysm
Surgical clipping or endovascular therapy
5% is caused by arteriovenous malformation
Endovascular therapy, radiosurgery and/or craniotomy
Prevent/manage secondary brain injury (vasospasm, hyponatremia)
Avoid complications
Initiate rehabilitation therapies

30. Stroke Rehabilitation/Post-Acute Management
Physical and Occupational Therapy to maximize functional independence
Body Weight Supported Treadmill Training
Constraint Induced Movement Therapy
Functional Electrical Stimulation
Mirror Therapy
Robotic Aided Systems
Virtual Reality
Cognitive Therapy
Cognitive Re-training
Provide memory tools to aid in maintaining safety

31. Stroke Rehabilitation/Post-Acute Management
Speech Therapy for communication disorders
Dysphagia Management
May require long-term or permanent feeding tube and enteral nutrition
Depression Management
Promote Socialization (social-isolation is common)
Seizure Management
prophylactic anticonvulsants are not recommended

32. How Do You Manage Severe TBI?
For people who have a severe TBI:
Intracranial hypertension 40-50%
Multiple injuries 50%
Surgical mass lesion 40-50%
Mortality 30-35%
Favorable Outcome 40-45%
Transfer to Level 1 Trauma Center
CDC research shows patient outcomes 25% better when sent to a Level 1 Trauma Center
For individuals hospitalized after a TBI, almost half (43%) have a related disability one year after the injury

33. Management of Severe TBI (minimizing secondary injury)
Dark, quiet, low stimulus environment
HOB elevated
Neck midline
3% saline infusion
ICP & PbtO2 monitor
CSF drainage
Sedation & Pain Mgmt: Propofol, Fentanyl, Ativan
23% saline bolus
Normothermia
Selective hypothermia
Decompressive craniectomy
Paralyze with Vecuronium
Osmotic therapy
Hyperventilation rescue therapy for acute herniation

34. How Do You Manage Mild TBI?
At least 75% of TBI are mild
CT usually “negative”
Patient usually alert and oriented
Range of symptoms that may or may not involve LOC
Manage the symptoms

35. Definition of Mild TBI
A patient with mild traumatic brain injury is a person who has had a traumatically induced physiological disruption of brain function, as manifested by a least one of the following:
any period of loss of consciousness;
Only 10% lose consciousness
any loss of memory for events immediately before or after the accident;
Anterograde and/or
Retrograde
focal neurological deficit(s) that may or may not be transient;
any alteration in mental state at the time of the accident (eg, feeling dazed, disoriented or confused);
but where the severity of the injury does not exceed the following:
Post-traumatic amnesia (PTA) not greater than 24 hours.
after 30 minutes, an initial Glasgow Coma Scale (GCS) of 13-15; and
loss of consciousness of approximately 30 minutes or less;

36. Mild TBI Symptoms Cognitive Affective Irritability Emotionally labile
Feeling anxious
Feeling depressed
Somatic
Headache
Dizziness, vertigo
Nausea
Tinnitus
Double or blurry vision
Insomnia/sleep disturbances, fatigue
Sensory disturbances, phono &/or photophobia
Cognitive
Feeling confused
Dazed, foggy
Amnesia
Memory impairment
Trouble concentrating
Trouble with math
Trouble finding the right word to say

37. Mild TBI Management Initial Treatment is Symptomatic: Time & Rest
Treat headache
Treat nausea & vomiting
Dark room/sunglasses for photophobia
Quiet for phonophobia and headache
No sleep medication (especially Ambien)
No video games, excessive TV watching, texting
If it causes symptoms, don’t do it

38. Mild TBI Management – Sent Home from ED
Rest, especially if you have any of the symptoms listed
Do not do any physical work or exercise until your symptoms go away. Anything that causes you to sweat is too much activity.
It is recommended that you see your family doctor within 2 weeks. Do not drive until your family doctor has told you it is okay to drive.
You should not work until you have not had any symptoms for 1 week.

39. Mild TBI Management – Sent Home from ED
If you go back to work and your symptoms come back and don’t go away for more than a week:
Stop working 
Go home
Call the HCMC TBI clinic for an appointment
Do not go back to work until you have seen a TBI clinic doctor
Do not use alcohol (beer, wine, hard liquor) for at least 2 months after your TBI.
Do not play any sports until you have not had any symptoms for at least 1 month.

40. Mild TBI - When do you need a Comprehensive TBI Clinic?
The natural evolution of concussion is that 80% of the people will be back to their usual baseline within a month
Someone still experiencing symptoms after 4 weeks should be evaluated at a comprehensive TBI Clinic
Students should be seen at 2-3 weeks if having problems in school

41. Evaluation at a Comprehensive TBI Clinic
Management based on history, social situation and
physical examination:
Patient history & subjective complaints
Review of medical records from TBI
Patient Education
Natural History of TBI & Expectations for Recovery
Potential Referrals:
Neuropsychological testing
Speech Language Pathology
Occupational Therapy
Vision Therapy
Physical Therapy
Clinical Psychology
Therapeutic Recreation
Vestibular clinic
Medications for headache, nausea, sleep

42. TBI Rehabilitation/Post-Acute Management
Severe TBI rehab similar to stroke
Mild TBI rehab focuses on treating the symptoms. Examples include:
Energy Management and Relaxation
Vestibular Management
Balance & Coordination
Epley Maneuver
Neuro Visual Rehab
Cognitive & Linguistic Rehab
Management of headache & other somatic symptoms
Working with employers & schools on accommodations

43. What Functional Changes Do You See After Stroke?
Physical/Somatic
Hemiparesis/plegia (occasionally bilateral)
Facial droop
Hemi-sensory loss/alteration (numbness, paresthesia)
Visual Changes (visual field cuts, monocular blindness)
Dizziness, loss of balance
Altered Gait
Photo/phono sensitivity (common with SAH)*
Headache (often resolves after acute phase)
Cranial Nerve Dysfunction (with brainstem involvement)

44. What Functional Changes Do You See After Stroke?
Communication Disorders
Dysarthria (ranges from mild to severe)
Expressive Aphasia
Word-finding difficulty
Hesitant or stuttering speech pattern
Fluent aphasia (word salad)
Agraphia (inability to communicate in writing)
Receptive Aphasia
Alexia (inability to understand written information)

45. What Functional Changes Do You See After Stroke?
Cognitive
Altered memory (especially short-term)
Slowed cognitive processing
Impaired judgment
Impulsivity
Disinhibition/boundary issues
Affective
Depression
Emotional lability
Sleep disorders

46. What Other Changes Do You See After Stroke?
Post-Stroke Seizures
Approximately 12% of stroke survivors will develop seizures within 5 years
Stroke is the most common cause of seizures in the elderly
Social Isolation

47. What Type of Functional Changes Do You See After TBI?
Physical/Somatic
Headache
Dizziness/Vertigo
Weakness or paralysis
Swallowing problems
Visual changes
Occulomotor dysfunction
Tinnitus
Photo/phonosensitivity
Balance/coordination
Sleep impairments/extreme fatigue
Seizure disorder

48. What Type of Functional Changes Do You See After TBI?
Communication Disorders
Similar to stroke, especially the expressive aphasia and word finding difficulties
Affective/Emotional
Personality changes
Emotional lability/quick mood changes
Disinhibition
Irritability
Anxiety
Depression

49. What Type of Functional Changes Do You See After TBI?
Cognitive
Amnesia
Short term memory
Insight
Judgment
Confusion
Attention
Concentration
Processing speed

50. Where Do People Go After a Stroke or TBI?
Home or home with assistance
51%
73%
Acute Rehabilitation
18%
11%
Long Term Acute Hospital (e.g. Bethesda) 1% 7%
Subacute Rehabilitation (SNF)
24% 6%

51. Hennepin County Medical Center
Questions?? Contact Information
Donna Lindsay, MN, RN, CNS-BC, SCRN
Program Coordinator
Hennepin Stroke Center
(612)
Carol Ann Smith, BAN, RN, CNRN
Traumatic Brain Injury Center
(612)
Hennepin County Medical Center
701 Park Avenue South
Minneapolis, MN 55415

52. Hennepin County Medical Center
Hennepin Stroke Center
A comprehensive center of excellence providing care to patients and families who have been affected by stroke, including early treatments, acute care management, rehabilitation and research. The Stroke Center is also dedicated to increasing public awareness and education regarding stroke.
Joint Commission Certified Primary Stroke Center
The Traumatic Brain Injury Center
A comprehensive, multidisciplinary center of excellence for patient care, education and research to serve people who have sustained a traumatic brain injury

53. Resources The Minnesota Stroke Association www.strokemn.org
National Stroke Association
American Stroke Association
National Aphasia Association
Minnesota Stroke Partnership

54. Resources The MN Brain Injury Alliance www.braininjurymn.org
Brain Trauma Foundation (
Guidelines for the Management of Severe TBI in the Adult- 3rd Edition – Brain Trauma Foundation – May 2007
Traumatic Brain Injury: The Journey Home
TBI Model Systems

55. Resources American Association of Neuroscience Nurses (www.aann.org)
AANN Core Curriculum for Neuroscience Nursing – 5th Edition
Clinical Practice Guidelines
Care of the Patient with Mild TBI+
Guide to the Care of Hospitalized Patients with Ischemic Stroke
Care of the Patient with Aneurysmal Subarachnoid Hemorrhage
Nursing Management of Adults with Severe Traumatic Brain Injury
Care of the Patient Undergoing Intracranial Pressure Monitoring/External Ventricular Drainage or Lumbar Drainage
Webinars

56. Resources – MN Concussion Law
Legislation on Concussion & Youth Sports signed into law June 2010 and took effect September 2011
Most comprehensive legislation in the nation
The goal of this new law is to improve the recognition and response of youth concussion injuries within all statewide youth athletic activities. This is the most comprehensive legislation in the country.
The Minnesota law applies to all players under the age of 18 and applies to ALL youth sports organizations both PUBLIC and PRIVATE. The law requires that parents have access to information on the risks and symptoms of concussions and coaches must have training on concussions once every 3 years.
The entire text of law can be seen online at the MN Legislature website Chapter 90, Senate File 612.

57. Resources BrainLineMilitary.org
a new online service to help service members — Army, Navy, Air Force, Marines, National Guard, and Reserve —and veterans with brain injury and their families.
The Clinical Practice of Neurological and Neurosurgical Nursing – Joanne Hickey
Consensus Statement on Concussion in Sport 3rd International Conference on Concussion in Sport – Zurich – November 2008 – McCory P., et al. Clin J Sport Med 2009;19:
“Guidelines for the Acute Medical Management of Severe TBI in Infants, Children and Adolescents”, a supplement to Pediatric Critical Care Medicine - July 2003

58. Resources MN State Law Concussion Training for Coaches:
Information on the education for coaches can be found at the Centers for Disease Control and Prevention
and their new National Center for Injury Prevention and Control website