1. Introduction to Traumatic Brain Injury Joe Rosenthal, MD Clinical Assistant Professor TBI Fellow 11/1/10

2. Objectives Definition Epidemiology Severity of injury Mechanisms/Types of Brain Injury Symptoms/Treatment Return to work and driving

3. 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

4. www.cdc.gov/features/dsTBI_BrainInjury/

5. National Center for Injury Prevention and Control at the Center for Disease Control

6. 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

7. Risk Factors Young (15-24 year olds – Highest Risk) Low income Unmarried Minority Inner city Male (2x more likely) Substance abuse Previous TBI

8. 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

9. What is the Most Common INDIRECT Cause of TBI?

10. Most Common INDIRECT Cause ALCOHOL

11. TBI Spectrum Mild/Concussion ModerateSevereDeath

12. Determining Severity Loss of Consciousness Duration Post Traumatic Amnesia & Confusion Wounds, Bruising, Swelling Tools: –Glascow Coma Scale (GCS) –Radiographic Imaging

13. 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.

14. Other Mild TBI Criteria GCS 13-15 No Head CT abnormalities Hospital stay < 48 hrs No operative lesions

15. Complicated Mild TBI Mild TBI with small amount of bleed, bruising, swelling, or skull fracture seen on imaging Higher risk of more chronic symptoms

16. 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

17. Severe TBI GCS 3-8 Coma duration 6+ hours

18. Why is the Brain so Vulnerable?

21. Brain Injury Types Contusion DAI Penetrating Injuries Intracranial Hemorrhage Secondary Injuries (including Hypoxia)

22. Contusion Low velocity impact Often symmetric (coup-countercoup) Not responsible for coma Focal deficits Recovery dependent on size and location Occasionally require resection

23. Injury Not Always Just at Impact Site

24. Diffuse Axonal Impact High velocity impact Almost always has some time of unconsciousness Diffuse pattern of deficits Recovery gradual

25. Diffuse Axonal Injury Widespread stretching of axons –Rotation on axis –Acceleration-deceleration Mild force - external Severe force - internal Often imaging is normal

26. http://braininjury.blogs.com/photos/uncategorized/closedheadinjury.jpg

27. Penetrating Injuries Missile (Gun shot wound) Non-missile (ice pick) Only primary mechanism on the rise

28. 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

29. 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

30. 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

31. Intracranial Hemorrhage Intraparenchymal hemorrhage –Cerebral parenchyma –Injury to deeper, larger cerebral vessels –Different mechanism and often more diffuse deficits compared to CVA bleed

32. Intraventricular Hemorrhage –Occur with very severe TBI –Unfavorable prognosis due to severity of injury

33. 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)

34. 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

35. Journey to Recovery

36. Immediate Treatment Observation – alertness, confusion, Headache, nausea, etc. Blood Pressure & other vitals monitoring Imaging Surgery Intracranial Pressure Monitoring

37. 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

38. Amnesia http://braininjuryrx.com/2009/06/misconceptions-made-by-nursing-students-about-amnesia-in-tbi/

39. Posttraumatic Amnesia Definitions 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

40. Post- Traumatic Headaches Very common, especially after Mild-Mod TBI Different Types: –Migraine –Tension –Related to Neck injury/pain Treatment –Time –Medications

41. 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

42. Cognitive Changes http://www.braybray.co.uk/cms/photo/misc/head_injuries.gif

43. Other Cognitive Deficits Short Term and Working Memory Problems Decreased Attention Cognitive Fatigue Problem Solving difficulties

44. Emotional/Personality Changes Depression Anxiety Irritability Anger/Aggression Obsessive/Compulsive Often pre-injury psychiatric conditions are exacerbated after injury

45. Incidence of Anxiety and Depression after Traumatic Brain injury Depression 61% Anxiety 17% Anxiety and depression 60%

46. Frequent Complaints with TBI related Depression Frustration81% Restlessness73% Boredom66% Sadness66%

47. 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)

48. Movement Disorders Weakness Spasticity Abnormal movements Difficulty coordinating movements

49. Visual Deficits Blurry Vision Double Vision Trouble opening and closing eyelids Blindness

50. Dizziness & Vertigo Inner ear damage -- ringing in ears Lightheadedness from blood pressure problems Injury directly to brain resulting in these symptoms Tx

51. Other Senses Taste change Loss of smell Numbness/tingling

52. 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

53. Rehabilitation Multi-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

54. Return To Work Dependent on multiple factors –Severity of injury –Cognitive functioning –Type of job –Symptoms –Physical limitations

55. Return to Work Tools to assess readiness –Physician visits –Therapy reports –Neuropsychological testing

56. Epidemiology of Traumatic Brain Injury in the United States Return to Work mild90-100% moderatepoor data severe10-25%

57. Return to Work Possible Accommodations New position (less demanding, safer) Frequent rest breaks Return Part Time Work Conditioning/Hardening with therapy Vocational Training (BVR) Memory Aids

58. 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

59. Questions

60. 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.htmhttp://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.