1. Craniocerebral Trauma Lawrence M. Richman, M.D., Neurology Certified in Neurology, American Board of Psychiatry and Neurology Certified in Electro-diagnostic Medicine, American Board of Electro- diagnostic Medicine Certification, Brain Injury Medicine (ABPN), to be designated 2016 Fellow, American Association of Neuro-muscular and Electro- diagnostic Medicine NIH Fellowship, Vestibular (Balance) disorders & Neuro- ophthalmology Asst. Clinical Prof., UCLA School of Medicine, 15 years, through 1997, Clinical Instructor Neurology Program, Cedars Sinai-present Team Physician, U.S. Alpine Olympic Team Medical Licenses, California & Utah

2. Post-Concussive Syndrome An array of symptoms following head injury with or without loss or alteration of consciousness. Approximately 50 % of individuals who sustain blunt head trauma without LOC, go on to develop PCS. Not all patients who sustain a concussion, go on to develop PCS. At four years, approximately 15-20% of patients who developed PCS are still symptomatic, i.e. chronic PCS

3. Symptoms of PCS Memory disturbance Impaired concentration Easy distractibility, slow reaction time Irritability, fatigue, diminished appetite Insomnia Hyper-somnolence Tinnitus Non-vestibular dizziness Anxiety, Depression Headaches, Blurring of vision, light/noise sensitivity

4. Concussion vacant stare (befuddled facial expression) Delayed verbal and motor responses (slow to answer questions or follow instructions) Confusion and inability to focus attention (easily distracted and unable to follow through with normal activities) Disorientation (walking in wrong direction, unaware of time, date, place) Slurred or incoherent speech (making disjointed or incomprehensible statements) Gross observable in-coordination (stumbling, inability to walk tandem/straight line) Emotions out of proportion to circumstances (distraught, crying for no apparent reason) Memory deficits (exhibited by repeatedly asking the same question that has already been answered, or inability to recall 3 words at 5 minutes. ) Any period of loss of consciousness ( coma, unresponsiveness )

8. Ritchie Russell Scale Duration of post-traumatic amnesia may be used to address severity of TBI. Less than 5 mts- Very mild Less than 1 hour-Mild 1 to 24 hours-Moderate 1 to 7 days-Severe More than 7 days-Very Severe More than 4 weeks- Extremely severe

14. Shear Injuries Also known as Diffuse Axonal Injury (DAI) Degeneration of cerebral white matter Shearing may not necessarily be realized at the time of injury except when injuries are severe. Injury may progress over 24 hours or weeks later; Increased permeability, Ca++ influx, mitochondrial swelling.

22. Acute Epidural Hematoma

23. Sub-Acute SDH, Acute ICH

24. Seizures and Head Trauma 1. Traumatic Induced Seizure-blunt trauma triggering a seizure, not a source for future epilepsy. Also referred to as “ Early Seizures,” may occur up to 2 weeks, post injury. 2. Seizure after blunt head trauma, LOC of 30’ or <, no skull fracture, no intracranial bleed, NON-statistical for future seizures ( incidence 1.0-2.2 =nl. pop.).

25. Head Trauma and Seizures 3. Head trauma with LOC of 30” to 24 hours, or associated with skull fracture ( excluding base of skull fracture ), risk of post-traumatic epilepsy: standardized incidence 0.7% @ 1 year, 1.6% 5 years, statistically significant increase for occurrence of epilepsy. 4. Head Trauma, LOC >24 hours, intracranial bleed, incidence 7% @ 1 yr., 11.5 % @ 5 yrs. Mayo Clinic Study, n. 2747.

26. Compensation Neurosis & Malingering 1study in the UK, 200 consecutive mild HT, 47 had psychoneurotic presentation, arrived late, over dramatization, martyrdom appearing but the author did not entirely reject a component of PCS. Another study of 398 mild HT patients, found the Dx of Accident Neurosis: bizarre & inconsistent complaints, exaggeration of the initial period of LOC, attention seeking.

27. Compensation Neurosis More common with manual workers than non- manual. Psychiatric treatment NOT helpful Not common found in only 6.8% of the study group. Litigants similar to non-litigants showing similar symptoms and improve over time. Those applying for compensation have the same symptoms and those not applying.

28. Favorable Verdict of Claim The end of litigation DOES NOT MEAN the end of symptoms and RTW. In one study, 39% of litigants were symptomatic at the time of settlement, 34% symptomatic one year later. Older patients and those employed with dangerous work most apt not RTW after settlement per one study.

29. Treatment mild PTHS/PCS Cognitive rehab controversial and costly. If psych symptoms are prominent, a course of psychotherapy may be useful Consider anti-depressants and anti-anxiety meds in that both these disorders can be a source of cognitive impairment on a neurochemical basis. No use for EEG, Dig. EEG, PET, SPECT, fMRI, (the latter 3 affected by depression) and repeat MRIs, CATs, etc.