Traumatic Brain Injury - I Scott S. Rubin, Ph.D. Department of Communication Disorders

States with Highest Rates of Traumatic Brain Injury-related Fatalities State/District Annual TBI Fatality Rate per 100,000 population 1 Rank by population size 2 Wyoming Montana Louisiana Nevada Mississippi District of Columbia Arkansas Idaho Alabama Oklahoma26.328

TBI Data –At Risk Groups Males - 15 and 24 years of age 2:1Males:Females Young children and individuals over 75 years of age Falls around the home are the leading cause of injury for infants, toddlers, and elderly people. Violent shaking of an infant or toddler is another significant cause.

TBI Risk Factors More Risk Factors - SES Lower SES = higher incidence of TBI Previous TBI

TBI Data The leading causes for adolescents and adults – 50% Automobile & motorcycle accidents, or pedestrians 20% violent crimes – assaults 20% falls Sports? Other causes? 0

TBI Data 200,000 Americans die each year from injuries. half million more hospitalized. 10 percent of the surviving individuals = mild to moderate, threatening their ability to live independently. 200,000 have serious problems that may require institutionalization or some other form of close supervision.

A 44 year old man was referred to the accident and emergency department by the psychiatric services, having claimed to have hammered several nails through his skull over a three month period. The patient had a long history of depression, personality disorder, and previous deliberate self-harm. He had remained well throughout this period and had been cleaning the wounds with weak antiseptic on a regular basis. He had concealed the injuries by wearing a hat. Two days prior to admission he had inserted a much larger 12.7 cm (5 inch) masonry nail and had developed left sided weakness and unsteadiness of gait. James, G., et al. (2006). A case of self- inflicted craniocerebral penetrating injury. Emerg. Med. J. 23: e32. [Summary] Summary

Type of Injury TBI – Open vs Closed Open Dural covering is penetrated Localized/Focal damage

Open head wound aka, “penetrating head injury”

Bullet 1/3

Open head wound aka, “penetrating head injury” Bullet 2/3

Open head wound aka, “penetrating head injury” Bullet 3/3

A 32-year-old Caucasian male with a history of repeated self- injury drilled a hole in his skull using a power tool and subsequently introduced intracerebrally a binding wire from a sketchpad. An emergency craniotomy was performed around the site of cranial injury, and the foreign body was carefully extracted. The wire was located partially in the subdural space and partially in the right hemisphere of the brain. The patient made an excellent recovery and was referred to a psychiatrist for further treatment. This is a rare case of unusual and complex repetitive self-destructive behavior without apparent suicidal intent. Karabatsou, K., et al. (2005). Self-Inflicted Penetrating Head Injury in a Patient With Manic-Depressive Disorder. Am. J. Forensic Med. Pathol. 26: [Summary]Summary

Open head wound aka, “penetrating head injury” Knife 1/5

Open head wound aka, “penetrating head injury” Knife 2/5

Open head wound aka, “penetrating head injury” Knife 3/5

Open head wound aka, “penetrating head injury” Knife 4/5

Open head wound aka, “penetrating head injury” Knife 5/5

Type of Injury Closed (CHI) – Meninges not torn! blow to head

Acceleration/Deceleration Linear Velocity Coup contusion & Contrecoup contusion

Coup - Contracoup

Angular Acceleration (movement of brain) Abrasions/Lacerations Twisting/Shearing DAI (diffuse axonal injury) Hemorrhages & Cranial Nerve trauma

Diffuse Axonal Injury Other than shearing – different types of axonal injury

Hemorrhage (from any cause) Extracerebral Intracerebral Hemorrhage versus Hematoma

TBI Hemorrhagic Contusion frontal & Temporal Subarachnoid hemorrhage

Edema & Midline Shift (CT)

Depressed Skull Fracture & Hematoma

Extradural Hematoma (CT)

Extradural Hematoma

Cerebral Edema Intercranial Pressure Hypoxic-Ischemic Damage Seizures Early onset Late onset

Issues to consider Consciousness Diminished Coma Reactivity – “reflexive” Perceptivity – Learned – language, gesture… Acquired – flinching from fear…

Damage Areas and Associated Deficits

Recovery – With Hyperbaric Treatments

Deficits Frontal Lobe Class? What deficits could you expect?

Deficits Frontal Lobe Problems: Paralysis Sequencing Attending Problem solving Loss of spontaneous interaction with others Loss of flexible thinking Perseveration Expressive language problems Mood changes Social behavior changes Personality

Deficits Parietal Lobe Functions? What deficits could you expect?

Deficits Parietal Lobe Problems: Inability to attend to more than one object at a time Anomia Agraphia Reading problems Drawing Distinguishing left from right Math Lack of awareness of self and/or surrounding space Lack of visual attention Hand to eye coordination

Deficits Occipital Lobe Functions? What deficits could you expect?

Deficits Occipital Lobe Problems: Vision Colors Inaccurately seeing objects Difficulty locating objects Hallucinations Inability to recognize movement Reading and writing problems

Deficits Temporal Lobe Functions? What deficits could you expect?

Deficits Temporal Lobe Problems: Difficulty recognizing faces Difficulty understanding spoken words Disturbance of selective attention Identification and verbalization about objects Short-term memory loss Changes in sexual behavior Problems with long-term memory Right lobe causes persistent talking

Deficits Brain Stem Problems: Decreased vital capacity for breathing Dysphagia Organization and perception of environment Balance and movement problems Dizziness and nausea Sleeping difficulties

Deficits Cerebellum Functions?

Deficits Cerebellum Problems: Coordination of fine movements Ability to walk Inability to reach out and grab objects Tremors Dizziness Slurred Speech Inability to make rapid movements

Frontolimbic Structures Begins next presentation

Frontolimbic Injury Executive System Impairment Reduced awareness of personal strengths and weaknesses Difficulty setting realistic goals Difficulty planning and organizing behavior to achieve the goals Impaired ability to initiate action needed to achieve the goals Difficulty inhibiting behavior incompatible with achieving the goals Difficulty self-monitoring and self-evaluating Difficulty thinking and acting strategically, and solving real-world problems in a flexible and efficient manner General inflexibility and concreteness in thinking, talking and acting

Frontolimbic Injury Cognitive Impairment Reduced internal control over all cognitive functions Impaired working memory Disorganized behavior related to impaired organizing schemes Impaired reasoning Concrete thinking Difficulty generalizing

Frontolimbic Injury Psychosocial/Behavioral Impairment Disinhibited, socially inappropriate, and possibly aggressive behavior Impaired initiation or paucity of behavior Inefficient learning from consequences Perseverative behavior; rigid, inflexible behavior Impaired social perception and interpretation

TBI - Change of Topic CAUTION - This is a transition! To understand the course of TBI patient recovery – one must understand Coma. So – On to Coma!

TBI - Coma Coma Defined: a deep state of unconsciousness. A person in a coma is alive but not able to move or respond to the environment. Coma may result from an illness, or from a traumatic head injury.

TBI - Coma Glascow Coma Scale: Based on level in 3 areas Eye Opening Motor Response Verbal Response Scores are determined as response is tested. Total score is determined by adding the three categories. Highest possible score is 15. This score would indicate a person who is awake, oriented, and following commands. Lowest score is 3. This score would indicate a person deeply unconscious. A score of 8 or lower generally indicates a person with a severe Brain Injury.

TBI - Coma Glascow Coma Scale: Eye Opening Patient ResponseScore Opens eyes on own4 Opens eyes when asked to in a loud voice 3 Opens eyes when pinched2 Does not open eyes1 First 2 are to speech – the last 2 are to pain.

TBI - Coma Glascow Coma Scale: Best Motor Response Patient ResponseScore Follows simple commands6 Pulls examiner's hand away when pinched 5 Pulls part of body away when examiner pinches patient 4 Flexes body inappropriately to pain – decorticate posturing 3 Body becomes rigid in an extended position when examiner pinches victim, decerebrate posturing 2 Has no motor response to pinch1 1 st is to verbal command – the rest are to pain.

TBI - Coma Glascow Coma Scale: Verbal Response Patient Response Score Carries on a conversation correctly & tells examiner where he is, who he is, and the month and year 5 Seems confused or disoriented 4 Talks so examiner can understand victim but makes not sense 3 Makes sounds that examiner can't understand 2 Makes no noise1

TBI - Coma Glascow Coma Scale: If you can not add 3 numbers – avalable as Pocket PC program!

TBI - Coma The Rancho Los Amigos Levels of Cognitive Functioning (RLA) Designed to measure and track an individual's progress early in the recovery period. They have been used as a means to develop "level- specific" treatment interventions and strategies designed to facilitate movement from one level to another. A RLA level is determined based on behavioral observations. The RLA scale designates eight (8) levels of function: - see the following…

TBI - Coma The Rancho Los Amigos Level I – No Response The individual appears to be in deep sleep and is completely unresponsive to any stimuli.

TBI - Coma The Rancho Los Amigos Level II – Generalized Response The individual reacts inconsistently and non-purposefully to stimuli. Responses are limited in nature and often the same regardless of the stimuli presented. Responses may include gross motor movements, vocalization, and physiologic changes. Response time is likely to be delayed. Deep pain evokes the earliest response.

TBI - Coma The Rancho Los Amigos Level III – Localized Response The individual responds specifically but inconsistently to stimulus. Responses are directly related to the type of stimuli presented. For example, an individual's head will turn toward a sound or his/her eyes will focus on an object when presented. The individual may follow simple commands and may respond better to some people (i.e. family and friends) than others.

TBI - Coma The Rancho Los Amigos Level IV – Confused – Agitated The individual is in a heightened state of activity with severely decreased ability to process information. Behavior is non-purposeful relative to the immediate environment. Attempts to climb out of bed, remove restraints, and hostility are common. The individual requires maximum assistance to perform self-care activities. An individual may sit, reach, or walk, but will not necessarily perform these activities upon request.

TBI - Coma The Rancho Los Amigos Level V – Confused – Inappropriate Patient appears alert and responds to simple commands. More complex commands, however, produce responses that are non-purposeful and random. The patient may show some agitated behavior it is in response to external stimuli rather than internal confusion. The patient is highly distractible and generally has difficulty in learning new information. He can manage self-care activities with assistance. His memory is impaired and verbalization is often inappropriate.

TBI - Coma The Rancho Los Amigos Level VI – Confused – Appropriate The individual shows goal-oriented behavior, but is dependent upon external input for direction. Response to discomfort is appropriate. Responses are incorrect due to memory problems, but are appropriate to the situation. Simple commands are followed consistently and carry-over for relearned activities is evident. Orientation is inconsistent but awareness of self, family, and basic needs is increased.

TBI - Coma The Rancho Los Amigos Level VII – Automatic – Appropriate The individual appears appropriate within hospital and home settings, goes through daily routine automatically but is robot-like, with shallow recall of activities performed. Has absent-to-minimal confusion and lacks insight. The individual frequently demonstrates poor judgment and problem solving and expresses unrealistic future plans. With structure the individual is able to initiate tasks or social and recreational activities.

TBI - Coma The Rancho Los Amigos Level VIII – Purposeful – Appropriate The individual is alert and oriented, able to recall and integrate past and recent events and is aware of and responsive to the environment. Independence in the home and community has returned. Carry-over for new learning is present, and the need for supervision is absent once activities have been learned. Social, emotional and cognitive abilities may still be decreased.

Transition Also in Presentation 2 Mild Head Injury Issues follows…

TBI – Mild head Injury Loss of consciousness (or alteration in consciousness) under an hour – probably more like 10 minutes. Referred to as “Concussion” Most likely return to “normal” May be associated with Post- concussion Syndrome. (see next slide)

TBI – Post-Concussion Syndrome Symptoms: headache, dizziness, concentration problems, memory problems, irritability, and decreased energy. Should clear in 5 to 10 weeks.

TBI – Accident Neurosis May accompany Post-Concussion Syndrome. Psychological disorder – exaggerates symptoms. Increases depression and anxiety. Higher incidence – in Men or Women? Higher incidence if litigation is involved.

TBI - Continued Next presentation begins with Prognosis in TBI.