1. Mild Traumatic Brain Injury: Diagnosis and Management Andy Jagoda, MD Department of Emergency Medicine Mount Sinai School of Medicine New York, New York

2. Andy Jagoda, MD Objectives Definitions –Glasgow coma scale score –Amnesia / loss of consciousness Neuroimaging –Skull radiographs –CT –MRI Postconcussive syndromes –Neuropsychiatric testing –Prognosis Management

3. Andy Jagoda, MD A 50-year-old driver is in a head-on collision at approximately 15 mph. She is not wearing a seat belt and strikes her head on the windshield. The windshield does not break, and though dazed for “several seconds” she does not lose consciousness and has no amnesia. She is taken to the ED where she is alert, oriented times three, and has no complaints. She has no past medical history and is on no medications. The Case

4. Andy Jagoda, MD Which of the Following is Not Used to Define Mild TBI? a. GCS >12 b. Loss of consciousness <1 hr c. Post-traumatic amnesia <24 hrs d. Non-focal neurologic exam e. CT scan

5. What would the GCS be in the presented case If on exam the patient kept her eyes closed but opened them to questions; answered questions with difficulty and was confused; moved her extremities appropriately on command? a. 15 b. 13 c. 11 d. 09 e. 07

6. If the presented patient had an occipital laceration with no hematoma, which of the following would be the best initial test? a. Skull radiographs b. Non-contrast CT c. Contrast CT d. MRI E. PET

7. Andy Jagoda, MD Postconcussive Syndrome (PCS) in Mild TBI, which of the following is true? a.Early PCS occurs primarily in patients with psychiatric problems. b.Early PCS occurs more frequently in patients involved in litigation. c.Early PCS occurs in up to 20% of patients. d.Late PCS occurs primarily in men. e.Late PCS has been linked to anxiety, stress, and depression.

8. Andy Jagoda, MD Epidemiology 6 million head injury cases in the USA each year (1 in 45) –Young male predominance 2 million ED evaluations 250,000 hospitalizations (1 in 1000) 60,000 deaths (1 in 5000) Most cases are classified as mild

9. Andy Jagoda, MD Pathophysiology Deceleration / rotation injury Blood vessel disruption –Petechial hemorrhage –Focal edema –Disruption of bridging veins Intra-axonal neurofilament organization / axonal swelling Secondary injury –Excitatory amino acids –Oxygen free radicals

10. Andy Jagoda, MD Diagnosing Mild TBI Mild TBI Committee of the American Congress of Rehabilitation Medicine Alteration in mental state at the time of the accident LOC <30 min After 30 min, GCS 13-15 Amnesia <24 hours

11. Andy Jagoda, MD Classification - GCS Eyes –4 opens spontaneously –3 opens to verbal –2 opens to pain –1 do not open Verbal –5 oriented –4 confused –3 inappropriate –2 incomprehensible –1 none Motor –6 obeys –5 localizes –4 withdraws –3 abnormal flex –2 extensor response –1 none Scoring –Mild >12 –Moderate 9-12 –Severe <9

12. Andy Jagoda, MD Classification - GCS - Mortality Developed for prognosis in severe TBI Timing of score is not standardized One score not sufficient - perform serial exams –Prognosis worse if score does not improve or if it worsens Does not account for drugs, seizures, or metabolic problems

13. Andy Jagoda, MD Classification - GCS - Mortality Severe = 40% –3 = 80% –4 = 55% –5 = 40% Moderate = 12% Mild = 01%

14. What would the GCS be in the presented case If on exam the patient kept her eyes closed but opened them to questions; answered questions with difficulty and was confused; moved her extremities appropriately on command? a. 15 b. 13 c. 11 d. 09 e. 07

15. Andy Jagoda, MD Which Of The Following Is Not Used To Define Mild TBI? a.GCS > 12 b.Loss of consciousness < 1 hr c.Post-traumatic amnesia < 24 hrs d.Non-focal neurologic exam e.Normal CT scan

16. Andy Jagoda, MD Use of CT in Diagnosing MTBI Retrospective study, 215 hospitalized patients –Mild TBI without complications –Mild TBI with complications (positive CT) –Moderate TBI Mild TBI patients with positive CT performed on neuropsychiatric testing like moderate TBI Williams et al. Neurosurgery 1990;27:422.

17. Andy Jagoda, MD Use of CT in Diagnosing MTBI Moderate group had worse function at 6 months Length of LOC or amnesia did not differentiate mild from moderate groups Depressed skull fractures without parenchymal lesions did performed as mild TABI Williams et al. Neurosurgery 1990;27:422.

18. Andy Jagoda, MD Skull Radiographs and Intracranial Lesions Retrospective review 207 hospitalized patients with intracranial lesions 63% had no skull fracture Skull films do not predict intracranial lesion Cooper P, Ho V. Neurosurgery 1983;13:136.

19. Andy Jagoda, MD Retrospective review 22,058 cases Patients with skull fractures, 91% did not have intracranial injury 51% of patients with intracranial injury did not have a skull fracture Masters et al. NEJM 1987;316:84-91. Skull Radiographs and Intracranial Lesions

20. Andy Jagoda, MD Skull Radiographs and Intracranial Lesions Prospective study: 7035 patients –Not all patients received same tests –48% lost to follow-up Skull fracture was associated with an intracranial injury Masters et al. NEJM 1987;316:84-91.

21. Andy Jagoda, MD Skull Radiographs and Intracranial Lesions Skull fracture did not predict an intracranial injury Absence of a skull fracture did not rule out an intracranial injury Plain films are neither sensitive nor specific for intracranial injury Masters et al. NEJM 1987;316:84-91.

22. Andy Jagoda, MD Low Risk Group For Intracranial Injury Asymptomatic Headache Dizziness Scalp hematoma, laceration, contusion Absence of moderate or high risk criteria, ie, LOC or amnesia No patients with neurologic deterioration identified No imaging study indicated Masters et al. NEJM 1987;316:84-91.

23. Andy Jagoda, MD Moderate Risk Group For Intracranial Injury Loss of consciousness Unreliable history Progressive headache Alcohol or drug intoxication Age less than 2 years Post traumatic seizure BSF / multiple trauma / possible penetrating trauma CT scan recommended Masters et al. NEJM 1987;316:84-91.

24. Andy Jagoda, MD Head CT In Mild TBI Retrospective review 1538 trauma admissions GCS > 12; all with history of LOC or amnesia 265 (17.2%) had intracranial lesion: –GCS 13: 37.5% –GCS 14: 24.2% –GCS 15: 13.2% 58 (3.8% of total 22% of patients with positive CT) required neurosurgery No patient with a normal CT deteriorated Stein S, Ross S. Ann Emerg Med 1993;22:1193.

25. Andy Jagoda, MD Head CT In Mild TBI Prospective study: 712 consecutive ED patients GCS 15; history of LOC or amnesia Nonfocal neurologic exam –4 object recall and digit span testing 67 (9.4%) had a positive head CT 2 (.28%) required emergent neurosurgery No statistical model could be created to classify 95% of patients into CT normal vs abnormal Jeret et al. Neurosurgery 1993;32:9.

26. Andy Jagoda, MD Head CT In Mild TBI 10% to 20% have a positive CT.2 to 4% have a neurosurgical lesion Patients without LOC or amnesia, normal exam, and GCS 15 do not need imaging –Direct trauma to the temporal area –Children <3 years

27. Andy Jagoda, MD Head CT in Mild TBI In patients with LOC or amnesia, there are no combination of findings that identify all patients who have a positive CT Patients with a normal CT can be safely discharged home

28. Andy Jagoda, MD Magnetic Resonance Imaging Prospective study 50 TBI patients; CT, MRI, neuropsych 72% had lesions on CT 80% had lesions seen on MRI –Scattered punctate lesions; Frontal temporal regions Levin et al. J Neurol Neurosurg Psych 1992;55:255.

29. Andy Jagoda, MD Magnetic Resonance Imaging MRI identified additional lesions in 52% of patients with lesions on CT No correlation with size of lesions and length of LOC: inconsistent relationship between lesions and neuropsych findings Levin et al. J Neurol Neurosurg Psych 1992;55:255.

30. Andy Jagoda, MD Other Diagnostic Modalities Brainstem auditory evoked potentials (BAEP) EEG power spectra analysis Singular photon emission computed tomography (SPECT) Positron emission tomography (PET)

31. If the presented patient had an occipital laceration with no hematoma. Which of the following is the best initial test? a.Skull radiographs b.Non-contrast CT c.Contrast CT d.MRI e.PET

32. Andy Jagoda, MD PCS: Reading the Literature Symptom complex related to TBI –Somatic Headache, sleep disturbance, dizziness, nausea, fatigue, sensitivity to light / sound –Cognitive Attention / concentration problems, memory problems –Affective Irritability, anxiety, depression, emotional lability Incidence in MTBI patients: –80% at 1 month –30% at 3 months –15% at 12 months

33. Andy Jagoda, MD PCS: Reading the Literature Lack of uniformity in definitions Selection bias No controls No pre-injury baseline Lack of standardization of testing Attrition in follow-up

34. Andy Jagoda, MD Postconcussive Syndrome Prospective study, 538 patients MTBI, hospitalized 3 month follow-up 79% headaches 59% memory dysfunction 33% had not returned to work Ongoing litigation did not correlate with complaints Rimel et al. Neurosurgery 1981;9:221.

35. Andy Jagoda, MD Postconcussive Syndrome 587 hospitalized, uncomplicated MTBI patients Prospective design over 1 year –68% lost to follow-up At discharge, 67% had at least one symptom 38% had symptoms at 3 months 23% had symptoms at 6 months 13% had symptoms at 12 months Presence of symptoms at hospital discharge were not predictive of symptoms at 3 months Alves et al. J Head Trauma Rehab 1993;8:48.

36. Andy Jagoda, MD PCS Symptoms and Other Injuries 170 patients with chronic pain, with no history of TBI All had at least one somatic complaint associated with PCS 42% had at least one cognitive complaint (forgetfulness, problem with attention or concentration) Emphasizes importance of assessing patients with PCS for concomitant physical or psychosocial problems Iverson. Brain Injury 1997;11:783.

37. Andy Jagoda, MD PCS: Neuropsychiatric Testing No consensus on tests Testing focuses on cognitive function: –Attention –Information processing –Choice reaction time Testing demonstrates clear deficits in the first 3 months that appear independent of psychosocial factors Persistence of symptoms after 3 months appears to be complicated by psychosocial factors

38. Andy Jagoda, MD LOC and Amnesia No correlation found between LOC and development of PCS symptoms No difference in neuropsych testing in patients with and without LOC No correlation found between length of postconcussive amnesia and PCS Yarnell. Brain Injury 1988;2:255. Lenninger. J Neurol Neurosurg Psych 1990;53:293. Williams. Neurosurgery 1990;27:422.

39. Andy Jagoda, MD Prognostic Predictors Of PCS Best prognosis –Young –Male –Educated –Social support Worse prognosis –Elderly –Female –Social / physical stressors –Substance abuse

40. Andy Jagoda, MD Postconcussive Syndrome (PCS) in Mild TBI, which of the following is true? a.Early PCS occurs primarily in patients with psychiatric problems. b.Early PCS occurs more frequently in patients involved in litigation. c.Early PCS occurs in up to 20% of patients. d.Late PCS occurs primarily in men. e.Late PCS has been linked to anxiety, stress, and depression.

41. Andy Jagoda, MD Disposition Saunders et al. Ann Emerg Med 1986;15:160. –47 consecutive MTBI discharged from the ED –No patient could remember more than 2 of the 8 items on the home care discharge instructions –20% denied ever having received instructions –Third party involvement improved compliance with instructions to 67%

42. Andy Jagoda, MD Disposition Levitt et al. Amer J Emerg Med 1994;12:172. –23% of MTBI patients discharged from the ED could not remember any of their discharge instructions Studies emphasize importance of involving third parties in discharge process

43. Andy Jagoda, MD Conclusions Mild TBI patients are at risk for intracranial injury and developing the PCS Plain film radiographs have low sensitivity and specificity for intracranial injury and are not indicated 10% - 20% of mild TBI patients have abnormalities on non-contrast head CT.2% - 4% of mild TBI pts have a neurosurgical lesion 80% after a mild TBI have symptoms of PCS and should be properly counseled