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Brain Injury 101: What You Need to Know. Jennifer M. Zumsteg, M.D. University of Washington Rehabilitation Medicine April 30, 2010. Thanks to Kathleen R. Bell, M.D. for slides Sign-up for slides – a copy will be emailed to you.

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brain injury 101 what you need to know
Brain Injury 101: What You Need to Know

Jennifer M. Zumsteg, M.D.

University of Washington

Rehabilitation Medicine

April 30, 2010

slide2
Thanks to Kathleen R. Bell, M.D. for slides
  • Sign-up for slides – a copy will be emailed to you
slide4
Bill Johnson, a U.S. Olympic gold medalist in downhill skiing, went into a coma and suffered brain injuries after this hard fall on March 22, 2001, in Big Mountain, Mont.
slide5
“The decision-making process is not one of his strong suits now”, Kakes (friend and neighbor) said.
  • “He just raises his voice. He’s not a swearing kind of person”, DB Johnson said. “He’ll get mad at me and I’ll stop him and say ‘Why are you mad at me?’ He’ll say, ‘I’m not mad at you.’ He doesn’t realize he’s doing it.”
slide6
Gold-Medal Skier Bill Johnson Arrested UPDATED - Sunday February 13, 2005 10:39am from our sister station WJLA-TV
  • PORTLAND, Ore. (AP) - Olympic ski champion Bill Johnson was charged with assaulting an officer and resisting arrest after punching a sheriff's deputy in the face during a traffic stop, police said.
slide7
“The problem became especially apparent earlier this year when he was pulled over by police and, because of his speech, suspected of drunk driving. There was no alcohol in his system, but Johnson became so agitated that he was arrested and charged with assault. Now he doesn’t drive, relying on family and friends…”
outline of presentation
Outline of Presentation
  • Epidemiology and prevalence of Traumatic Brain Injury (TBI)
  • What is TBI and how does it happen?
    • Moderate to severe TBI
    • Mild TBI (Concussion)
  • The results of TBI
    • Medical
    • Cognitive
    • Behavioral
epidemiology of traumatic brain injury
Epidemiology of Traumatic Brain Injury
  • 1 million people are treated and released from hospital emergency departments each year
  • 230,000 people/year are hospitalized and survive
  • 50,000 people die each year
  • 5.3 million Americans are living today with a TBI-related disability
risk factors and causes
Risk Factors and Causes
  • WHO?
    • Males, adolescents, young adults, older than 75
  • WHAT?
    • Motor vehicle crashes
    • Violence
    • Falls
    • Military
    • Sports/Recreational
costs of tbi
Costs of TBI
  • Direct annual expenditures
    • $4.5 billion
  • Indirect annual costs
    • $33.3 billion
  • Total costs
    • $37.8 billion (in 1985 dollars)
mechanisms of injury
Mechanisms of Injury
  • Primary mechanism
    • Penetrating (high velocity, more damage, e.g., gunshot wound)
      • Lacerating and crushing
      • Cavitation
      • Shock waves
      • Skull and bullet fragments
slide14
Closed/Moderate-Severe
    • High velocity translational (inferior frontal and temporal lobes)
    • High velocity rotational (shearing at grey-white interface)
    • Diffuse axonal injury
slide15
Blunt Force
    • skull fracture
    • contusion at point of impact
    • contrecoup injury (fall)
slide16
Primary
  • Space occupying lesions
    • epidural hematomas 6%
    • subdural hematomas 24%
    • intracerebral hemorrhage/intraventricular hemorrhage
    • herniation from mass effect
secondary brain injury
Secondary Brain Injury
  • altered cerebral blood flow
  • hypotension
  • release of neurotoxic compounds
    • cellular inflammatory response
    • cytokines
    • calcium influx
    • oxygen free radicals
blast injury more of the same
Likely same types of brain injury

High stress environment

Associated injuries: hearing loss, limb injury

PTSD/Anxiety Disorders

Blast Injury: More of the Same?
glasgow coma scale
Best Eye Response. (4)

No eye opening.

Eye opening to pain.

Eye opening to verbal command.

Eyes open spontaneously.

Best Verbal Response. (5)

No verbal response

Incomprehensible sounds.

Inappropriate words.

Confused

Orientated

Best Motor Response. (6)

No motor response.

Extension to pain.

Flexion to pain.

Withdrawal from pain.

Localising pain.

Obeys Commands.

E + V + M = Total

Severe 3-8

Moderate 9-12

Mild 13-15

Glasgow Coma Scale
posttraumatic amnesia
Posttraumatic Amnesia
  • length of time from the point of injury until the individual has a continuous memory for ongoing events
  • Better predictor of functional outcome than GCS
what is concussion
What is concussion?
  • Mild Traumatic Brain Injury (MTBI)
  • Defined by symptoms (1 or more)
    • Any period of observed or self-reported
      • Transient confusion, disorientation or impaired consciousness
      • Dysfunction of memory around the time of the injury
      • Loss of consciousness lasting less than 30 minutes
slide25
Observed signs of neurological or neuropsychological problem
    • Seizures right afterwards
    • Young children – irritability, lethargy, vomiting
    • Symptoms like headache, dizziness, irritability, fatigue or poor concentration soon after injury
what happens in the brain
What Happens in the Brain?
  • Decreased blood flow
    • May not see it for 2-3 days afterwards and can last for a week
  • Hyperglyocolysis (high metabolism)
  • Excitotoxicity (glutamate)
  • Abnormal ion flows from cells
how often does it happen
How often does it happen?
  • Centers for Disease Control estimates:
    • 1.5 million people a year have a TBI
    • About 75% of these are mild (like concussions)
    • Don’t really know how many because:
      • No one keeps track outside of hospitals
      • Lots of concussions aren’t reported to anyone
features of concussion
Features of concussion
  • Vacant stare (befuddled expression)
  • Delayed verbal and motor responses
  • Confusion and inability to focus attention
  • Disorientation
  • Slurred or incoherent speech
  • Gross observable incoordination
features of concussion31
Features of concussion
  • Emotions out of proportion to circumstances
  • Memory deficits
  • Any period of loss of consciousness
symptoms of concussion
Symptoms of concussion
  • Early symptoms
    • Headache
    • Dizziness or vertigo
    • Lack of awareness of surroundings
    • Nausea or vomiting
late symptoms of concussion
Late symptoms of concussion
  • Persistent low grade headache
  • Light-headedness
  • Poor attention and concentration
  • Memory dysfunction
  • Easy fatiguability
  • Irritability and low frustration tolerance
  • Intolerance of bright lights or diffulty focusing vision
  • Intolerance of loud noises, ringing in the ears
  • Anxiety and/or depressed mood
  • Sleep disturbance
dysautonomia
Dysautonomia
  • hypertension (HTN), fever, tachycardia, tachypnea, pupillary dilation, and extensor posturing
  • Elevated catecholamine levels in proportion to the severity of injury, diffuse axonal injury, and brainstem injury
treatment for posturing
Treatment for posturing
  • Range of motion
  • Splinting or casting
  • Botulinum toxin or phenol injections
  • Dantrolene
  • Control of dysautonomic episodes
metabolic electrolyte disturbances
Metabolic/Electrolyte Disturbances
  • Disorders of Sodium: Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
    • hyponatremia, lethargy, nausea, seizures
      • exclude adrenal insufficiency, drug causes (carbamazepine)
      • water restriction, free sodium use, NSS
metabolic electrolyte disorders
Metabolic/Electrolyte Disorders
  • Disorders of sodium: Diabetes insipidus
    • polydipsia, polyuria, hypernatremia, fatigue, altered mental status
      • treatment: 1-d-amino-8-D-arginine-vasopressin (DDAVP) nasal spray, carbamazepine
nervous system late intracranial mass lesions
Nervous System - Late Intracranial Mass Lesions
  • Subdural Hematoma
    • Acute immediate
    • Subacute 3-20 days
    • Chronic > 3 weeks
hydrocephalus
Hydrocephalus
  • Clinical presentation:
    • classic - dementia, ataxia, urinary incontinence
    • TBI - loss of upgaze, akinetic mutism
    • Headache, nausea, vomiting and lethargy or decreasing mental status
    • Hypertension
  • Usually within 30 days but can be further delayed
risk factors for hydrocephalus
Risk Factors for Hydrocephalus
  • Subarachnoid hemorrhage
  • More severe injuries
  • Skull fractures (depressed)
  • Infectious processes
cns infection
CNS Infection
  • Risk factors:
    • depressed skull fractures
    • basilar skull fractures and fistulas
    • CSF leaks (otorrhea, rhinorrhea)
    • pneumocephalus
    • penetrating injuries
    • cranioplasty
types of infections
Types of Infections
  • Meningitis
  • Brain Abscess
  • Subdural Empyema
  • Skull Osteomyelitis
seizures
Seizures
  • Incidence: 2-2.4% entire population with TBI
    • Mild 1.5, Moderate 2.9, Severe 17.0
    • Early – week one
    • Late – after one week
  • Most initial seizures (80%) will occur in the first 2 years
risk factors for seizures
Risk Factors for Seizures
  • Severity of trauma
  • Penetrating head injuries
  • Intracranial hematoma
  • Depressed skull fracture
  • Hemorrhagic contusion
  • Coma lasting more than 24 hours
  • Early PTS
types of seizures
Types of Seizures
  • Generalized tonic-clonic
  • Partial or focal
    • simple - consciousness maintained
    • complex - consciousness impaired
  • Pseudoseizures (psychogenic)
  • Temporal lobe (psychic, sensory, behavior)
  • Orbitofrontal (automatisms, behavior)
seizure management
Seizure management
  • Important to prevent further brain injury
  • For moderate to severe TBI, standard of care is to treat with antiepileptic drugs (usually Dilantin) for one week
  • Afterwards, treat only if seizure recurs
  • Problems with AEDs: sedation, slowed learning, ataxia
seizure management52
Seizure management
  • Driving – Washington State requires 6 months seizure-free before resuming driving
  • Duration of Treatment?
endocrine disorders
Endocrine Disorders
  • Approximately 20% of persons with moderate to severe injuries
hypothalamic pituitary adrenal axis regulation
Hypothalamic-pituitary-adrenal axis regulation

Hypothalamus

Anterior

Pituitary

Adrenal

Glands

CRH

ACTH

Cortisol

CRH

TRH

GHRH

GRH

PRH/PIH

GH

TSH

FSH

LH

ACTH

types of disorders
Types of Disorders
  • Hypothyroidism
  • Growth Hormone deficiency
  • Hypogonadism
motor disorders
Motor Disorders
  • Spastic hypertonia
    • Contractures
  • Ataxia
  • Tremor
  • Dystonia
  • Parkinsonism
  • Tics
musculoskeletal involvement after tbi
Musculoskeletal Involvement after TBI
  • Limb Fractures
    • 62% have associated fractures
    • ~10% undiagnosed at time of rehab admission
    • 5% cervical spine
    • Open reduction and fixation
    • Frequently missed - distal radius
  • Peripheral nerve injuries
    • Also about 10% undiagnosed initially
heterotopic ossification
Heterotopic Ossification
  • Occurrence: 11-35% of patients
  • Risk factors: prolonged coma, spasticity, pressure ulcers, edema, skeletal trauma, increased severity of brain injury
  • Large joints (hip, shoulder, elbow)
visual deficits
Visual deficits
  • Affects vision, balance, cognition
  • Cranial nerve injuries
    • 3, 4, 6th nerve resulting in decreased eye movements and diplopia
  • Occipital cortex injury
    • Visual field loss, cortical blindness
  • Optic tract injury
    • Variety of visual field loss patterns
  • Visuoperceptual or visuospatial deficits
post trauma vision syndrome
Post-trauma vision syndrome
  • Can occur even after mild TBI
  • Problem in near focusing and movements involving eye-teaming
    • Saccades (overshooting)
    • Pursuit (blurring)

Treatments:

Time, visual occlusion, prism lenses, eye exercises, surgery

dizziness and balance impairment
Dizziness and Balance Impairment
  • Central vertigo
  • Benign paroxysmal positional vertigo
    • Epson maneuver
  • Vision
  • Motor impairment
special senses
Special Senses
  • Anosmia – loss of smell
    • Up to 50% of persons with moderate to severe TBI
  • Parosmia – altered smell
posttraumatic headache
Posttraumatic Headache
  • Most common symptom following mild or minor injury (30-50%)
  • Somewhat less common with increasing severity of brain injury
  • Possibly anatomic reasons that more women complain of PTHA than men
posttraumatic headache66
Posttraumatic Headache
  • Tension-type PTHA - dull, aching, varying intensity, chronic or episodic
  • PT migraine headache
  • Mixed posttraumatic headache
  • Cluster-like headache - unusual
  • Temporomandibular joint syndrome (dental pain)
posttraumatic headache67
Posttraumatic Headache
  • Contributing factors:
    • psychosocial stress, anxiety, depression, sleep disorder
  • Natural history: improvement
  • Treatment: directed at suspected type and contributing factors
behavioral and affective disorders
Behavioral and Affective Disorders
  • Acute in hospital: Agitation
    • Rule out delirium
      • Sepsis
      • Medications
      • Electrolyte Imbalance
      • Late neurological complications
      • Detox
    • Inversely related to level of attention
post acute behavioral syndromes
Post Acute Behavioral Syndromes

Episodic Dyscontrol

Impulsivity

Possible temporal or frontal lobe seizure

Agitated Depression

Depression

Anxiety Disorder

Psychotic Disorders

Substance Abuse Disorders

cognitive deficits
Cognitive Deficits
  • Emergence of Deficits
  • For milder injuries, as function improves, deficits may become more apparent and disturbing
    • formal testing vs “everyday life”
  • For mild injuries, residual problems may become evident on return to work
cognitive deficits72
Cognitive Deficits
  • Intellectual deficits
    • usually quite modest after recovery
  • Memory and Learning deficits
    • among the most common effects (major reason for failure to RTW)
    • learning, retention, and retrieval of new information
  • Attentional Deficits
    • reduced capacity to sustain and to divide attention
  • Slowed processing time
cognitive deficits73
Cognitive Deficits
  • Executive function
    • lack of flexibility, impersistence, perseveration, planning, lack of initiation, foresight, problem-solving, quality control
    • subtle and pervasive
  • Insight and denial
    • anosognosia - unawareness of deficit
    • parallel process in family members
slide74
Language and Communication
    • significant dysphasia uncommon
    • problems with conversational fluency and naming common
    • pragmatics: clarity of expression, style, appropriateness of subject, body language
emotional and behavioral changes
Emotional and Behavioral Changes
  • Personality change Lack of Insight
  • Undercontrol (lability)
  • Apathy and tiredness
  • Depressed and anxious mood
    • self-report 20%, relatives report 60%
    • 1/5 contemplate suicide during 1st five years
    • obsessional or phobic behavior
  • Stress disorders
emotional and behavioral changes76
Emotional and Behavioral Changes
  • Social behavior
    • loss of social skills (talk excessively, socially embarrassing style, intrusive or prying, withdrawing)
    • loss of ability to “read” social behavior
  • Psychiatric diagnoses
    • often do not quite meet DSM-IV criteria
ad