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TBI - Neuroanatomy of TBA. Primary Effects: Diffuse Axonal Injury Contusions Secondary Effects: Hematomas Cerebral Edema Hydrocephatus Infections Neurotoxicity ↑ ICP Hypoxic or anoxic event. Prediction of Outcome after TBI. Injury severity Duration of Post-Traumatic Amnesia

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tbi neuroanatomy of tba
TBI - Neuroanatomy of TBA
  • Primary Effects:
    • Diffuse Axonal Injury
    • Contusions
  • Secondary Effects:
    • Hematomas
    • Cerebral Edema
    • Hydrocephatus
    • Infections
    • Neurotoxicity
    • ↑ ICP
    • Hypoxic or anoxic event
prediction of outcome after tbi
Prediction of Outcomeafter TBI
  • Injury severity
  • Duration of Post-Traumatic Amnesia
  • Type of damage (contusion vs. DAI)
  • Premorbid intelligence
  • Alcohol intoxication at time of injury
  • Premorbid OBS or history of substance abuse
  • Premorbid psychiatric/behavioral history
tbi risk factors for tbi
TBI - Risk Factors for TBI
  • Men 2:1
  • 15-24 Years Old
  • Alcohol
  • Trauma
tbi personality changes common
TBI - Personality Changes – Common
  • Worsening of premorbid behavioral traits
  • Childishness
  • Disinhibition
  • Social inappropriateness
  • Restlessness
  • Emotional lability
  • Decreased social contact
  • Less spontaneity/poverty of interest
  • Decreased social interaction
tbi executive function changes decreased mental flexibility
TBI – Executive Function Changes – Decreased Mental Flexibility
  • Decreased capacity to:
    • Concentrate
    • Use language
    • Abstract calculate
    • Reason remember
    • Plan
    • Access information
post concussion syndrome and tbi
Post Concussion Syndrome and TBI
  • Criteria:
    • Any period of LOC
    • Any loss of memory
    • Any alteration in mental status
    • Mild focal neurological deficits
post concussion and tbi syndrome
Post Concussion andTBI Syndrome
  • Somatic: HA, dizziness, fatigue, insomnia
  • Cognitive: memory deficits, impaired concentration
  • Perceptual: tinnitus, noise sensitivity, light sensitivity
  • Emotional: depression, anxiety, irritability
  • Other: decreased reasoning, information processing, verbal learning, attention
tbi assessment
TBI - Assessment
  • Neuropsychological Testing:
    • Attention
    • Concentration
    • Memory
    • Verbal Capacity
    • Executive Functions:
      • Problem Solving
      • Reasoning Abilities
      • Abstract Thinking
      • Planning
psychiatric complications of tbi
Psychiatric Complicationsof TBI
  • Depression
  • Mania and mood instability
  • Delirium:
    • Restlessness
    • Agitation
    • Confusion
    • Disorientation
    • Delusions – hallucinations
    • Usual during coma emergence
  • Sleep Disturbance
  • Psychoses
  • Anxiety
  • Personality Changes
  • Emotional Instability
  • Chronic Aggression and Violence
post concussion and tbi workup
Post Concussion andTBI Workup
  • Comprehensive assessment
  • Validate cognitive and emotional problems
  • Treat both cognitive and emotional difficulties
  • Treat underlying anxiety and psychological symptoms
general principles of treatment
General Principles of Treatment
  • Review all current meds – indications
  • Examine current or potential side effects
  • OBS patients: increased sensitivity to side effects
  • Start low – go slow
  • Allow sufficient time to work
  • Reassessness medication need
tbi treatment of depression
TBI - Treatment of Depression

See Depression Guidelines for MDD and Bipolar Depression

  • Tricyclic anticholinergic effects may

impair cognition

tbi treatment of mood instability mania hypomania mixed
TBI - Treatment of Mood Instability – Mania,Hypomania, Mixed

See Treatment Guidelines.

  • Lithium levels – keep level less than 1.0
tbi treatment of psychoses
TBI - Treatment of Psychoses

See Clinical Guidelines for Treatment of


  • Increased sensitivity to EPS
  • Atypicals – less EPS potential, greater metabolic side effects, OHD, CVA
  • Risperdal – higher EPS
tbi treatment of chronic aggression episodic dyscontrol
TBI -Treatment of Chronic Aggression –Episodic Dyscontrol

See Management of Chronic Aggression Guidelines.


TBI - Treatment of Lability of Mood and Affect

  • Emotional incontinence
  • Antidepressants are best choice:
    • Fluoxetine (20-80 mg/d) – Prozac
    • Sertraline (25-150 mg/d) – Zoloft
    • Nortriptyline (50-150 mg/d) – Pamelor
    • Effexor (150-450 mg/day) – higher doses needed to get NE effect
tbi treatment of acute aggression
TBI - Treatment of Acute Aggression
  • Antipsychotic meds: Haldol, Geodan
    • Problems: EPS, Akathisia, Retardation of neuronal recovery
  • Benzodiazepines:
    • Disinihibition, hostility, ataxia confusion, sedation, decreased memory
  • Treatment of choice:
    • Haldol plus Ativan – lowest dose needed
tbi treatment of impaired cognitive function and arousal
TBI -Treatment of Impaired Cognitive Function and Arousal
  • Psychostimulants:
    • Dexedrine
    • Ritalin
  • Indications for stimulants:
    • ADD or ADHD
    • Anergy/Apathy
    • Rage outbursts
    • Emotional incontinence
    • Emotional irritability
    • Frontal Lobe Syndrome – left sided
tbi treatment of cognitive dysfunction and arousal
TBI – Treatment of Cognitive Dysfunction and Arousal
  • Psychostimulants:
    • May increase neuronal recovery
    • Side effects: paranoia, dysphoria, anorexia, irritability, agitation, insomnia
    • Wellbutrin – alternative to stimulants, no lower seizer threshold on SL formulation
    • Cylert – no proven help
    • Concerta – liver toxicity
    • Provigil (modafinil):
      • Awake, alert, but no cognitive improvement
      • Used for narcolepsy
tbi treatment of cognitive dysfunction and arousal30
TBI – Treatment of Cognitive Dysfunction and Arousal
  • Dopamine agonist:
    • Symmetrel (Amantadine hcl) – dose 100-400 mg/d
      • Improves: arousal, attention, initiation, processing speed, and agitation
      • Drug of choice for management of agitation post TBI
      • Side Effects: Hallucinations, GI upset, low blood pressure, lower seizure threshold
      • Action: NMDA antagonism, release Dopamine to stimulate interaction of neurons
sleep disorders and tbi
Sleep Disorders and TBI
  • 50% of TBI patients with pain
  • 27-56% of all patients with TBI
  • Common symptom of co-existing depression
  • Acute phase of TBI – diffuse disruption of cerebral functioning, direct physical damage to brain, secondary neuropathological events
  • Decreased REM and slow wave sleep
  • Increase awakening at night
  • Shortening of total sleep time:
    • Decrease or disappearance of deep sleep
  • DIMS – common in recent injury
treatment of sleep disorders in tbi patients
Treatment of Sleep Disorders in TBI Patients
  • Melatonin – 3.0 to 7.5 mg at bedtime
  • Ambien (5 to 20 mgs.) – shorter activity, preserves REM sleep, decreased daytime effects
  • Chloral Hydrate – rapid sleep induction, increases total sleep time, potential for tolerance, narrow therapeutic window
  • Trazadone (Desyrel) – useful in depressed-TBI patients with insomnia

Stepped Algorithm for the Treatment of Anxiety Disorders

Step 1

Medication Treatment

(Usually an SSRI, titrated to a therapeutic dose. If the agent is not tolerated, a second SSRI may be tried.)

Cognitive behavior therapy

Evaluate response to treatment in step 1.

Patients who have a full response to either treatment go to maintenance treatment.

Others go to step 2.


Medication treatment

Cognitive behavior therapy

Partial response

Augment anti- depressant


add cognitive

behavior therapy

No response

Cognitive behavior




antidepressant type

Partial response

Augment cognitive behavior

therapy (additional sessions)


add first-line antidepressant

No response

Augment cognitive

behavior therapy


add first-line


Evaluate response to step 2 treatments. Patients with full response go to maintenance treatment. Others are considered for step 3.

Step 3

  • Consider:
  • Trial of second or third type of antidepressant (e.g., SNRI, venlafaxine, nefazadone, mirtazapine, and clomipramine)
  • Intensive cognitive behavior therapy (several times a week)
  • Other augmentation of antidepressants (if patient had a partial response to an antidepressant in step 2)
  • Referral to specialty mental health care for more ongoing treatment if more complex problems are present (e.g., childhood abuse and PTSD
  • TCU Screening
  • Clinical Assessment
  • CAGE