Traumatic Brain Injury Zara Melikyan, Ph.D. Fall 2015.
-
Upload
chester-bruce -
Category
Documents
-
view
213 -
download
0
Transcript of Traumatic Brain Injury Zara Melikyan, Ph.D. Fall 2015.
Traumatic Brain Injury
Zara Melikyan, Ph.D.Fall 2015
Lecture Plan• TBI problem significance• TBI causes• Definitions: TBI, concussion, DAI• TBI mechanism• TBI classification• TBI symptoms• TBI diagnosis• TBI treatment, rehabilitation• TBI prognosis• TBI prevention
TBI Problem Significance
• TBI is a major social, economic, health problem
• Major cause of death and disability
– Epidemiology in the US• 52,000 deaths• 1.5 million head injuries reported in ER• 5.3 million (2%) with TBI-related disabilities• Moderate & severe head injury associated with increased
risk of AD
TBI Problem Significance
– Mostly affects children and young adults
– Males > females sustain TBI
– Milder cases undiagnosed and untreated
– May cause long-lasting/disabling deficits
TBI Causes• Falls (e.g., construction)• Vehicle accidents• Violence, abuse• Sports• War
Definitions
• Traumatic brain injury = intracranial injury – injury to the brain
• Head injury – injury to the brain + other parts of the head (i.e. scalp, scull)
• Concussion – (from “concutere” = shake violently) most common type of TBI
• Diffuse axonal injury – brain injury, damage to white matter, brain tracts
TBI Mechanism
External force injures the brain:
• Sudden acceleration/deceleration within the cranium– Impact– Blast waives– Penetration
• Impact + acceleration
TBI Mechanism
• Contact – head struck by smth – focal injuries• Non-contact – moving brain within the skull –
diffuse injuries– E.g. shaken baby syndrome
• Coup injury – injury under the site of impact
• Counter-coup injury
TBI Mechanism
• Type of force• Direction of forces• Intensity of forces• Duration of forces
Types of forces:• Angular• Rotational• Shear• Translational
Lecture Plan• TBI problem significance• TBI causes• Definitions: TBI, concussion, DAI• TBI mechanism• TBI classification• TBI symptoms• TBI diagnosis• TBI treatment, rehabilitation• TBI prognosis• TBI prevention
Primary and Secondary TBI
• Primary injury – damage that occurs at the moment of trauma (tissues and blood vessels stretched, compressed, torn)
• Secondary injury – biochemical cascade of events minutes – days following injury:– Alterations in cerebral blood flow: ischemia, hypoxia– Edema– Changes of pressure within the scull– BBB damage
TBI Classification• Severity
• Injury mechanism– Closed/non-penetrating/blunt– Penetrating
• Anatomical features of the injury
GCS PTA LOCMild 13-15 <1 day 0-30 minModerate 9-12 1-7 days 30min-24 hoursSevere 3-8 >7 days >24 hours
Assessment of Level of ConsciousnessGlasgow Coma Scale
Eyes opening Verbal Motor1 Does not open No sounds No movements
2 In response to pain Incomprehensible sounds Extension to pain3 In response to voice Inappropriate words Abnormal flexion to
pain4 Spontaneously Confused, disoriented Withdrawal to pain5 N/A Normal Localizes painful
stimuli6 N/A N/A Obeys commands
InterpretationSevere GCS <8-9Moderate GCS 8 – 9-12Minor >=13
Levels of Consciousness
Level Summary Metaconscious Monitor and control own cognitive
processes. Prefrontal cortexConscious Normal. Orientation X3 (self, place,
time). SleepConfused Disoriented, slow to orient, difficulty
following instructionsDelirious Disoriented, restless, agitated,
hallucinations, delusions
Levels of ConsciousnessLevel Summary
Somnolent Sleepy, drowsy, slow and disorganized response to stimuli
Obtunded Decreased alertness, slow responses, sleepiness, decreased interest in surroundings
Stuporous Sleep-like state, no spontaneous activity, respond only to painful stimuli
Comatose Can not be aroused no response to stimuli. No corneal/gag reflex, may not have pupillary response to light
First/Transient Symptoms After TBI
• Loss of consciousness (LOC)• Headache• Vomiting• Nausea• Dizziness• Balance problems• Lack of motor coordination• Lightheadedness• Blurred vision• Tinnitus (ringing in ears)• Fatigue, lethargy• Change in sleep pattern
Longer Lasting Impairments Following TBI
• Physical – Damage of the brain – intra-axial– Damage in the skull but outside of the brain – extra-axial– Swelling (edema)– Increased intracranial pressure– Hematoma (blood collection): epidural. subdural– Hemorrhage (bleeding): subarachnoid, intraventricular– Focal lesions
• Orbitofrontal cortex• Anterior temporal lobes
– Diffuse injury - DTI
Longer Lasting Impairments Following TBI
• Cognitive– Memory: PTA, short-term memory– Language– Executive function: decision making– Alexithymia
• Motor• Social• Emotional (regulation)• Behavioral
Diagnosis
• Neurological examination• Neuroimaging– Computerized tomography (CT)– Magnetic resonance imaging (MRI)
• Neuropsychological testing of cognitive, emotional, behavioral changes after TBI
Normal Brain Imaging
TBI Brain Imaging
TBI Brain CT - Hematoma
TBI Brain CT – Intracerebral Hemorrhage
TBI Brain CT – Subarachnoid Hemorrhage
TBI Brain CT – Diffuse Axonal Injury
TBI Brain Imaging
TBI Treatment & Rehabilitation
• Acute stage, “golden hour”:– Stabilize: O2, blood flow, ICP– Prevent further injury• Surgery• Medications• Rest• Prevent seizures
TBI Treatment & Rehabilitation
• Subacute, chronic stages:Multidisciplinary team: impatient/outpatient– Neurology– Psychiatry– Physical therapy– Speech therapy– Recreation therapy– Occupational therapy– Cognitive rehabilitation– Counseling– Supported employment
Prognosis
• The more severe the injury the worse the prognosis
• Permanent disability:– Mild injuries – 10%– Moderate injuries – 66%– Severe injuries – 100%
TBI Prevention
• Protection from accidents: belts, helmets• Changes in sports practice – helmets• Environmental changes – For elderly: grab bars in bathroom, rails; remove
tripping hazards– For children: safety gates, shock-absorbing surfaces
• Safety education• Enforcement of law• Abuse prevention
Thank you!