Traumatic Brain Injury

What are the 4 types of brain injury

-Skull Fractures
- Closed head Injuries
- Penetrating Wounds
- Traumatic Injury to Extracranial Blood Vessels

Brain injury is estimated to be 5-10x’s more likely with a ____

skull fracture

What are the 4 types of skull fractures

-Linear fracture
- Depressed fracture
- Diastatic fracture
- Basilar fracture

What is a Linear Skull Fracture

Breaks that transverse the full thickness of the skull; fairly straight and no bone displacement

What are some possible complications from a Linear Skull Fracture?

-Suture diastasis
- Venous sinus thrombosis
- Epidural hematoma

What type of skull fracture occurs in 11% of severe head injuries

Depressed Skull Fractures

What do Depressed Skull Fractures result from?

Blunt force trauma

What is a Depressed Skull Fracture?

Broken bones are displaced inward

What is a Diastatic Skull Fracture?

Occurs when the fracture line transverses one or more of the sutures

What is a Basilar Skull Fracture?

Fracture in the base of the skull

Basilar Skull Fractures occur in __% of severe head injuries

4%

What are the 4 signs/symptoms of a Basilar Skull Fracture?

-Blood in sinuses
- CSF leaking from the nose
- Bruising at the orbits of the eyes
- Battle’s sign

What are the 3 kinds of Closed Head Injuries?

- Focal Injury
- Diffuse Injury
- Coup and Contra-Coup Injuries

What are some symptoms associated with closed head injury?

-Loss of consciousness
- Dilated pupils
- Respiratory issues
- Headache
- Dizziness
- CSF leaking
- Vision issues

What is a Focal Injury?

Damage to a specific area of the brain, generally seen in frontal and temporal lobes but can be seen in other areas

True or False: Cerebral contusions are not always identifiable on CT scan

True

What is a Diffuse Axonal Injury?

High-speed injury that causes widespread damage and causes altered consciousness

Diffuse Axonal Injuries are present in about ___ of all severe brain injuries

1/2

What is the leading cause of death in TBI population?

Diffuse Axonal Injury

What is a Coup injury?

The point of impact

What is a Contra-Coup injury?

Injury that results from the brain recoiling back and striking the area opposite the side of impact

What are some complications from a coup, contra-coup injury?

-Edema
- Hypoxia
- Hemorrhage or Hematoma
- Seizures

What is the Glasgow Coma Scale?

Assessment of patient with brain injury that reflects changes in patient’s level of consciousness

The Glasgow Coma Scale is based on three indicators:

-Stimulus used to elicit eye opening
- Type of verbal response
- Type of motor response

Glasgow Coma Scale Eyes Open To: (rankings)

1 - Never
2 - To Pain
3 - To Verbal Stimuli
4 - Spontaneously

Glasgow Coma Scale Best Verbal Response To: (rankings)

1 - No Response
2 - Incomprehensible Sounds
3 - Inappropriate Words
4 - Disoriented and Converses
5 - Oriented and Converses

Glasgow Coma Scale Best Motor Response To: (rankings)

1 - No Response
2 - Extension (Decerebrate)
3 - Flexion Abnormal (Decorticate)
4 - Flexion Withdrawal
5 - Localizes Pain
6 - Obeys

Glasgow Coma Scale ranges from ____

3-15

Glasgow Coma Scale 7 or less reflects…

significant trauma and poor clinical state

Glasgow Coma Scale 8-12 reflects…

a moderate injury

Glasgow Coma Scale 12-15 reflects…

a mild injury

Rancho Los Amigos Scale Levels 1 - 8

1 - No response
2 - Generalized response
3 - Localized response
4 - Confused agitated
5 - Confused inappropriate
6 - Confused appropriate
7 - Automatic appropriate
8 - Purposeful appropriate

What are some specific traumatic cranial lesions

-Epidural hematoma
- Acute subdural hematoma
- Chronic subdural hematoma
- Contusion hemorrhage
- Intraventricular hemorrhage
- Subarachnoid hemorrhage
- Subdural hygroma

What’s the Causative Factor of a Epidural Hematoma?

Laceration of Middle Cerebral Artery or Dural Sinus

What are some typical locations for an Epidural Hematoma?

Lateral Cerebral Convexities

What’s the Evolution of an Epidural Hematoma?

Hours

What’s the Clinical Profile for an Epidural Hematoma?

-Lucid interval then coma
- Pupillary dilatation with contralateral and then bilateral limb weakness

What’s the age at risk for an Epidural Hematoma?

Children and young adults

What’s the Radiologic features of an Epidural Hematoma?

Acute bulging epidural clot bounded by cranial sutures

What’s the Surgical Intervention for an Epidural Hematoma?

Urgent evacuation

What’s the Causative Factor for an Acute Subdural Hematoma?

Tearing of bridging pial veins and arteries

What’s the Typical Location of an Acute Subdural Hematoma?

Lateral Cerebral Convexities

What’s the Evolution of an Acute Subdural Hematoma?

Many hours

What’s the Clinical Profile for an Acute Subdural Hematoma?

-Drowsiness
- Coma
- Pupillary dilation with contralateral then bilateral limb weakness
- Progressive stupor then coma

What’s the age at risk for an acute subdural hematoma?

Any

What’s the Radiologic Features for an Acute Subdural Hematoma?

Acute blood rimming broad region of cerebral convexity

What’s the Surgical Intervention for Acute Subdural Hematoma?

Urgent evacuation is large enough to cause symptoms

What’s the Causative Factor for Chronic Subdural Hematoma?

-Trauma (may or may not)
- Risk factors including coagulopathy and severe brain atrophy

What’s the Typical Location for Chronic Subdural Hematoma?

Lateral Cerebral Convexities, may be bilateral

What’s the Evolution of Chronic Subdural Hematoma

Days to weeks

What’s the Clinical Profile for Chronic Subdural Hematoma?

-HA
- Progressive alteration in mental status
- Focal neurologic signs

What’s the Age at Risk for Chronic Subdural Hematoma?

Elderly

What’s the Radiologic Features for Chronic Subdural Hematoma?

-Hyper or isodense
- Unilateral or bilateral

What’s the Surgical Intervention for Chronic Subdural Hematoma?

Evacuation in some circumstances

What’s the Causative Factor for Contusion Hemorrhage?

-Shearing of parenchymal vessels
- Risk factors include coagulopathy and amyloid vasculopathy

What’s the Typical Location for Contusion Hemorrhage?

Inferior frontal and temporal lobes

What’s the Evolution for Contusion Hemorrhage?

Expand over 12-48 hours

What’s the Clinical Profile for Contusion Hemorrhage?

-Stupor to coma
- Dilated pupils
- Progressive hemiplegia
- Spasticity

What’s the Age at Risk for Contusion Hemorrhage?

Any

What’s the Radiologic Features for Contusion Hemorrhage?

-Multiple
- Confluent regions of edema intermixed with focal, acute blood

What’s the Surgical Intervention for Contusion Hemorrhage?

Evacuate if large

What’s the Causative Factor for Intraventricular Hematoma?

-Shearing of parenchymal vessels
- Rule out vascular defects

What’s the Typical Location for Intraventricular Hematoma?

Lateral and Third Ventricles Blood Filled

What’s the Evolution of Intraventricular Hematoma?

Progressive signs of hydrocephalus

What’s the Age at Risk for Intraventricular Hematoma?

Any

What’s the Radiologic Features for Intraventricular Hematoma?

Focal, acute blood within ventricles; may layer with gravity

What’s the Surgical Intervention for Intraventricular Hematoma?

Shunting

What’s the Causative Factor for Subarachnoid Hemorrhage?

Exclude underlying aneurysmal rupture

What’s the Typical Location for Subarachnoid Hemorrhage?

Basilar Cisterns

What’s the Evolution for Subarachnoid Hemorrhage?

Minutes to Hours

What’s the Clinical Profile for Subarachnoid Hemorrhage?

-HA
- Meningusmus
- Delayed manifestations
- Vaso-spasm

What’s the Age at Risk for Subarachnoid Hemorrhage?

Any

What’s the Radiologic Features for Subarachnoid Hemorrhage?

Acute blood lining cortex in subarachnoid space

What’s the Surgical Intervention for Subarachnoid Hemorrhage?

May cause secondary vasospasm or late hydrocephalus

What’s the Causative Factor for Subdural Hygroma?

Arachnoid tear following meningitis

What’s the Typical Location for Subdural Hygroma?

Days to weeks

What’s the Clinical Profile for Subdural Hygroma?

Mimics chronic subdural hematoma

What’s the Age at Risk for Subdural Hygroma?

Any (usually older)

What’s the Radiologic Features for Subdural Hygroma?

-Focal CSF density
- Fluid collection

What’s the Surgical Intervention for Subdural Hygroma?

Aspiration of fluid

What’s a Penetrating Wound of the Skull?

Missile and fragments penetrating the skull and brain

When would a Penetrating Wound not require surgery?

The objects causes a high-temperature coagulative lesion that is sterile and the projectile remains in the skull

When would a Penetrating Wound require surgery?

If the brain is penetrated at the lower levels of the brainstem - death is instantaneous

What is a Traumatic Intracerebral Hemorrhage?

One or several intracerebral brain hemorrhages that may be apparent after head injury

In a Traumatic Intracerebral Hemorrhage, where does bleeding typically occur?

Subcortical white matter of one lobe of the brain or in deeper structures such as basal ganglia or thalamus

What are some Clinical Signs of a Traumatic Intracerebral Hemorrhage

-Deepening coma with hemiplegia
- Dilating pupil
- Bilateral Babinski signs
- Irregular respirations

What’s the intervention for a Traumatic Intracerebral Hemorrhage?

Craniotomy and evacuation

What are some Consequences of TBI?

-Neurologic Impairment
- Sensory loss
- Sleep disturbances
- Cognitive impairment
- Language Deficits
- Personality Changes
- Lifestyle Changes for Family

What are some possible Musculoskeletal Injuries?

-SCI
- Brachial Plexus Injury
- Fractures
- Dislocations
- Contractures due to spasticity
- Pressure sores
- Scoliosis
- Atrophy
- Weakness

What is a Cardiopulmonary Impairment that may be seen after a TBI?

Hypertension

If a Cardiopulmonary Impairment is persistent longer than 6 weeks after injury, it may indicate…

a decreased chance of recovery

Reduced vital capacity, inspiratory capacity and total lung capacity are thought to be linked effects on the _____

brain stem

After a TBI, the greatest amount of recovery occurs within the first ____

12 months