Neuro TBI

What is a TBI?

An alteration in brain function, or other evidence of brain pathology caused by external force

Concussion can be considered mild TBI

What is the job of the Falx Cerebri?

Anchors meninges/brain to skull

What is the difference between coup & contrecoup?

Coup → site of original impact

Contrecoup → injury to the opposite side of impact, from brain rebound

What is a contusion?

Localized hemorrhage at the site of injury, usually frontal & temporal regions

What is a diffuse axonal injury?

Most common for mod to severe TBI

Acceleration, deceleration, rotational forces

Shearing & retraction of damaged axons

Grades of diffuse axonal injury

1: widespread axonal damage in white matter

2: white matter axonal damage extending to the corpus callosum with tissue tear hemorrhages

3: pathology of grade 2 with tissue tear hemorrhages in brain stem

What is a secondary injury?

Cascade of event due to initial trauma & hypoxia

Glutamate neurotoxicity, influx of Ca & cytokines lead to cell death

What is Intracranial Pressure caused by?

Edema inside closed skull → increases pressure

Hematomas → space occupying lesions

Normal ICP: 4-15 mmHg, >20 requires tx

What can ICP cause?

Brain herniation → brain is squeezed across structures w/in skull

Hemispheric midline shift → size of hematoma or edema leads to displacement of the brainstem & medial CNS structures

What is a craniotomy?

Removal of part of skull to allow brain to swell externally w/o pressure

Pt needs to wear protective helmet

Can later replace part of skull w/ cranioplasty

What are the symptoms of ICP?

Changes in behavior

HA

Altered levels of consciousness

Seizures

Vomiting

Neurological Sx → weakness, numbness, double vision

What are indications of increased ICP or herniation?

Dilated, sluggish or fixed pupils → cause by compression of CN 3

Hemiplegia contralateral to injury

Classic Triad: coma, fixed & dilated pupils, decerebrate posturing

What type of complications can occur with a TBI pt?

Heterotopic ossification

Seizures

Hematomas, fractures

What are the two types of head injury?

Open head: fracture & rupture of skull/meninges with penetration to brain ie. Gun shot, object penetration

Closed head: skull & meninges intact ie. concussion, hematoma, drug overdose, coup-contrecoup

Epidural hematoma

Bleed btwn skull & dura mater, ruptured blood vessel via mild or traumatic blow to the head

Present as brief loss of consciousness followed by period of awareness that may last several hrs before brain function deteriotes → can result in coma AS WELL as headache, vomiting, seizure, rapid neurological decline

Subdural Hematoma

Bleed between dura mater & arachnoid mater in the subdural space

Symptoms: fluctuating periods of lucency, impaired speech, impaired motor & balance, confusion, lethargy, LOC, vomiting, HA, seizures

High morbidity & mortality

Intracerebral Hematoma

Blood deeper in brain, more severe & can cause shift

Interventions: craniotomy or cranioplasty

Present with alteration of level of consciousness, nausea & vomiting, HA, weakness/paralysis, seizures

Subarachnoid Hemmorrhage

Bleed between arachnoid mater & brain

Causes: aneurysms, AVM, HTN, idiopathic

Symptoms: impaired consciousness & vision, nausea/vomiting, numbness/weakness, mood changes

Glasgow Coma Scale

3 Domains: eye opening, motor response, verbal response

13-15: mild injury, LOC <30 min

9-12: moderate injury, LOC >30 min & <24hr

3-8: severe, LOC >24hrs

Rancho Los Amigos Scale 1-3

1. No response; pt in deep sleep & completely unresponsive to stimuli

2. Generalized response; pt reacts inconsistently & non purposefully to stimuli, responses are limited

3. Localized response: pt reacts specifically but inconsistently to stimuli, may follow simple commands in an inconsistent, delayed manner

Rancho Los Amigos Scale 4 & 5

4. Confused/Agitated; behavior bizarre & non purposeful, pt does not discriminate & unable to cooperate w tx, verbalizations are incoherent & inappropriate, confabulation, attention is short & selective, lacks short term recall

5. Confused/Appropriate: pt able to response to simple commands fairly consistently but when complex → non purposeful, has attention to environment but is highly distractible/lacks ability to focus, memory severely impaired, often shows inappropriate use of objects, may perform previously learned tasks but unable to learn new info

Rancho Los Amigos Scales 6-8

6. Confused/Appropriate: goal directed behavior but dependent on external input, follow simple directions consistently & shows carryover for relearned tasks with little to no carryover for new task, responses may be incorrect due to memory but appropriate, past memories show more depth/detail than recent memories

7. Automatic/Appropriate: appropriate/oriented w/in hospital & home settings, goes through daily routine automatically/like a robot, minimal to absent confusion, carryover for new learning but decreased rate, judgement remains impaired, with structure pt can return to social activities

8. Purposeful/Appropriate: able to recall past & recent events, show carryover for new learning w/ no supervision, may have decreased abstract reasoning, tolerance to stress, judgement in emergencies

Rancho Los Amigos Scale 9 & 10

9. Purposeful/Appropriate(SBA); independently shifts between task, uses assistive memory devices, aware & acknowledges impairments & take appropriate action but requires SBA, acknowledges others’ needs/feelings, depression may continue & may be easily irritable & low frustration tolerance

10. Purposeful/Appropriate (Modl-I); able to handle multiple task simultaneously but require breaks, able to maintain assistive memory devices, anticipates impact of impairment on ability to complete daily living task, able to independently think about consequences of actions, periodic depression may occur, irritability & low frustration tolerance when sick, fatigued or under emotional stress

Interventions & Education

Decrease stimulation; light, sound, environment

Communication; calm reassuring voice, short direct phrases

Rest

Increase various tactile stimulation

Memory books/journal

Redirection of inappropriate behaviors

Concussion

Majority of symptoms resolve w/in 2 weeks & proper recovery almost dissipate w/in a month

Can have axonal shearing w/o bleeding

Initial tx: remove self from additional risk, IMMEDIATE REST

Post Concussion Syndrome

Symptoms lasting longer than 1-2 month

Risk factors: history of previous concussion & prolonged recovery, double impact

Second Impact Syndrome

Second head injury when still healing from 1st, usually involves brain herniation & death w/in mins

Symptoms: dilated pupils, loss of eye mov’t, unconsciousness, respiratory failure, death

Response: immediately stabilize with airway emphasis, transport to hospital/trauma center, relief of ICP

Concussion Grading

Mild (Grade 1): confusion/symptoms < 15min, no LOC

Mod (Grade 2): symptoms >15min, no LOC

Severe (Grade 3): LOC

Graduated Return to Play Protocol

1. No activity

2. Light aerobic ex HR <70%, 15 min bout

3. Sport specific ex HR <80%, 45 min bout

4. Non-contact training drills HR <90%, 60 min bout

5. Full contact

Chronic Traumatic Encephalopathy

Result of repetitive hits to the head over years of exposure

Protein called Tau forms clumps that slowly spread thru brain & kill brain cells

Mood & behavioral symptoms usually begin before cognitive, early symptoms in 20/30’s & later in 40/50’s