TRAUMATIC BRAIN INJURY

what ages do we see TBI m/c in?

bimodal; younger individuals- MVA & elderly- falls

what is a concussion?

transient trauma induced amnesia in mental status +/- LOC

do you have to have LOC to have a concussion?

no, concussion can occur +/- LOC

what is amnesia?

partial or total loss of memory

what is a common cause of concussion?

sports injury

is a concussion due to a penetrating or non penetrating injury?

non-penetrating

is there structural damage associated with concussion on CT/MRI?

no structural damage is seen on imaging

what are the hallmarks of a concussion?

amnesia, confusion, +/- LOC

what is the severity of concussion proportional to?

duration of amnesia

what are some s/sx of concussions?

HA, vision disturbances, dizziness,n/v, impaired balance, confusion, memory loss, ringing, difficulty concentrating, photophobia, loss of smell/taste

when should you ALWAYS get a CT on someone that is concussed?

IF GCS <15

what are other warranting factors for obtaining a CT for a concussion?

severe HA, intoxication, persistent anterograde amnesia, seizure, distracting injuries, mech of action, persistent vomiting, age >60

what are the 3 categories of the glasgow coma score?

eye opening (E), verbal response (V), motor response (M)

what is the grading of eye opening in the glasgow coma score?

4= open spontaneously

3= opens to voice

2= opens to pain

1= none

what is the grading of verbal response in the glasgow coma score?

5= normal convo

4= disoriented convo

3= words, incoherent

2= incomprehensible sounds

1= none

what is the grading of motor response in the glasgow coma score?

6= normal

5= localizes pain

4= withdraws from pain

3= decorticate posturing

2= decerebrate posturing

1= none

what is important to know in patient's coming in with TBIs?

NEUROLOGICAL BASELINE OF GLASGOW COMA SCALE TO COMPARE

what is a good prognostic indicator in TBIs?

GCS scale

what applies to children with a GCS >14?

PECARN--> determine if they should get a CT (due to risk of malignancy)

is a concussion reversible or irreversible?

reversible neurological deficit

what are the causes of a concussion?

rapid acceleration-deceleration injury, blunt injury to head, temporary cessation of RAS

where is the RAS located?

brainstem

What does a Grade 1 concussion consist of?

mild; post traumatic amnesia <30 min, No LOC, transient confusion, resolution of sx <30 min

what does a Grade 2 concussion consist of?

moderate; LOC < 5 min or post traumatic amnesia >30 min, transient confusion

what does a Grade 3 concussion consist of?

severe; LOC > 5 min or post traumatic amnesia >24 hrs

what is the tx for a concussion?

AVOID ALL CONTACT SPORTS UNTIL SX COMPLETELY RESOLVED, rest from physical exertion, prevent recurrent injury, rest from stimulation (TV/ phone), concussion centers

what is second impact syndrome (SIS)?

when the brain swells rapidly shortly after a person suffers a second concussion before sx from an earlier concussion have subsided

what is a contrecoup injury?

injury tot he brain at the direct point of impact AS WELL ASS injury to the opposite point from the force imparted by the skull against the brain

what is a cerebral contusion?

bruising of the brain; hemorrhage mixed w/ brain that usu occurs @ either site of injury or opposite (contrecoup)

how will radiology describe a cerebral contusion?

petechial hemorrhages & extravasations of fluid from injured vessels

what does cerebral contusion result in?

focal ischemia (lack of blood flow) & edema, w/ potential for infarction , necrosis & inc ICP

what does the clinical presentation of cerebral contusion look like?

specific to location in brain; widespread injury w/ mass effect causing varied sx

what is the tx for a cerebral contusion?

usu conservation; RARE: lesion >25 cc may be considered for a resection (depending upon location)

what is the cause of skull fractures?

focal application of force to the head (categorized as open/closed, displaced/nondisplaced, basilar or convexity)

what do we do if depression is > width of bone?

operative repair is likely required

what do we do if a depressed skill fracture is associated w/ laceration?

surgery is often required

how do we manage basilar skull fractures?

usu mnmgt conservatively, unless injury to CN or vascular injury

what do we do with fractures involving the sinus?

surgery is considered due to potential spread of infection to the epidural space

what is an epidural hematoma?

bleeding that occurs on the outside of the dura and collects in the epidural space

what can cause an epidural hematoma?

skull fracture that lacerates an artery in the dura

what is the m/c example of an epidural hematoma?

temporal bone frx lacerating the middle meningeal artery

what is the classic presentation of an epidural hematoma?

injury or blow to the temple associated w/ brief LOC followed by a lucid interval

what can we see if compensatory mechanisms are exhausted or if the hematoma inc in size?

ipsilateral CN III palsy & contralateral hemiparesis

how is epidural hematoma dx?

sx, hx & CT showing lens shaped/ convex appearance

how do we tx an epidural hematoma?

lesion >1 cm in 30 min from injury --> surgical evacuation

burr hole vs craniotomy

what is an acute subdural hematoma (SDH)?

blood collecting b/w dura and arachnoid membranes

what is acute SDH a result of?

trauma to the brain which causes rupture of veins over the surface of the brain (direct blow to diffuse rotational force- MVA, fall down stairs)

what is common adjacent to the SDH?

focal bruising (cerebral contusion)

what is the presentation of a SDH?

altered LOC & other sx which are related to location & severity

what does a CT of a SDH show?

crescent shaped; may cross suture lines, often assoc w. intracerebral hemorrhage & edema

what is the tx of SDH?

lesions >1cm thick or lesions w/ midline shift >5mm: require emergency evacuation via craniotomy

how do we manage pt's who receive a craniotomy after a SDH?

managing inc ICP & underlying brain injury

what can outcomes of SDH be predicted by?

admission GCS score

what is the medical management for pt's w/ SDH?

antiseizure prophylaxis: blood irritates brain- Keppra (load 1g then 500 mg q 12) or Dilantin; ICU neuro checks & BP mgmt

what is the surgical tx of SDH?

burr holes (single vs 2) or formal craniotomy/ectomy w/ excision of SD membrane

why do SDH occur more in elderly?

atrophy of the brain (ex: alcoholics/drug abusers- raisin brains)& anticoags/anti plts (follow reversal guidelines)

what are the RFs for chronic SDH?

ETOH, seizures, CSF shunts, coagulopathies, falls

how do chronic SDHs present?

TIA like sx, HA, confusion, language difficulties, seizures, swaying one way more than the other

what is the tx for chronic SDH?

seizure prophylaxis, reverse coagulopathy, surgical evacuation for sx lesions (deficits or AMS) & thickness >10mm

what is an emerging tx for chronic SDH?

middle meningeal artery embolization; "gluing" of middle meningeal artery w/ non-adhesive liquid embolic agent

what is common in pt's suffering from severe traumatic TBI?

traumatic subarachnoid hemorrhage

what is the M/C/C of subarachnoid hemorrhage (SAH)?

trauma

what is atraumatic SAH caused by?

typically from aneurysm or AVM ruptures

what is the tx of traumatic SAH?

antiseizure meds (Keppra), neuro monitoring, BP <140, serial CT scans (q12-24 hrs), reversal of antiplt/anticoag, ICP monitoring depending on GCS

what causes diffuse axonal injury (DAI)?

rapid brain accel-decel

what happens during diffuse axonal injury?

axons become sheared off @ boundary b/w gray & white matter; widespread disruption of neuro function w/o any focal lesions

how does mild DAI present?

prolonged mildly concussive state of confusion/memory loss

how does severe DAI present?

depressed LOC

what are the CT findings of DAI?

multiple small hemorrhages scattered throughout the brain at the junction of gray & white matter

what is associated w/ poor outcomes in DAI?

effacement of basal cisterns & midline shift

what is the tx of DAI?

maintain normal ICP/adequate CPP, normothermia, DVT prevention, seizure prevention, nutrition & glycemic control

what is vasogenic cerebral edema caused by?

damage to BBB & consists of protein rich fluid

ex: brain tumors, infection, HTN crisis

what is cytotoxic cerebral edema caused by?

cerebral ischemia, trauma, intoxications, metabolic disorders

what are additional interventions of TBI?

neuromonitoring (via ICP monitor or external ventriculostomy drain), measuring CPP & ICP

what is sustained ICP >20 indicative of?

worse neurological outcome

what does measuring CPP & ICP help us quantify?

associated secondary brain injury

how is CPP calculated?

MAP-ICP

what is the monro-kellie doctrine?

the sum of intracranial volumes is constant & any inc must be offset by an equal dec in another

what is normal ICP in adults & older children?

<10-15 mmHg

what conditions elevate ICP?

cerebral edema, hyperemia, traumatic masses, hydrocephalus

what is hyperemia?

autoregulatory response to head injury- brings blood to brain to inc ICP

what is Cushing's Triad?

elevated systolic BP, widened pulse pressure, bradycardia & respiratory irregularity

what is the indication for ICP monitoring?

salvageable pts w/ severe TBI (GCS <8)

- dont follow commands

- dont localize noxious stimuli

-w/ traumatic intracranial mass

what are CIs to ICP monitor placement?

awake pt, coagulopathies, CTH negative for lesion, + ETOH, + tox

when should you D/C ICP monitor?

when ICP normal for 48-72 hrs

what are potential complications of an ICP monitor?

infection, hemorrhage, malfunction, malposition

what are some other noninvasive mgmts of TBI?

HOB elevation 30-45º, light sedation, prevent hyperglycemia, hypertonic saline (used more than mannitol now), etc