Brain Injury 101: What You Need to Know

Jennifer M. Zumsteg, M.D.University of WashingtonRehabilitation MedicineApril 30, 2010

Thanks to Kathleen R. Bell, M.D. for slides

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Bill Johnson, a U.S. Olympic gold medalist in downhill skiing, went into a coma and suffered brain injuries after this hard fall on March 22, 2001, in Big Mountain, Mont.

“The decision-making process is not one of his strong suits now”, Kakes (friend and neighbor) said.

“He just raises his voice. He’s not a swearing kind of person”, DB Johnson said. “He’ll get mad at me and I’ll stop him and say ‘Why are you mad at me?’ He’ll say, ‘I’m not mad at you.’ He doesn’t realize he’s doing it.”

Gold-Medal Skier Bill Johnson Arrested UPDATED - Sunday February 13, 2005 10:39am from our sister station WJLA-TV

PORTLAND, Ore. (AP) - Olympic ski champion Bill Johnson was charged with assaulting an officer and resisting arrest after punching a sheriff's deputy in the face during a traffic stop, police said.

“The problem became especially apparent earlier this year when he was pulled over by police and, because of his speech, suspected of drunk driving. There was no alcohol in his system, but Johnson became so agitated that he was arrested and charged with assault. Now he doesn’t drive, relying on family and friends…”

Outline of Presentation

Epidemiology and prevalence of Traumatic Brain Injury (TBI)

What is TBI and how does it happen? Moderate to severe TBI Mild TBI (Concussion)

The results of TBI Medical Cognitive Behavioral

Epidemiology of Traumatic Brain Injury

1 million people are treated and released from hospital emergency departments each year

230,000 people/year are hospitalized and survive

50,000 people die each year 5.3 million Americans are living

today with a TBI-related disability

Risk Factors and Causes

WHO? Males, adolescents,

young adults, older than 75

WHAT? Motor vehicle

crashes Violence Falls Military Sports/Recreational

Costs of TBI

Direct annual expenditures $4.5 billion

Indirect annual costs $33.3 billion

Total costs $37.8 billion (in 1985 dollars)

Mechanisms of Injury

Primary mechanism Penetrating (high

velocity, more damage, e.g., gunshot wound)

Lacerating and crushing

Cavitation Shock waves Skull and bullet

fragments

Closed/Moderate-Severe

High velocity translational (inferior frontal and temporal lobes)

High velocity rotational (shearing at grey-white interface)

Diffuse axonal injury

Blunt Force skull fracture contusion at

point of impact contrecoup injury

(fall)

Primary Space occupying lesions

epidural hematomas 6% subdural hematomas 24% intracerebral hemorrhage/intraventricular

hemorrhage herniation from mass effect

Secondary Brain Injury

altered cerebral blood flow hypotension release of neurotoxic compounds

cellular inflammatory response cytokines calcium influx oxygen free radicals

Blast Injury: More of the Same?

Likely same types of brain injury

High stress environment

Associated injuries: hearing loss, limb injury

PTSD/Anxiety Disorders

Glasgow Coma Scale

Best Eye Response. (4) No eye opening. Eye opening to pain. Eye opening to verbal

command. Eyes open spontaneously.

Best Verbal Response. (5) No verbal response Incomprehensible sounds. Inappropriate words. Confused Orientated

Best Motor Response. (6) No motor response. Extension to pain. Flexion to pain. Withdrawal from pain. Localising pain. Obeys Commands.

E + V + M = Total

Severe 3-8Moderate 9-12Mild 13-15

Posttraumatic Amnesia

length of time from the point of injury until the individual has a continuous memory for ongoing events

Better predictor of functional outcome than GCS

Mild Traumatic Brain Injury (Concussion)

What is concussion?

Mild Traumatic Brain Injury (MTBI) Defined by symptoms (1 or more)

Any period of observed or self-reported Transient confusion, disorientation or

impaired consciousness Dysfunction of memory around the time of

the injury Loss of consciousness lasting less than 30

minutes

Observed signs of neurological or neuropsychological problem Seizures right afterwards Young children – irritability, lethargy,

vomiting Symptoms like headache, dizziness,

irritability, fatigue or poor concentration soon after injury

What Happens in the Brain?

Decreased blood flow May not see it for 2-3 days afterwards

and can last for a week Hyperglyocolysis (high metabolism) Excitotoxicity (glutamate) Abnormal ion flows from cells

How often does it happen?

Centers for Disease Control estimates: 1.5 million people a year have a TBI About 75% of these are mild (like

concussions) Don’t really know how many because:

No one keeps track outside of hospitals Lots of concussions aren’t reported to

anyone

How do people get concussions?

YOU DON’T HAVE YOU DON’T HAVE TO BE KNOCKED TO BE KNOCKED OUT TO HAVE A OUT TO HAVE A CONCUSSION!!CONCUSSION!!

Features of concussion

Vacant stare (befuddled expression) Delayed verbal and motor

responses Confusion and inability to focus

attention Disorientation Slurred or incoherent speech Gross observable incoordination

Features of concussion

Emotions out of proportion to circumstances

Memory deficits Any period of loss of consciousness

Symptoms of concussion

Early symptoms Headache Dizziness or vertigo Lack of awareness of surroundings Nausea or vomiting

Late symptoms of concussion

Persistent low grade headache Light-headedness Poor attention and concentration Memory dysfunction Easy fatiguability Irritability and low frustration tolerance Intolerance of bright lights or diffulty focusing

vision Intolerance of loud noises, ringing in the ears Anxiety and/or depressed mood Sleep disturbance

The Results of TBI

Dysautonomia

hypertension (HTN), fever, tachycardia, tachypnea, pupillary dilation, and extensor posturing

Elevated catecholamine levels in proportion to the severity of injury, diffuse axonal injury, and brainstem injury

Treatment for posturing

Range of motion Splinting or casting Botulinum toxin or phenol injections Dantrolene Control of dysautonomic episodes

Metabolic/Electrolyte Disturbances

Disorders of Sodium: Syndrome of Inappropriate Antidiuretic Hormone (SIADH) hyponatremia, lethargy, nausea,

seizures exclude adrenal insufficiency, drug causes

(carbamazepine) water restriction, free sodium use, NSS

Metabolic/Electrolyte Disorders

Disorders of sodium: Diabetes insipidus polydipsia, polyuria, hypernatremia,

fatigue, altered mental status treatment: 1-d-amino-8-D-arginine-

vasopressin (DDAVP) nasal spray, carbamazepine

Neurological Complications

Nervous System - Late Intracranial Mass Lesions

Subdural Hematoma Acute

immediate Subacute 3-20

days Chronic

> 3 weeks

Hydrocephalus

Clinical presentation: classic - dementia, ataxia, urinary

incontinence TBI - loss of upgaze, akinetic mutism Headache, nausea, vomiting and

lethargy or decreasing mental status Hypertension

Usually within 30 days but can be further delayed

Risk Factors for Hydrocephalus

Subarachnoid hemorrhage More severe injuries Skull fractures (depressed) Infectious processes

Hydrocephalus

CNS Infection

Risk factors: depressed skull fractures basilar skull fractures and fistulas CSF leaks (otorrhea, rhinorrhea) pneumocephalus penetrating injuries cranioplasty

Types of Infections

Meningitis Brain Abscess Subdural Empyema Skull Osteomyelitis

Seizures

Incidence: 2-2.4% entire population with TBI Mild 1.5, Moderate 2.9, Severe 17.0 Early – week one Late – after one week

Most initial seizures (80%) will occur in the first 2 years

Risk Factors for Seizures

Severity of trauma Penetrating head injuries Intracranial hematoma Depressed skull fracture Hemorrhagic contusion Coma lasting more than 24 hours Early PTS

Types of Seizures

Generalized tonic-clonic Partial or focal

simple - consciousness maintained complex - consciousness impaired

Pseudoseizures (psychogenic) Temporal lobe (psychic, sensory,

behavior) Orbitofrontal (automatisms, behavior)

Seizure management

Important to prevent further brain injury

For moderate to severe TBI, standard of care is to treat with antiepileptic drugs (usually Dilantin) for one week

Afterwards, treat only if seizure recurs Problems with AEDs: sedation, slowed

learning, ataxia

Seizure management

Driving – Washington State requires 6 months seizure-free before resuming driving

Duration of Treatment?

Endocrine Disorders

Approximately 20% of persons with moderate to severe injuries

Hypothalamic-pituitary-adrenal axis regulation

HypothalamusAnterior Pituitary

AdrenalGlands

CRH ACTH Cortisol

GHTSHFSHLHACTH

CRHTRHGHRHGRHPRH/PIH

Types of Disorders

Hypothyroidism Growth Hormone deficiency Hypogonadism

Motor Disorders

Spastic hypertonia Contractures

Ataxia Tremor Dystonia Parkinsonism Tics

Musculoskeletal Involvement after TBI

Limb Fractures 62% have associated fractures ~10% undiagnosed at time of rehab

admission 5% cervical spine Open reduction and fixation Frequently missed - distal radius

Peripheral nerve injuries Also about 10% undiagnosed initially

Heterotopic Ossification

Occurrence: 11-35% of patients Risk factors: prolonged coma,

spasticity, pressure ulcers, edema, skeletal trauma, increased severity of brain injury

Large joints (hip, shoulder, elbow)

Visual Disorders

Visual deficits

Affects vision, balance, cognition Cranial nerve injuries

3, 4, 6th nerve resulting in decreased eye movements and diplopia

Occipital cortex injury Visual field loss, cortical blindness

Optic tract injury Variety of visual field loss patterns

Visuoperceptual or visuospatial deficits

Post-trauma vision syndrome

Can occur even after mild TBI Problem in near focusing and

movements involving eye-teaming Saccades (overshooting) Pursuit (blurring)

Treatments:Time, visual occlusion, prism lenses, eye exercises, surgery

Dizziness and Balance Impairment

Central vertigo Benign paroxysmal positional

vertigo Epson maneuver

Vision Motor impairment

Special Senses

Anosmia – loss of smell Up to 50% of persons with moderate to

severe TBI Parosmia – altered smell

Posttraumatic Headache

Most common symptom following mild or minor injury (30-50%)

Somewhat less common with increasing severity of brain injury

Possibly anatomic reasons that more women complain of PTHA than men

Posttraumatic Headache

Tension-type PTHA - dull, aching, varying intensity, chronic or episodic

PT migraine headacheMixed posttraumatic headacheCluster-like headache - unusualTemporomandibular joint

syndrome (dental pain)

Posttraumatic Headache

Contributing factors: psychosocial stress, anxiety,

depression, sleep disorder Natural history: improvement Treatment: directed at suspected

type and contributing factors

Behavioral and Affective Disorders

Acute in hospital: Agitation Rule out delirium

Sepsis Medications Electrolyte Imbalance Late neurological complications Detox

Inversely related to level of attention

Post Acute Behavioral Syndromes

Episodic DyscontrolImpulsivityPossible temporal or frontal lobe seizureAgitated Depression

DepressionAnxiety DisorderPsychotic DisordersSubstance Abuse Disorders

Cognitive Deficits

Emergence of Deficits For milder injuries, as function

improves, deficits may become more apparent and disturbing formal testing vs “everyday life”

For mild injuries, residual problems may become evident on return to work

Cognitive Deficits

Intellectual deficits usually quite modest after recovery

Memory and Learning deficits among the most common effects (major reason

for failure to RTW) learning, retention, and retrieval of new

information Attentional Deficits

reduced capacity to sustain and to divide attention

Slowed processing time

Cognitive Deficits

Executive function lack of flexibility, impersistence,

perseveration, planning, lack of initiation, foresight, problem-solving, quality control

subtle and pervasive Insight and denial

anosognosia - unawareness of deficit parallel process in family members

Language and Communication significant dysphasia uncommon problems with conversational fluency and

naming common pragmatics: clarity of expression, style,

appropriateness of subject, body language

Emotional and Behavioral Changes

Personality change Lack of Insight Undercontrol (lability) Apathy and tiredness Depressed and anxious mood

self-report 20%, relatives report 60% 1/5 contemplate suicide during 1st five years obsessional or phobic behavior

Stress disorders

Emotional and Behavioral Changes

Social behavior loss of social skills (talk excessively,

socially embarrassing style, intrusive or prying, withdrawing)

loss of ability to “read” social behavior Psychiatric diagnoses

often do not quite meet DSM-IV criteria