The Impact of Traumatic Brain Injury - Open Mic Scienceopenmicscience.weebly.com/uploads/6/0/5/6/6056616/... · sequelae of TBI: all with different causes, treatments and outcomes

The Impact of Traumatic Brain Injury

Open Mic ScienceJune 4, 2012Lance Stewart

6/4/2012 1TBI Open Mic Science

6/4/2012 TBI Open Mic Science 2

TBI is caused by a bump, blow or jolt to the head or a penetrating head injury that disrupts the normal brain function, leading to loss of consciousness, or being dazed and confused.

• ~1.7 Million TBI’s in US / Year– ~52,000 Deaths ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐– ~275,000 Severe TBIs (sTBIs) ‐‐‐‐‐‐‐‐‐‐‐‐‐– ~1.37 M Mild TBIs (mTBIs)‐‐‐‐‐‐‐‐‐‐‐‐– ?? M Unreported TBIs ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

• ~5.5 Million TBI survivors in the US– Could be a lot more depending on classification concussion severity.

• TBI is a contributing factor to a third (30.5%) of all injury‐related deaths in the United States.

Traumatic Brain Injury Numbers


Costs of TBI / Year

• In 2000, the medical costs of TBI in the US, together with indirect costs such as lost productivity totaled an estimated $76.5 billion.

• In 2012, the medical costs for TBI and PTSD comorbidity could be as high as ~$100 billion in the US, and $1 trillion Worldwide

• 10 million people affected annually by TBI World Wide.


TBI‐ Heterogeneity is a Challenge

6 common, but heterogeneous pathoanatomic and pathophysiologicsequelae of TBI:

all with different causes, treatments and outcomes all classified as “severe TBI” for diagnosis and inclusion criteria in clinical trials

Illustration of the challenge:

Saatman, KE and Manley, GT. Classification of Traumatic Brain Injury for Targeted Therapies.

Journal of Neurotrauma 25:719‐738 (July 2008)


Diffuse Axonal Injury (DAI)• Multiple small lesions in white‐matter tracts • Patients with DAI are usually

– In profound coma, no high ICP, poor outcome – 90% of patients with severe DAI never regain consciousness. – Those who do wake up, often remain significantly impaired.


Disruption in Blood Brain Barrier


Brain Secondary Damage Types


Moderate and severe traumatic brain injury in adults. Lancet Neurol 2008; 7: 728–41 Andrew I R Maas, Nino Stocchetti, Ross Bullock

Measuring ICP• Monitor Intra‐Cranial Pressure (ICP), and if high, then cut scull and remove half of your head bones to allow swelling. Reassemble after swelling gone down.


Severe TBI, Craniectomy• Day 1, 12 Yr Old, ATV Accident, with open depressed skull fracture.• Day 2, Cerebral edema > malignant ICP (Brain Swelling, due to local

disruption of BBB at injury)• Day 3, decompressive craniectomy (Remove Part o Skull, allows brain to

swell beyond skull)• Day 21, Brain still swollen way out side of skull,


Campbell et al. Nature Communications 3,Article number:849, Published 22 May 2012

Surviving Acute Stage of TBI

• Acute Stage (stabilizing patient and prevent further injury) ‐ Primary concerns:– Controlling raised intracranial pressure (ICP), decompressive craniectomy

– Ensuring proper oxygen supply– Maintaining adequate cerebral blood flow– Prevention of seizures– Body temperature, heart rate, infection, blood chemistry

– Surgery to remove mass lesions or objects that have penetrated the brain


State of TBI Drug Research• No drug is approved to directly treat any phase of TBI or the associated medical complications.

• Cocktails of Nutraceuticals are used in the clinic– Extra Vitamin C (anti‐oxidant, seems to reduce damage)– Metals like iron and Zn++ (improve blood chemistry)

• Possible Drug Treatments– Progesterone, is in late stage Phase 3 clinical testing– Amantadine, seems to show some promise in Phase 2– Modulators of Blood Brain Barrier Function– Cocktails of Drugs and for getting out of Coma / Vegetative State– Nutraceuticals, DHEA, and a variety of others

• Possible Therapies– Hyper‐Baric Oxygen Treatment (HBOT).– Deep brain stimulation for getting out of long term Coma / Vegetative State


TBI Causes / Age

• Falls > Other > MV > Struck > Assault


The TBI Causes

• Between Ages 15‐45 TBI is the Biggest Health Threat.– Falls (Very young / Very Old)– Other crazy stuff / Unknown ? (Complicated)– Automobile accidents– Being Struck By / Against Person or Object = Sports– Violence / Assault– War


Vehicle Accidents, Teenagers, TBI• Vehicle Accidents = ~300,000 TBI’s / yr in US. : 17% of TBIs

– Hospitalizations / ER Visits / Death

• 1 in 3 ‐‐ of teens and their passengers injured in auto accidents suffer head injuries.

• ~8 teens die every day around the country due to motor vehicle accidents.

• ~9.5 deaths per 100,000 teens / yr in US– 3.9 in Massachusetts – 29.1 in Montana

• Strength of Graduated Driver Licensing (GDL) Laws


WA State GDL

• Need parental software control over teenage cars ! – Google car drives itself…. – Why can’t you buy a car that you can dial the top speed of 45 mph?


Every Parent’s Worst Nightmare• Jackson Stewart, Automobile Hit Tree, August 8, 2011• No Cerebral Edema, ICP Stable, but DAI and EDH, possible

Hypoxia, Required Life Support Airlift to Harborview• 21 Day Coma, Facial Reconstruction, In Harborview for 60 Days


Efforts to Improve TBI Clinical Trials• TBI‐Imact.Org


Prognosis Calculator

• TBI‐Imact.Org

• Jackson’s Condition• 37% Chance Death• 50% Chance of Unfavorable Outcome


Effects of TBI on Vision• Cranial Nerve 3 Damage is Common• Fixed Dilated Pupil = Not a good outcome


What You Can Experience after sTBI

• Hypothalamus controls body temp (wacked, due to brain swelling)– Crazy bouts of fever, Ice blankets– Heart rate going out of control, 150‐160 bpm for hours

– Propanolol and Pain Killers• Respirator / Trache Tube / Catheter / Spinal Tap

• Strapped to Bed, Gloves, so won’t rip tubes out.• Bolted neck brace so you won’t pull it off.


Chance of Getting out of a Coma

• Stories of people coming out of Coma’s beyond a year. But rare.

• Recommend waiting at least a year.

• Hard to find good published data on the topic.


Every TBI Different?

• Some mTBI can be really bad outcomes, Post Concussion Syndrome (PCS)

• Some sTBI can be really good outcomes, (The younger, you are the better the outcome)

• “Once you have seen a TBI, you have only seen one TBI.”

• Ask a Phlebotomist. They see 1,000s of patients and may have a better sense of outcomes.


Rehab / Recovering from TBI• Occupational Therapy (OT)

– Hand coordination, Hygiene, Dressing, Automated Procedures, Everyday Life Activities

• Physical Therapy (PT)– Focused on Mobility, Strength, Cardio, Balance

• Speech Therapy (ST)– Speaking, Swallowing , Understanding Meaning of Sentences

• Recreational Therapy (RT)– Go Outside, Go to the Mall, Zoo, Park,

• Memory Training – Not just for TBIs. Lumosity, Brain Resource

• Neuropsychiatric Evaluation, Pharmacology– Anti‐seisure / epilepsy drugs– Anti‐depressants – Dealing with Post Traumatic Stress Disorder (PTSD)


Recovering after Surviving a TBI

• Talk positive to patient, key to their own belief

• Patients may be in a Coma but their chance of recovery could be related to what they hear


Lucky TBIs Leave The Hospital


TBIs from Being Struck• Being Struck = ~270,000 TBI’s / yr in US : 16.5%


Nail removed from man's head: Accident appears to have left no ill effectsJanuary 20, 2012|By Peter Nickeas and Andy Grimm, Chicago Tribune reporters

An X‐ray shows the 3 1/2‐inch nail lodged in the brain of Dante Autullo(Family handout )


Brain Injury Data, Maps Intelligence• 182 Vietnam veterans with highly localized brain damage from penetrating head injuries.


Photo courtesy Aron Barbey

Orange = IntelligenceYellow = Exec FunctionRed = Both

Sports and TBI, <20yrs old in US• ~2.6 M Sports Accidents = Hospital / Yr in US. • Sports = ~180,000 TBI’s / yr in US.

– Hospitalizations / ER Visits / Death – 10% of all TBIs are from Sports– ~6% of Sports accidents result in TBIs


Sport Total/yrTBI/yr

Top 12 Most Dangerous Sports

TBI %s

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6039a1.htm

Zachery Lystedt Law 5‐14‐09

• Requires medical clearance of youth athletes suspected of sustaining a concussion, before sending them back in the game, practice or training.

• Now in 34 states and D.C.

• Pending in 12 others.


Suicide After Sports

• Junior Seau 5/2/12, NFL• Ray Easterling 4/19/12, NFL• Wade Belak 8/31/11, NHL• Rick Rypien 8/15/11, NHL• Derek Boogaard 5/13/11, NHL• Dave Duerson 2/17/11, NFL


Chronic Traumatic Encephalopathy (CTE)

• In 2002, Dr. Bennet Omalu and Dr. Julian Bailes identified the first clinical evidence of Chronic Traumatic Encephalopathy (CTE) – in NFL Players.

• CTE found in individuals with repetitive TBIs, cognitive deterioration with symptoms that can include: – mood swings, – failure in executive functions, – psychotic problems, – memory disturbance, – dementia – suicide


CTE Histopathology, Tau Tangles


Normal 65 Yr Old

John Grimsley46 Yr Old NFL

World Class Boxer 73 Yr Old with Dementia

Tauopathy


Relationship to Alzheimer’s Disease

• TBI sufferers have increased risk of developing Alzheimer’s Disease.

• Tauopathy and Amyloid plaques are both found in AD.


Violence / Assault• Assault = ~170,000 TBI’s / yr in US. : 10% of TBIs.


• January 8, 2011, U.S. Rep. (AZ) Gabrielle Giffordsshot through the head, by Jared Lee Loughner

• Six others died.


Warrior TBIs (wTBI)

• ~1.7 M deployed in Iraq and Afghanistan• 320,000 of the US soldiers who were deployed to Iraq or Afghanistan since 2001 have suffered TBIs.

• “Blast Exposure” the “Signature wound of War”

• 40% of wTBIs may have Post Traumatic Stress Disorder (PTSD)

• 225,000 OEF/OIF returnees suffer from diagnosed PTSD.


High Power Explosives in War


1o Primary Blast Overpressure (BOP)2o Flying debris or shrapnel.3o Body propelled against objects (e.g. walls of a vehicle)4o Exposure to toxic materials, gases, burning compounds.Slide Provided by Dr. David Cook, UW / VA

September 2, 2007. Camp Taji, 12 mi NW of Baghdad, Iraq DGC-TBI 4/9/12

Interview Warriors to Estimate Number and Nature of Blast Exposure

• Average Blast Exposure / with Loss of Consciousness (LOC)


Slide Provided by Dr. Elaine Peskind, UW / VA

Afghanistan Shooter Robert Bales• Trained sniper in a front line

US infantry unit• Three tours of duty• Decorated 12 times• 2008 drinking car accident• 2010 suffered a minor

traumatic brain injury after the vehicle in which he was travelling rolled over.

• 2012 Killed 16 in rampage

• PTSD / CTE ????


Twitter Resources and Information

• @LJStewartTweet, Following Neuro / TBI


B.I.G Event, Oct. 27, 2012


Thank you for the Invite

• We are lucky to be here today to talk to each other.

• Thank you Bainbridge for your support !


Advocacy Organizations


People Who Share Stories / Care


Research


Brain Fitness


EXTRA


TBI Types

• Mild TBT (mTBI)– Can result in loss of consciousness, headache, vomiting, nausea, lack of motor coordination and balance, dizziness, blurred vision, fatigue, lack of concentration, memory loss, mood changes, confusion, and trouble with thinking

• Severe TBI (sTBI)– Can result in ongoing headaches, repeated vomiting, convulsions, inability to awaken, slurred speech, loss of coordination, weakness of numbness in limbs, and changes in appropriate social behavior


Coma vs. Vegetative State

• Coma– State of unconsciousness, lasting more than six hours in which a person cannot be awakened, fails to respond normally to painful stimuli, light, sound, lacks a normal sleep‐wake cycle and does not initiate voluntary actions.

• Vegetative State– Severe brain damage, in a state of partial arousal rather than true awareness.

– Between 10% and 15% of patients with severe TBI are discharged from acute care in a vegetative state.

– belief that patients in a vegetative state are awake but not aware has been challenged.


Glasgow Coma Scale• GCS is an objective measure of conscious state.• Coma Scale is a Range from

– 3 (deep unconsciousness) to – 15 (fully conscious) – V6motor, the Jackson 5 (verbal), and 4‐eyes (sight)


http://en.wikipedia.org/wiki/Glasgow_Coma_Scale

Lystedt Law now in 34 States and D.C.

• 12 more states have legislation pending in 2012.6/4/2012 TBI Open Mic Science 52



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The Impact of Traumatic Brain Injury - Open Mic Scienceopenmicscience.weebly.com/uploads/6/0/5/6/6056616/... · sequelae of TBI: all with different causes, treatments and outcomes