Brain Injury 101: What You Need to Know

1. Brain Injury 101: What You Need to Know Jennifer M. Zumsteg, M.D. University of Washington Rehabilitation Medicine April 30, 2010

2. Thanks to Kathleen R. Bell, M.D. for slides • Sign-up for slides – a copy will be emailed to you

4. 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.

5. “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.”

6. 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.

7. “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…”

8. 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

9. 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

10. Risk Factors and Causes • WHO? • Males, adolescents, young adults, older than 75 • WHAT? • Motor vehicle crashes • Violence • Falls • Military • Sports/Recreational

11. Costs of TBI • Direct annual expenditures • $4.5 billion • Indirect annual costs • $33.3 billion • Total costs • $37.8 billion (in 1985 dollars)

13. Mechanisms of Injury • Primary mechanism • Penetrating (high velocity, more damage, e.g., gunshot wound) • Lacerating and crushing • Cavitation • Shock waves • Skull and bullet fragments

14. Closed/Moderate-Severe • High velocity translational (inferior frontal and temporal lobes) • High velocity rotational (shearing at grey-white interface) • Diffuse axonal injury

15. Blunt Force • skull fracture • contusion at point of impact • contrecoup injury (fall)

16. Primary • Space occupying lesions • epidural hematomas 6% • subdural hematomas 24% • intracerebral hemorrhage/intraventricular hemorrhage • herniation from mass effect

18. Secondary Brain Injury • altered cerebral blood flow • hypotension • release of neurotoxic compounds • cellular inflammatory response • cytokines • calcium influx • oxygen free radicals

19. Likely same types of brain injury High stress environment Associated injuries: hearing loss, limb injury PTSD/Anxiety Disorders Blast Injury: More of the Same?

20. 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 3-8 Moderate 9-12 Mild 13-15 Glasgow Coma Scale

21. 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

22. Mild Traumatic Brain Injury (Concussion)

24. 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

25. 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

26. 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

27. 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

28. How do people get concussions?

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

30. 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

31. Features of concussion • Emotions out of proportion to circumstances • Memory deficits • Any period of loss of consciousness

32. Symptoms of concussion • Early symptoms • Headache • Dizziness or vertigo • Lack of awareness of surroundings • Nausea or vomiting

33. 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

34. The Results of TBI

35. 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

37. Treatment for posturing • Range of motion • Splinting or casting • Botulinum toxin or phenol injections • Dantrolene • Control of dysautonomic episodes

38. 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

39. 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

41. Neurological Complications

42. Nervous System - Late Intracranial Mass Lesions • Subdural Hematoma • Acute immediate • Subacute 3-20 days • Chronic > 3 weeks

43. 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

44. Risk Factors for Hydrocephalus • Subarachnoid hemorrhage • More severe injuries • Skull fractures (depressed) • Infectious processes

45. Hydrocephalus

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

47. Types of Infections • Meningitis • Brain Abscess • Subdural Empyema • Skull Osteomyelitis

48. 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

49. 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

50. 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)