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Traumatic Brain Injury

Traumatic Brain Injury. Galen V. Henderson, M.D. Brigham and Women ’ s Hospital Harvard Medical School. Outline. Epidemiology Concussion Types of hemorrhages with TBI Treatment of intracranial HTN Penetrating injuries Surgical decompression

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Traumatic Brain Injury

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  1. Traumatic Brain Injury Galen V. Henderson, M.D. Brigham and Women’s Hospital Harvard Medical School

  2. Outline • Epidemiology • Concussion • Types of hemorrhages with TBI • Treatment of intracranial HTN • Penetrating injuries • Surgical decompression • Intracranial monitoring vs. neuro exam and cerebraling

  3. TBI in the United States At least 1.7 million TBIs occur in the United States each year.* 52,000 Deaths 275,000 Hospitalizations 1,365,000 Emergency Department Visits ??? Receiving Other Medical Care or No Care * Average annual numbers, 1995-2001

  4. Causes of Death in US, 2012 (37/100,000)

  5. Causes of Death in US, 2012 Age > 65: Accidents are #9 cause of death; rate 94.5/100,000

  6. Minimal GCS 15 Mild GCS 14-15 Moderate GCS 9-13 Severe GCS < 8 Glasgow Coma Scale Best Motor Response: Obeys 6 Localizes pain 5 Flexion withdrawal 4 Flexion abnormal (decorticate rigidity) 3 Extension (decerebrate rigidity) 2 No response 1 Best Verbal Response: Oriented and converses 5 Disoriented and converses 4 Inappropriate words 3 Incomprehensible sounds 2 No response 1 Eye Opening: Spontaneously 4 To verbal stimuli 3 To pain 2 Never 1 3-15 Classification of Head (Brain) Injury

  7. Concussion • Immediate and transient loss of consciousnessaccompanied by a brief period of amnesia after a blow to thehead. • 128/100,000 population in the US • The clinicalstatus of the momentary sensation of being "starstruck," ordazed, after head injury without a brief period of loss of consciousnessis uncertain, but it is generally considered the mildest formof concussion. • Young children have the highest rates. • Sports and bicycle accidents account for the majority of casesamong 5- to 14-year-olds • Falls and vehicular accidentsare the most common causes of concussion in adults.

  8. Mechanism of Concussion Ropper A, Gorson K. N Engl J Med 2007;356:166-172

  9. Symptoms of post-concussive syndrome Somatic Symptoms • Persistent low grade headache • Dizziness • Vertigo • Fatigability • Insomnia • Nausea/vomiting Mood • Anxiety • Depression • Irritability • Cognitive Deficits • Slow thinking • Poor attention and concentration • Impaired memory

  10. Control group Low PCS group Moderate PCS group High PCS group 2 1 ∆ BOLD (%) ∆ BOLD (%) 1 * 2 * fMRI and symptom severity Chen JK, Johnston KM, Collie A, McCrory P, Ptito A. J Neurol Neurosurg Psychiatry  2007; 78(11): 1231-1238. Control Low PCS Moderate PCS High PCS

  11. Spectrum of Pathologic Features and Outcomes of Traumatic Brain Injury DeKosky ST et al. N Engl J Med 2010;363:1293-1296.

  12. Epidural Hemorrhage • Occurs in about 3% of head injuries • Acute presentation; 40% have lucid interval with delayed (hrs) LOC • 90% have skull fx; 85% of these are temporal • Children get EDHs without fx • Elderly rarely get EDHs – dura firmly adherent • Amount of blood seen in fatal EDHs is 100-150ml

  13. Source of blood • Torn meningeal vessels • Torn dural sinus • Diploic veins • Marrow sinusoids

  14. Epidural Hemorrhage • Hyperdense Bi-Concave • Limited by sutures (unless fracture crossed suture line)

  15. Subdural Hemorrhage • Acute to subacute presentation • Associated with severe trauma (except in elderly and especially those with coagulopathy) • Associated with non-traumatic events (hypertensive hemorrhage or ruptured AVM with SAH/SDH • Source of blood • Torn bridging veins • Laceration of cortical vessels • Expanding contusion hematoma

  16. Acute SDH • 50% associated with a skull fx (not always at site of SDH) • Most lethal form of SDH; 40-60% mortality rate • Frequently associated with other forms of injury (DAI, contusions etc.)

  17. Acute SDH • Amount of blood which is “significant” depends on pt age and rate of accumulation • Infants: few mls • Toddlers: 30-50 ml • Children and adults: 150-200 ml

  18. Subarachnoid Hemorrhage • Traumatic • Most common cause • Seen in almost any significant injury (+/- impact) • In areas of contusions, lacerations, penetrating injuries • Under SDHs where traction on bridging veins tears arachnoid vessels • Non-traumatic • Ruptured aneurysm/vascular malformation • Torn/dissection of vertebral artery

  19. Acceleration/Deceleration • Brain: • SDH • Diffuse vascular injury • Traumatic axonal injury • Contusional Tears • Eye: • Retinal hemorrhages, Optic nerve sheath hemorrhage • Spine: • Stretching

  20. Gunshot Wounds • Damage is dependent on energy of missile which is dependent on the velocity • Tissue damage • Permanent track of bullet • Temporary cavity which follows bullet • Low-velocity bullet: 4-5 x bullet size • Hi-velocity bullet: up to 15 times bullet size • Secondary missiles (bone fragments)

  21. Gunshot Wounds • Low Velocity Bullets (most civilian handguns) • Most often do not exit skull • Ricochet off inner table to form secondary track • Exhaust energy and come to rest in brain • High Velocity Bullets or Shotgun at close/contact range • Most often exit skull producing massive fractures • Large temporary cavity • Often thrusts much of brain out of head

  22. DON’T FORGET TO PROTECT THE C-SPINE !!

  23. Liver lacerations Hemopericardium

  24. FACTORS CAUSING SECONDARY BRAIN INJURY THE 4 H’s HYPERCAPNEA HYPOXIA ( PaO2 < 60 mmHg; SpO2 < 90%) SYSTEMIC HYPOTENSION ( < 90 mmHg ) INTRACRANIAL HYPERTENSION

  25. OTHER FACTORS CAUSING SECONDARY BRAIN INJURY ISCHEMIA VASOSPASM SEIZURES LOSS OF AUTOREGULATION

  26. Intracranial HTN Treatment Modalities • Insert ICP monitor • General goals: Maintain ICP < 20 mm Hg and CPP > 70 mm Hg • For ICP > 20-25 mm Hg for > 5 minutes • Drain CSF via ventriculostomy • Elevate head of bed • Osmotherapy • Sedation, agitation and fever control • Hyperventilation • Pressor therapy to maintain MAP and ensure CPP • For refractory intracranial HTN • Phenobarbital/Hypothermia/Decompressive craniotomy

  27. Osmolality of IV fluids

  28. Surgical Treatment of Intracranial HTN

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