TBI and Stroke: What is the Same? What is Different?

1. TBI and Stroke: What is the Same? What is Different? Carol Ann Smith, RN, CNRN Program Coordinator - Traumatic Brain Injury Center Donna Lindsay, MN, RN, SCRN Program Coordinator - Hennepin Stroke Center

2. Objectives • At the end of this presentation the learner will be able to: • Define traumatic brain injury (TBI) and stroke • Describe similarities in TBI and stroke neurological & functional impairments • Identify differences in TBI and stroke prevention

3. Definition • TBI and Stroke are both types of acquired brain injury • Acquired brain injury is damage to the brain that occurs after birth • The two main types of acquired brain injury are: • Traumatic brain injury • Direct or indirect trauma to the brain • Non-traumatic brain injury • Includes brain damage from stroke, brain tumors, infection, hypoxia or substance abuse

4. Definition • In both TBI and Stroke, brain injury is often categorized as primary or secondary • Primary brain injury occurs at the time of the initial insult to the brain (trauma, hemorrhage or infarct) • Secondary injury occurs over hours to days and involves an array of cellular processes that may be the result or independent of the primary insult • Common causes of secondary brain injury are impaired cerebral perfusion, altered brain metabolism & oxygen utilization, increased intracranial pressure, cerebral edema, seizure activity, electrolyte abnormalities and hypoxemia

5. Stroke Definitions • The rapid loss of brain function due to disturbance in the blood supply to the brain • Stoppage of blood flow to brain: a sudden blockage or rupture of a blood vessel in the brain • A stroke or "brain attack" occurs when a blood clot blocks an artery or a blood vessel breaks, interrupting blood flow to an area of the brain

6. Traumatic Brain Injury Definitions • Traumatic Brain Injury (TBI) is caused by a blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain • Mild TBI • apathophysiological process affecting the brain induced by direct or indirect biomechanical forces • GCS 14-15 • Severe TBI • CT scan shows bleeding, bruising, shear injury, swelling • Major changes in blood flow & how the brain uses oxygen • Unconscious, GCS score 3-8

7. Stroke Statistics • Approximately 795,000 Americans suffer a stroke each year • Stroke is the 4th leading cause of death and the leading cause of serious, long-term disability in the US. • The cost of stroke in the US is approximately $28.6 billion annually. • On average in the US, every 40 seconds someonehas a stroke and every 4 minutes someone dies. • 87 % of all strokes are ischemic, 10 % areintracerebral hemorrhage, and 3 % aresubarachnoid hemorrhage.

8. Stroke Statistics in Minnesota • Over 97,000 Minnesotans have had a stroke • Approximately 11,500 new strokes occur each year • Stroke is the 5th leading cause of death and the leading cause of long-term disability • In 2011, $414 million was spent on hospital care for stroke

9. TBI Statistics • According to research from CDC, approximately 3.5 million persons have a TBI in the United States each year. • 2.1 million receive care in emergency departments, • 300,000 are hospitalized, • 84,000 are seen in outpatient departments, • 1.1 million receive care from office-based physicians, • 53,000 die • TBI is a contributing factor to a third (30.5%) of all injury-related deaths • An Estimated $76.5 billion in direct medical costs and indirect costs such as lost productivity due to TBI each year • 5.3 million Americans living with long term disability

10. TBI Statistics in Minnesota • 14,548 Minnesotans sustained traumatic brain injury in 2012: (MDH - MIDAS) • 10,310 were discharged from the emergency department • 3.960 were hospitalized • 278 died • 58% male and 42% female • This only counts people who present to the ED • Over 100,000 Minnesotans live with a disability as a result of a brain injury • 83% of offenders entering the Minnesota prison system have a history of TBI

11. Non-fatal TBI in Minnesota

12. Types of Stroke • Ischemic • Atherothrombotic • Embolic • Transient Ischemic Attack • Hemorrhagic • Intracerebral Hemorrhage • Subarachnoid Hemorrhage

13. Types of Traumatic Brain Injury • Brain injuries can be classified as: • Mild, moderate or severe • As determined by the Glasgow Coma Scale • Open or Closed • Skull fracture or no skull fracture • Linear, depressed, basilar • Penetrating wound (knife, bullet or other object) • Focal or diffuse • The injury is localized to one area (focal) • Hematoma, contusion • The injury is throughout the entire brain (diffuse) • Concussion, shear injury

14. Types of TBI • Concussion • Contusion • Epidural Hematoma • Subdural Hematoma • Intraparenchymal Bleed • Subarachnoid Hemorrhage • Intraventricular Hemorrhage • Diffuse Axonal Injury (Shear)

15. What Causes Stroke? • Controllable Risk Factors • High blood pressure (> 140/85 or if diabetic > 130/80)* • High cholesterol (LDL > 130 if no other risk factors, > 100 if other risk factors present) • Smoking* • Atrial Fibrillation • Heart Disease ( dilated cardiomyopathy, heart valve disease, artificial heart valve, heart failure) • Carotid Artery Disease • Diabetes*

16. What Causes Stroke? • Controllable Risk Factors (cont.) • Alcohol and Substance Abuse* • Physical Inactivity • Sleep Apnea • Clotting Disorders* • Vasculitis* • Uncontrollable Risk Factors • Age(every decade over age 55 the risk of ischemic stroke doubles) • Gender(men are at slightly higher risk) • Race/Ethnicity* • Family History* • Vascular Abnormality* * Risk factor for both hemorrhagic and ischemic stroke

17. How Do You Prevent Stroke? • It is believed that 80 – 85% of ischemic strokes could be prevented if risk factors were identified and controlled • Challenges to stroke prevention • Lack of healthcare screening (risk factors not identified) • Failure of patients to adhere to risk reduction measures • Failure of healthcare providers to implement aggressive risk reduction measures

18. How Do You Get a TBI? • Etiologies: • Falls (35.2%) • Leading cause of TBI • Rates highest in children 0-4 & elderly > 75 • Motor Vehicle Collision (17.3%) • Results in greatest # of hospitalizations • Rate highest in 15-19 age group • Struck by/fell against (16.5%)

19. How Do You Get a TBI? • Assault (10%) • Firearm use leading cause of death related to TBI • Blasts leading cause of TBI for active duty military personnel in a war zone • Unknown (0%) • Other (7%) • Bicycle/non-MV (3%) • Suicide (1% (Source CDC)

20. How Do You Prevent a TBI? • The only known cure for brain injury is prevention!! • Protect your brain - always wear a helmet for sports and recreational activities • Purchase only consumer product safety commission (CPSC) certified helmets • Concentrate on driving - never talk on a cell phone or text while driving • Everyone buckle up every time – infant car seats, booster seats for children under 8 or under 40 lbs, then seat belts • Stay focused & have a clear mind, do not drive impaired by drugs or alcohol • Stay steady - prevent falls from ladders and steps. • Never shake a baby, never • Keep small children away from open/screened windows and stairs • Prevent falls in the elderly • Home safety evaluations, medication & vision checks

21. How Do You Manage Ischemic Stroke? • Recanalization Therapy • 0 – 4.5 hours after last known well • IV rtPA • 0 – 6 hours after last known well • Mechanical Thrombectomy • Intra-arterial Thrombolysis

22. IV rtPA 0–3 hours – Outcome Data • Favorable outcome (complete or nearly complete recovery 3 months after stroke): • 50% in treated group • 38% in placebo group • For a favorable outcome, NNT = 8.3 • For an improved outcome, NNT = 3.1 National Institute of Neurologic Disorders and Stroke (NINDS) Acute Stroke Trial - December 1995

23. IV rtPA 0-3 hours – Outcome Data • Symptomatic intracerebral hemorrhage • 6.4% in treated group • 0.6% in placebo group • Mortality rate at 3 months and 1 year • 17% and 24% in treatment group • 20% and 28% in placebo group National Institute of Neurologic Disorders and Stroke (NINDS) Acute Stroke Trial - December 1995

24. IV rtPA 3-4.5 hours – Outcome Data • Favorable outcome (complete or nearly complete recovery 3 months after stroke): • 52.4% in treated group • 45.2% in placebo group • This is a modest but statistically significant difference • For a favorable outcome, NNT = 14 • For an improved outcome, NNT = 8 European Cooperative Acute Stroke Study (ECASS - 3) - 2008

25. IV rtPA 3-4.5 hours – Outcome Data • Symptomatic intracerebral hemorrhage • 7.9% in treated group • 3.5% in placebo group • Mortality rate at 3 months • 7.7% in treatment group • 8.4% in placebo group European Cooperative Acute Stroke Study (ECASS - 3) - 2008

26. IV rtPA – Timing of Treatment • Odds ratios for favorable outcome by time of drug initiation from onset of symptoms: • 0 – 90 minutes 2.81† • 91 – 180 minutes 1.55 † • 181 – 270 minutes 1.3  †Alteplase Thrombolysis for Acute Non-interventional Treatment of Stroke (ATLANTIS) - IV rtPA 0.9 mg/Kg 0–5 hours from stroke onset. U.S. based, industry funded trial Pooled data from ECASS-1, ECASS-2, ECASS-3 and ATLANTIS

27. Mechanical Thrombectomy Image courtesy of ev3. • Solitaire revascularization device

28. Mechanical Thrombectomy

29. Mechanical Thrombectomy

30. How Do You Manage Ischemic Stroke? • Acute Stroke Treatment • Minimize secondary brain injury • Allow “permissive hypertension” for first 24-48 hours • Maintain Normothermia • Decompressive craniotomy/ICP management if edema is severe • Avoid complications (swallow screening and if needed modified diet, VTE prophylaxis, early mobilization, fall prevention) • Initiate rehabilitation therapies • Diagnostic work-up to identify cause of stroke and stroke risk factors • Implement stroke risk factor reduction measures

31. How Do You Manage Hemorrhagic Strokes? • Intracerebral Hemorrhage • Most common type of hemorrhagic stroke • Mortality rate is 35 – 55% • Emergent reversal of INR if anticoagulated • Decompressive craniotomy, hematoma evacuation • Minimize secondary brain injury (similar to TBI) • Avoid complications • Initiate rehabilitation therapies

32. How Do You Manage Hemorrhagic Strokes? • Subarachnoid Hemorrhage (non-traumatic) • Mortality rate is approximately 50% (15% die prior to reaching medical attention) • Treat the underlying cause • 80% of SAH is caused by ruptured aneurysm • Surgical clipping or endovascular therapy • 5% is caused by arteriovenous malformation • Endovascular therapy, radiosurgery and/or craniotomy • Prevent/manage secondary brain injury (vasospasm, hyponatremia) • Avoid complications • Initiate rehabilitation therapies

33. How Do You Manage Hemorrhagic Strokes? Treatment of Aneurysm - Clipping

34. How Do You Manage Hemorrhagic Strokes? Treatment of Aneurysm - Coiling

35. How Do You Manage Hemorrhagic Strokes? Treatment of Aneurysm – Pipeline Stent

36. How Do You Manage Hemorrhagic Strokes? Treatment of AVM – embolization/surgery

37. Stroke Rehabilitation/Post-Acute Management • Physical and Occupational Therapy to maximize functional independence • Body Weight Supported Treadmill Training • Constraint Induced Movement Therapy • Functional Electrical Stimulation • Mirror Therapy • Robotic Aided Systems • Virtual Reality • Cognitive Therapy • Cognitive Re-training • Provide memory tools to aid in maintaining safety

38. Stroke Rehabilitation/Post-Acute Management • Speech Therapy for communication disorders • Dysphagia Management • May require long-term or permanent feeding tube and enteral nutrition • Depression Management • Promote Socialization (social-isolation is common) • Seizure Management • prophylactic anticonvulsants are not recommended

39. How Do You Manage Severe TBI? • For people who have a severe TBI: • Intracranial hypertension 40-50% • Multiple injuries 50% • Surgical mass lesion 40-50% • Mortality 30-35% • Favorable Outcome 40-45% • Transfer to Level 1 Trauma Center • CDC research shows patient outcomes 25% better when sent to a Level 1 Trauma Center • For individuals hospitalized after a TBI, almost half (43%) have a related disability one year after the injury

40. Management of Severe TBI(minimizing secondary injury) • Dark, quiet, low stimulus environment • HOB elevated • Neck midline • 3% saline infusion • ICP & PbtO2 monitor • CSF drainage • Sedation & Pain Mgmt: Propofol, Fentanyl, Ativan • 23% saline bolus • Normothermia • Selective hypothermia • Decompressive craniectomy • Paralyze with Vecuronium • Osmotic therapy • Hyperventilation rescue therapy for acute herniation

41. How Do You Manage Mild TBI? • At least 75% of TBI are mild • CT usually “negative” • Patient usually alert and oriented • Range of symptoms that may or may not involve LOC • Manage the symptoms

42. Definition of Mild TBI A patient with mild traumatic brain injury is a person who has had a traumatically induced physiological disruption of brain function, as manifested by a least one of the following: • any period of loss of consciousness; • Only 10% lose consciousness • any loss of memory for events immediately before or after the accident; • Anterograde and/or • Retrograde • focal neurological deficit(s) that may or may not be transient; • any alteration in mental state at the time of the accident (eg, feeling dazed, disoriented or confused); • but where the severity of the injury does not exceed the following: • Post-traumatic amnesia (PTA) not greater than 24 hours. • after 30 minutes, an initial Glasgow Coma Scale (GCS) of 13-15; and • loss of consciousness of approximately 30 minutes or less;

43. Mild TBI Symptoms • Cognitive • Feeling confused • Dazed, foggy • Amnesia • Memory impairment • Trouble concentrating • Trouble with math • Trouble finding the right word to say • Affective • Irritability • Emotionally labile • Feeling anxious • Feeling depressed • Somatic • Headache • Dizziness, vertigo • Nausea • Tinnitus • Double or blurry vision • Insomnia/sleep disturbances, fatigue • Sensory disturbances, phono &/or photophobia

44. Mild TBI Management • Initial Treatment is Symptomatic: • Time & Rest • Treat headache • Treat nausea & vomiting • Dark room/sunglasses for photophobia • Quiet for phonophobia and headache • No sleep medication (especially Ambien) • No video games, excessive TV watching, texting • If it causes symptoms, don’t do it

45. Mild TBI Management – Sent Home from ED • Rest, especially if you have any of the symptoms listed • Do not do any physical work or exercise until your symptoms go away. Anything that causes you to sweat is too much activity. • It is recommended that you see your family doctor within 2 weeks. Do not drive until your family doctor has told you it is okay to drive. • You should not work until you have not had any symptoms for 1 week.

46. Mild TBI Management – Sent Home from ED • If you go back to work and your symptoms come back and don’t go away for more than a week: • Stop working  • Go home • Call the HCMC TBI clinic for an appointment • Do not go back to work until you have seen a TBI clinic doctor • Do not use alcohol (beer, wine, hard liquor) for at least 2 months after your TBI. • Do not play any sports until you have not had any symptoms for at least 1 month.

47. Mild TBI - When do you need a Comprehensive TBI Clinic? • The natural evolution of concussion is that 80% of the people will be back to their usual baseline within a month • Someone still experiencing symptoms after 4 weeks should be evaluated at a comprehensive TBI Clinic • Students should be seen at 2-3 weeks if having problems in school

48. Evaluation at a Comprehensive TBI Clinic • Management based on history, social situation and physical examination: • Patient history & subjective complaints • Review of medical records from TBI • Patient Education • Natural History of TBI & Expectations for Recovery • Potential Referrals: • Neuropsychological testing • Speech Language Pathology • Occupational Therapy • Vision Therapy • Physical Therapy • Clinical Psychology • Therapeutic Recreation • Vestibular clinic • Medications for headache, nausea, sleep

49. TBI Rehabilitation/Post-Acute Management • Severe TBI rehab similar to stroke • Mild TBI rehab focuses on treating the symptoms. Examples include: • Energy Management and Relaxation • Vestibular Management • Balance & Coordination • Epley Maneuver • Neuro Visual Rehab • Cognitive & Linguistic Rehab • Management of headache & other somatic symptoms • Working with employers & schools on accommodations

50. What Functional Changes Do You See After Stroke? • Physical/Somatic • Hemiparesis/plegia (occasionally bilateral) • Facial droop • Hemi-sensory loss/alteration (numbness, paresthesia) • Visual Changes (visual field cuts, monocular blindness) • Dizziness, loss of balance • Altered Gait • Photo/phono sensitivity (common with SAH)* • Headache (often resolves after acute phase) • Cranial Nerve Dysfunction (with brainstem involvement)