INTRODUCTION
 Traumatic brain injury is common and
devastating .
 Totaling more than 5,00,000 such
hospitalizations every year 70,000 people
will develop intellectual behavioral and
physical disabilities, and 2000 people will
exist in persistent vegetative state.
Motor vehicle accidents cause
50% of TBI
Fall - 21% of TBI
Assaults and Violence- 12% of TBI
Sports and Recreation – 10% of TBI
Causes of brain injury
 Airway obstruction
 Near-drowning, throat swelling, choking,
strangulation, crush injuries to the chest
 Electrical shock or lightening strike
 Trauma to the head and/or neck
 Traumatic brain injury with or without
skull fracture, blood loss from open wounds,
artery impingement from forceful impact,
shock
 Vascular Disruption
Mechanism of injury
Brain Injury
Primary
2.Intracranial hypertension
and mass lesion
Secondary
1.Delayed cell death
3.Ischemia systemic
hypoxia,hypercarbia and
hypotension
Primary injury
Cerebral Contusion
Most common Focal brain Injury
Sites  Impact site/ under skull #
Anteroinferior frontal
Anterior Temporal
Occipital Regions
Petechial hemorrhages  coalesce
 Intracerebral Hematomas later
Coup contrecoup injury
 In head injury, a coup injury occurs under the site of
impact with an object, and a countercoup injury
occurs on the side opposite the area that was impacted
Diffuse Axonal Injury
Hallmark of severe traumatic
Brain Injury
Differential Movement of
Adjacent regions of Brain
during acceleration and
Deceleration.
DAI is major cause of
prolonged COMA after TBI,
probably due to disruption
of Ascending Reticular
connections to Cortex.
Angular forces > Oblique/
Sagital Forces
Secondary Injury
 Hypoxic ischemic injury (HII)
 Arterial hypoxemia
 Intracranial hematomas
Types of brain injury
 Closed head injury
occurs when an outside force impacts the head hard
enough to cause the brain to move within the skull
 Open head injury
can occur from motor vehicle crashes, gun shot wounds,
falls, shaking (a baby), sports, and physical violence,
such as hitting or striking with an object
Concussion
It is the most common and minor form of head injury.
Ideally, concussion refers to a temporary loss of
consciousness in response to head injury.
Contusion
Fracture of the skull can lead to a contusion.
Any bruising on the brain as a result of skull fracture is
referred to as a contusion and represents a specific
brain region of the brain that is swollen and mixed with
blood from the damaged blood vessels.
Levels of Injury
 May result in mild, moderate, or severe
impairments in one or more areas
 Injuries can range from very mild to very severe,
and depending on the location of the brain injury,
impairments may include ….
Impairments may include…
 Lack of coordination
 Slowness or confusion in the planning and
sequencing of movements
 Muscle spasticity
 Speech disorders
 Seizures, paralysis
 Chronic, persistent pain (nerve damage,
fractures)
 Sensory impairments (e.g., vision and hearing
loss
Social, emotional, and behavioral
impairments
 Mood swings
 Depression, blunted affect
 Lack of motivation, decreased initiative
 Agitation
 Impulse control
 Interpersonal difficulties, impaired empathy
Cognitive impairments
 Short and/or long term memory loss
 Poor attention, judgment, and concentration
 Communication disorders related to speech,
writing, and reading
Neurological Assessment
Rapid Trauma Neurological Examination
1. Level Of Consciousness
2. Pupils
3. Fundi
4. Extremity Movement
5. Response To Pain
6. Deep Tendon Reflexes
7. Plantar Responses
8. Brainstem Reflexes
Level Of Consciousness
Glasgow Coma Scale
Eye Opening
Best Verbal
Best Motor
Spontaneous
4
Oriented
5
Obeys Command
To Voice
3
Confused
4
Localizes
To Pain
2
Inappropriate
3
Withdraws 4
None
1
Incomprehensible 2
Flexion
3
None
Extension
2
None
1
1
5
6
Glasgow Coma Scale
Mild scores 13 – 15
Moderate scores 9 – 12
Severe < 8
Gross predictor of outcomes at
6 months
Pupillary Exam
 Pupillary size is balance b/n Sympath and parasympathetic
influences.
 Size, shape and reactivity to light are tested parameters
Eye Movements
Injury location
Abnormality
Cavernous sinus/Sup Orbital fissure
All 3 Cr.N’s ( 3,4,6) are affected + V1 division
Transtentorial ( Uncal ) herniation
3 Cr.N
Raised ICP ( false localizing sign)
Isolated Abducens(6) palsy
Frontal eyes field ( brodman’s area 8)
Ipsilateral tonic conjugate deviation
Seizure involving frontal eyes field
Conjugate deviation to contralateral side
Occipital lobe injury ( unilateral)
Hemianopsia + ipsilateral conjugate gaze
preference
Brainstem Reflexes
Facial palsy unilateral
7 N injury- Basilar skull #
Corneal reflex ( V1+V2)
Rostral Pontine function
Dolls eye maneuver
Vestibuloocular function
Ice water caloric test ( never in awake
child)
COWS normal response
Coma – same side deviation
Stuporous/obtunded – nystagmus to
contralateral rapid component
Gag and cough reflex
9,10th N + brainstem swallowing centers
Periodic( Cheyne-stokes)
b/l hemispheric/diencephalic injury to as
caudal as upper pons
Apneustic ( prolonged ispiratory plateau) Mid- caudal pons injury
Ataxic breathing( irregular stuttering
resp)
Medullary respiratory generator center.
Deep tendon and superficial reflexes
 DTR’s exaggerated after TBI due to cortical

disinhibition
Decreased / absent after Spinal cord injury
Asymmetric DTR’s unilateral brain/spine injury
Superficial lost/decreased in corticospinal
dysfunction and helpful in localizing lesions
Plantar response 




Normal reflex
Intact descending corticospinal inhibition
Positive Babinski
Interrupted inhibition pathways



Neurodiagnostic Evaluation
CT
MRI
Cerebral angiography
Initial Stabilization
Initial assessment and resuscitative
efforts proceed concurrently.
Few things to watch for,
1.Airway
2.Cervical spine injury
3.Hypotension
4.Hypothermia
5.Neurogenic Hypertension
A brain injury is unpredictable
 A person with a brain injury is a person first
 No two brain injuries are exactly the same
 The effects are complex and vary greatly
from person to person
 The effects may depend on such factors as
cause, location, and severity
Management of pts with Head
Injury
 Acute Medical Management
 Preservation of life
 Prevention of further damage
 Rehabilitative Management
Initial Management
• checking that the Airway is clear
• checking that you're Breathing, and starting cardio-
pulmonary resuscitation (CPR or mouth-to-mouth) if
you're not
• Circulation improve
• stabilizing your neck and spine, for instance using a
neck brace.
• stopping any severe bleeding
Neurosurgery
 Neurosurgery is any type of surgery that is used to deal
with a problem with the central nervous system (the
brain, spinal cord and nerves.
 Neurosurgery is required in 1-3% of individuals with a
severe head trauma.
 Possible causes of neurosurgery include
 Haemorrhage (severe bleeding)
 Haematoma (blood clot)
 cerebral contusions (bruises on the brain),
 skull fracture
Neurosurgery
 Craniotomy
 Craniotomy is any bony opening that is cut into the
skull. A section of skull, called a bone flap, is removed
to access the brain underneath
 remove or treat large brain tumors, aneurysms, or
AVMs
 treat the brain following a skull fracture or injury (e.g.,
gunshot wound)
 remove tumors that invade the bony skull
PT MANAGEMENT IN HEAD INURY
 Positioning and movement of limbs to maintain full






range of movement
prevent contractures
Ensuring that paralyzed limbs are positioned to
prevent damage to joints and soft tissue
Managing the effects of tone and spasticity
Relieving pain
Early mobilization
Improving quality of life.
Rehabilitative Management
 Training in safe transfer techniques
 Facilitating walking
 Challenging and retraining balance and dynamic skills
eg running.
 Gait, mobility and balance improved.
 Strength and endurance are increased.