Traumatic Brain Injury (TBI) in 2013
Thomas G. Seastrunk, D.O.
-Past President Brain Injury Association of S.C.
-Associate Professor USC-SOM College of NeuroBehavioral Sciences
-Volunteer Professor USC-COM
Some General Facts:
• “Traumatic brain injury means an acquired
injury to the brain caused by an external
physical force, resulting in total or partial
functional disability or psychosocial
impairment or both, that adversely affects a
child’s educational performance.”
General Facts:
• The term applies to open or closed head
injuries resulting in impairments in one or
more areas, such as cognition; language;
memory; attention; reasoning; abstract
thinking; judgment; problem-solving; sensory,
perceptual and motor abilities; psychosocial
behavior; physical functions; information
processing; and speech.
General Facts:
• Traumatic Brain Injuries
• Open head injuries - penetrating wound to the
brain
• Closed head injuries - skull and protective
tissue around brain remain intact; damage
comes from acceleration-deceleration forces
– Coup contra coup injury
General Trends
• Each year, 230,000 persons are hospitalized with TBI
and 22% of those persons with TBI die
• Twice as many males experience TBI as females
• From age 3 onward, boys are 2 - 4 times more likely
to sustain BI, and 4 - 6 times more likely to die than
females
• Youth from ages 15 to 25 are at highest risk from
brain injury
• Preschoolers are the second highest risk group
Silent Epidemic
- #1 cause of death in people under 44 yo
- 1.7 million people sustain a TBI annually, which is
8 times the number of people diagnosed with breast
cancer and 34 times the number of new cases of
HIV/AIDS
-80,000 people are left with permanent cognitive
deficits annually
Other Demographic Trends
• Brain injury victims are two times more likely to
have a second injury.
• After the second brain injury, survivors are eight
times more likely to sustain a third injury.
Socioeconomic class - low
• Alcohol use - more than 50% of adults with brain
injury were intoxicated at the time of injury.
• Youth with preexisting problems such as
hyperactivity, impulsivity, and aggression are four
times more likely to incur a mild, but not severe,
brain injury
Signature War Wound
• We live in a military state
• Signature wound of the Middle East wars
• Soldiers do not want to undergo exams
– Multiple reasons we will discuss
• HUGE expense an drain on our government
• Symptoms may not show for years after injury
Severity : Mild
• Any period of loss of consciousness
• Any loss of memory for events immediately before or after
the accident
• Any alteration in mental state at the time of the accident (e.g.,
feeling dazed, disoriented, or confused)
• Focal neurological deficits(s) that may or may not have been
transient but where the severity if the injury does not exceed
the following...
– loss of consciousness of approximately 30 minutes or less
– after 30 minutes, an initial Glasgow Coma Scale (GCS) of 13-15
and
– posttraumatic amnesia (PTA) not greater than 24 hours.
• Concussion considered Mild TBI
Severity : Moderate
• Coma <24 hours duration
• Neurological signs of Brain Trauma
– skull fractures with contusion (tissue damage)
– hemorrhage (bleeding)
• Focal findings on EEG or CT scan
Severity : Severe
• Coma >24 hours
• Coma, vegetative state, minimally responsive
state
• Very poor outcome
Consequences of Brain Injury
Thinking Skills
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Memory
Concentration
Problem Solving
Mental Speed
Consequences of Brain Injury
Physical Skills
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Fatigue
Coordination
Balance
Spacticity
Weakness
Consequences of Brain Injury
Behavioral
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Depression
Changes in Personality
Irritability
Impulsivity
Anxiety
Sexual inappropriateness
Definition of Concussion
• From the Latin concussus or “action of striking
together”
• A complex process affecting the brain which is
induced by traumatic forces
• May be caused either by a direct blow to the
head, face, neck, or body where force is
transmitted to the head
• Typically results in the rapid onset of shortlived impairment of neurological function that
resolves spontaneously
Definition of Concussion
• May result in neuropathological changes but
the acute clinical s/s largely reflect a
functional rather than a structural injury
• Results in a graded set of clinical s/s that may
or may not involve LOC
• Usually follow of sequential resolution but
symptoms may be prolonged
• NO abnormality of standard structural
neuroimaging studies
Depression in Concussion
• It has been reported in multiple sources that
depression follows moderate to severe TBI at
an extremely high rate including sports related
concussion
• MRI studies have suggested “that a depressed
mood following concussion may reflect an
underlying pathophysiological abnormality
consistent with a limbic-frontal model of
depression”
Chronic TBI from concussion
• Studies have suggested an association
between repeated sports concussions and
later-in-life cognitive impairment
– Punch drunk syndrome- Dementia pugilistica
• No consensus reached on the significance of
this observation
• Clinicians should be mindful of long term
problems occurring with multiple concussions
Factors Influencing Recovery
• Initial neurological severity
• Age
• Existence of serial lesions
– Second Impact Syndrome
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Systemic co-morbidities
Substance use
Genetic factors
Educational Background
What Do We Know?
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More studies ongoing because of Iraq War
Advocacy reaching new heights
More people involved in advocacy
Stronger National Organizations
– ie: BIAA, NASHIA, Military, State BIA affiliates
– Pushing Doctors to learn more to help patients
– Educating the public on TBI including concussion
What Do Doctors Know?
• In my opinion, the 4 most important words a
doctor can learn are:
I DO Not Know!!!!!!!!!!!
But I will try to find the answer
What Doctors Know
• The importance of Rehab
– Physical, occupational, cognative
• The importance of continuing rehab by
patients once they are released
• Multiple studies show that people who
continue their rehab at home daily-
DO MUCH BETTER
What We Do Know
• People who discontinue their exercises, either
physical or mental, Do Much Worse in the
Long Run
• Must develop discipline to continue what you
have learned
• Strong family or other social network, a
definite plus may say a must
• Rehab is “The Key to Good Outcomes”
TBI Research in 2013
• Most research conducted in rehab fields
• Researching changes in brain chemistry post
TBI
• Prevention
• Concussion- “Hot Topic Now”
– Student Athlete Concussion Bill signed into S.C.
Law 8/15/2013
• Post Acute Rehab
TBI Research 2013
• A Lot of research with concussion
– NFL, NHL, NCAA, High School Sports all involved
– Long term effects of concussion and multiple
concussions
• Dementia Pugilistica- “punch drunk syndrome”
• Increased risk of Alzhiemer’s Disease & Dementia
• Imagining research- great deal being done
now
– Changes in brain structure post injury
– Changes in brain structure post rehab
TBI Research 2013
• Hormone therapy acute phase of recovery
– Has been somewhat discredited recently
– Recent study showed diabetes drug useful
• Exendin-4 which promotes insulin secretion
• Studies in mice as of now
– Metformin also shows promising results in mice
• Helps damaged brain cells recover faster
Brain Injury Association of SC
Phone number: 803-731-9823
Director: Joyce Davis
Address: 800 Dutch Square Boulevard, Suite B-225
Columbia, SC 29210
Toll Free: 877-TBI-FACT (877-824-3228)