Brain Injury 101:
What You Need to Know
Jennifer M. Zumsteg, M.D.
University of Washington
Rehabilitation Medicine
April 30, 2010

Thanks to Kathleen R. Bell,
M.D. for slides

Sign-up for slides – a copy
will be emailed to you

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.


“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.”


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.

“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…”
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
Epidemiology of Traumatic Brain
Injury



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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
Risk Factors and Causes

WHO?


Males, adolescents,
young adults, older
than 75
WHAT?





Motor vehicle
crashes
Violence
Falls
Military
Sports/Recreational
Costs of TBI

Direct annual expenditures


Indirect annual costs


$4.5 billion
$33.3 billion
Total costs

$37.8 billion (in 1985 dollars)
Mechanisms of Injury

Primary
mechanism

Penetrating (high
velocity, more
damage, e.g.,
gunshot wound)
 Lacerating and
crushing
 Cavitation
 Shock waves
 Skull and bullet
fragments

Closed/ModerateSevere
 High velocity
translational
(inferior frontal
and temporal
lobes)
 High velocity
rotational
(shearing at
grey-white
interface)
 Diffuse axonal
injury

Blunt Force
 skull fracture
 contusion at
point of impact
 contrecoup injury
(fall)
Primary

Space occupying lesions
epidural hematomas 6%
 subdural hematomas 24%
 intracerebral hemorrhage/intraventricular
hemorrhage
 herniation from mass effect

Secondary Brain Injury



altered cerebral blood flow
hypotension
release of neurotoxic compounds




cellular inflammatory response
cytokines
calcium influx
oxygen free radicals
Blast Injury: More of the Same?




Likely same types
of brain injury
High stress
environment
Associated
injuries: hearing
loss, limb injury
PTSD/Anxiety
Disorders
Glasgow Coma Scale

Best Eye Response. (4)


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Best Verbal Response. (5)
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

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No eye opening.
Eye opening to pain.
Eye opening to verbal
command.
Eyes open spontaneously.
No verbal response
Incomprehensible sounds.
Inappropriate words.
Confused
Orientated
Best Motor Response. (6)



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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
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
Mild Traumatic Brain Injury (Concussion)
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


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
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
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

How do people get concussions?
YOU
DON’T HAVE TO
BE KNOCKED OUT
TO HAVE A
CONCUSSION!!
Features of concussion




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
Vacant stare (befuddled expression)
Delayed verbal and motor
responses
Confusion and inability to focus
attention
Disorientation
Slurred or incoherent speech
Gross observable incoordination
Features of concussion



Emotions out of proportion to
circumstances
Memory deficits
Any period of loss of consciousness
Symptoms of concussion

Early symptoms




Headache
Dizziness or vertigo
Lack of awareness of surroundings
Nausea or vomiting
Late symptoms of concussion
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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
The Results of TBI
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
Treatment for posturing



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Range of motion
Splinting or casting
Botulinum toxin or phenol injections
Dantrolene
Control of dysautonomic episodes
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

Metabolic/Electrolyte Disorders

Disorders of sodium: Diabetes
insipidus

polydipsia, polyuria, hypernatremia,
fatigue, altered mental status

treatment: 1-d-amino-8-D-argininevasopressin (DDAVP) nasal spray,
carbamazepine
Neurological Complications
Nervous System - Late Intracranial
Mass Lesions

Subdural
Hematoma



Acute
immediate
Subacute
days
Chronic
weeks
3-20
>3
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
Risk Factors for Hydrocephalus


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Subarachnoid hemorrhage
More severe injuries
Skull fractures (depressed)
Infectious processes
Hydrocephalus
CNS Infection

Risk factors:




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depressed skull fractures
basilar skull fractures and fistulas
CSF leaks (otorrhea, rhinorrhea)
pneumocephalus
penetrating injuries
cranioplasty
Types of Infections


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
Meningitis
Brain Abscess
Subdural Empyema
Skull Osteomyelitis
Seizures

Incidence: 2-2.4% entire
population with TBI

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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
Risk Factors for Seizures
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Severity of trauma
Penetrating head injuries
Intracranial hematoma
Depressed skull fracture
Hemorrhagic contusion
Coma lasting more than 24 hours
Early PTS
Types of Seizures

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Generalized tonic-clonic
Partial or focal

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simple - consciousness maintained
complex - consciousness impaired
Pseudoseizures (psychogenic)
Temporal lobe (psychic, sensory,
behavior)
Orbitofrontal (automatisms,
behavior)
Seizure management


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Important to prevent further brain
injury
For moderate to severe TBI,
standard of care is to treat with
antiepileptic drugs (usually Dilantin)
for one week
Afterwards, treat only if seizure
recurs
Problems with AEDs: sedation,
slowed learning, ataxia
Seizure management


Driving – Washington State requires
6 months seizure-free before
resuming driving
Duration of Treatment?
Endocrine Disorders

Approximately 20% of persons with
moderate to severe injuries
Hypothalamic-pituitary-adrenal axis
regulation
Hypothalamus
CRH
TRH
GHRH
GRH
PRH/PIH
CRH
Anterior
Pituitary
GH
TSH
FSH
LH
ACTH
ACTH
Adrenal
Glands
Cortisol
Types of Disorders
 Hypothyroidism
 Growth
Hormone deficiency
 Hypogonadism
Motor Disorders

Spastic hypertonia

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Contractures
Ataxia
Tremor
Dystonia
Parkinsonism
Tics
Musculoskeletal Involvement after
TBI

Limb Fractures





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62% have associated fractures
~10% undiagnosed at time of rehab
admission
5% cervical spine
Open reduction and fixation
Frequently missed - distal radius
Peripheral nerve injuries

Also about 10% undiagnosed initially
Heterotopic Ossification



Occurrence: 11-35% of patients
Risk factors: prolonged coma,
spasticity, pressure ulcers, edema,
skeletal trauma, increased severity
of brain injury
Large joints (hip, shoulder, elbow)
Visual Disorders
Visual deficits


Affects vision, balance, cognition
Cranial nerve injuries


Occipital cortex injury


Visual field loss, cortical blindness
Optic tract injury


3, 4, 6th nerve resulting in decreased eye
movements and diplopia
Variety of visual field loss patterns
Visuoperceptual or visuospatial deficits
Post-trauma vision syndrome


Can occur even after mild TBI
Problem in near focusing and
movements involving eye-teaming


Saccades (overshooting)
Pursuit (blurring)
Treatments:
Time, visual occlusion, prism lenses,
eye exercises, surgery
Dizziness and Balance Impairment


Central vertigo
Benign paroxysmal positional
vertigo

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
Epson maneuver
Vision
Motor impairment
Special Senses

Anosmia – loss of smell


Up to 50% of persons with moderate to
severe TBI
Parosmia – altered smell
Posttraumatic Headache



Most common
symptom following
mild or minor
injury (30-50%)
Somewhat less
common with
increasing severity
of brain injury
Possibly anatomic
reasons that more
women complain
of PTHA than men
Posttraumatic Headache
Tension-type PTHA - dull, aching,
varying intensity, chronic or
episodic
 PT migraine headache
 Mixed posttraumatic headache
 Cluster-like headache - unusual
 Temporomandibular joint
syndrome (dental pain)

Posttraumatic Headache

Contributing factors:



psychosocial stress, anxiety,
depression, sleep disorder
Natural history: improvement
Treatment: directed at suspected
type and contributing factors
Behavioral and Affective Disorders

Acute in hospital: Agitation

Rule out delirium
Sepsis
 Medications
 Electrolyte Imbalance
 Late neurological complications
 Detox


Inversely related to level of attention
Post Acute Behavioral Syndromes
Episodic Dyscontrol
Impulsivity
Possible temporal or frontal lobe seizure
Agitated Depression
Depression
Anxiety Disorder
Psychotic Disorders
Substance Abuse Disorders
Cognitive Deficits


Emergence of Deficits
For milder injuries, as function
improves, deficits may become
more apparent and disturbing


formal testing vs “everyday life”
For mild injuries, residual problems
may become evident on return to
work
Cognitive Deficits

Intellectual deficits


Memory and Learning deficits



among the most common effects (major
reason for failure to RTW)
learning, retention, and retrieval of new
information
Attentional Deficits


usually quite modest after recovery
reduced capacity to sustain and to divide
attention
Slowed processing time
Cognitive Deficits

Executive function



lack of flexibility, impersistence,
perseveration, planning, lack of
initiation, foresight, problem-solving,
quality control
subtle and pervasive
Insight and denial


anosognosia - unawareness of deficit
parallel process in family members

Language and Communication



significant dysphasia uncommon
problems with conversational fluency and
naming common
pragmatics: clarity of expression, style,
appropriateness of subject, body language
Emotional and Behavioral
Changes



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Personality change Lack of Insight
Undercontrol (lability)
Apathy and tiredness
Depressed and anxious mood




self-report 20%, relatives report 60%
1/5 contemplate suicide during 1st five years
obsessional or phobic behavior
Stress disorders
Emotional and Behavioral
Changes

Social behavior



loss of social skills (talk excessively,
socially embarrassing style, intrusive or
prying, withdrawing)
loss of ability to “read” social behavior
Psychiatric diagnoses

often do not quite meet DSM-IV criteria