Traumatic Brain Injury Quiz

Introduction to NeuroRehab

• Nora Cullen, MD, MSc, FRCPC is a Specialist in PM&R, Professor at McMaster University and Chief of PM&R at Hamilton Health Sciences and St. Joseph's Healthcare Hamilton.
• The presentation date is November 26, 2021.

Overview

• Who gets a Brain Injury?
  • Predicting recovery
  • Functional problems
  • Team members
  • Other Neurologic Insults
    • Stroke
    • Multiple Sclerosis
    • Parkinson's Disease

Objectives

• Participants will be able to identify how injury affects basic brain function.
• Recognize signs and symptoms of mild, moderate, and severe brain injuries.
• Describe functional, physical, and psychiatric issues faced by brain-injured patients and provide appropriate responses for treatment and referral as needed.

Where is the lesion?

• Each body function can be traced to a specific area of the brain.
  • Physical
  • Motor
  • Sensory
  • Autonomic
  • Cognitive
  • Behavioral

Acquired Brain Injury

• Types of Acquired Brain Injury:
  • Non-Traumatic Brain Injury:
    • Anoxia
    • Infections
    • Strokes
    • Tumors
    • Metabolic Disorders
  • Traumatic Brain Injury:
    • Open Brain Injury:
      • Penetrating Injuries:
        • Assaults
        • Falls
        • Accidents
        • Abuse
        • Surgery
    • Closed Brain Injury:
      • Internal Pressure & Shearing:
        • Assaults
        • Falls
        • Accidents
        • Abuse

Comparison of Annual Incidence

• Traumatic Brain Injuries: 1,500,000
• Multiple Sclerosis: 10,400
• Spinal Cord Injuries: 11,000
• HIV/AIDS: 43,681
• Breast Cancer: 176,300

Estimated Economic Costs of TBI

• $76.3 Billion in 2010
• Medical costs: $11.50 Billion (~15%)
• Indirect costs: $64.80 Billion (~85%)

Epidemiology of TBI

• Annual incidence of TBI is 250/100,000.
• Males aged 15-24 and those older than 75 are most affected.
• Male-to-female ratio is 3:1.
• 80% of cases are mild, 20% are moderate to severe.
• Leading cause of death and disability in children and young adults.
• 500,000 new cases of TBIs occur in the US each year.
• Closed TBI - 200/100,000 population.
• Penetrating TBI - 12/100,000 population.
• 74% are not married.
• Mostly employed, students (10%), or homemaker/retired (9%).
• Accidents tend to happen between 8 pm and 4 am on Saturdays or Sundays.
• 73% have associated fractures that can obscure or delay TBI detection.

Traumatic Brain Injury Causes

• Falls (28%)
• Assaults (11%)
• Traffic Accidents (struck by/against) (20%)
• Unknown (9%)
• Other (7%)
• Suicide (1%)
• Bicycle (3%)
• Other Transport (2%)

Traumatic Brain Injury Epidemiology

• TBI is often a result of substance abuse, crime, environmental hazards, driving safety and supervision of children and elderly.

Acquired Brain Injury - Traumatic

• Non-degenerative, non-congenital.
• Mechanical force.
• Permanent or temporary impairments of cognitive, physical, and psychosocial functions.

Traumatic Brain Injury Pathophysiology

• Classification
  • Primary - Occurs at the trauma moment due to direct mechanical damage (closed or open).
  • Secondary - Occurs after the trauma due to physiological responses to an initial injury.

Open Brain Injuries

• Missiles (e.g., gunshot wounds).
• High-velocity missiles cause the most damage.
• Bullets often fragment, causing damage in multiple directions.

Skull Fractures

• Associated with an increased risk of brain injury, hematoma, and cranial nerve damage.
• Vault fractures can be closed or open, simple or compound, linear or stellate, non-depressed or depressed.
• Basal skull fractures.

Basal Skull Fractures

• Images of inferior and superior views show longitudinal fracture of the basilar skull.

Closed Head Injuries

Intracranial Hemorrhages

• Epidural
• Subdural
• Subarachnoid
• Intracerebral
• Intraventricular
• Diffuse Axonal Injuries

Epidural Hematomas

• Relatively uncommon (less than 1% of head-injured patients, less than 10% of comatose patients).
• Located between the skull and dura mater.
• Commonly associated with a tear in the middle meningeal artery (often in the presence of skull fracture).

Subdural Hematomas

• More common than epidurals (30% of severe head injuries).
• Located between the dura mater and the arachnoid layer of the meninges.
• Poor prognosis; high mortality (60-80%) due to underlying parenchymal injury.
•  Blood collection between the dura and arachnoid.

Subarachnoid Hemorrhages

• Occur frequently in TBI.
• Result from shearing of microvessels in the subarachnoid space.
• May lead to communicating hydrocephalus.

Intraventricular Hemorrhages

• Tend to occur in the presence of very severe TBI.
• Associated with an unfavorable prognosis.

Cortical Contusions

• Vascular and tissue damage (bruising).
• Coup contusions occur at the area of direct impact.
• Countercoup contusions occur as the brain rebounds in a contralateral direction.

Intracerebral Hemorrhages

• Commonly associated with moderate/severe head injuries.
• Majority of cases occur in frontal and temporal lobes.
• Arise from brain lacerations or contusional hemorrhages (bruising).

Diffuse Axonal Injury

• Most significant cause of morbidity in TBI patients (frequent cause of persistent vegetative state).
• Acceleration and deceleration forces cause axons to twist and tear resulting in neuronal death.

Acquired Brain Injury - Non-Traumatic

• Spontaneous bleeds (ruptured aneurysm, AVM, SAH, ICH).
• Infections (encephalitis, focal infections).
• Hypoxia (cardiac arrest, shock).
• Autoimmune (vasculitis).
• Tumors.
• Stroke.

Glasgow Coma Scale

• A scale used to assess the level of consciousness of a patient after a head injury.
• The scale assesses eye opening, verbal response, and motor response.
• Higher scores indicate better consciousness.
• Mild TBI- GCS score of 13-15 at lowest point in resuscitation.
• Moderate TBI- GCS score 9-12.
• Severe TBI- GCS score 3-8.

Predictors of Outcome

• Glasgow Coma Scale
• Duration of coma
• Length of PTA (Post-Traumatic Amnesia)

Secondary Brain Injury

• Evolves over hours or days following a traumatic insult.
• Causes cerebral ischemia and tissue hypoxia, leading to further neuron loss.
• Mechanisms include neurochemical and cellular events, cerebral edema, and hydrocephalus.

Impairments Following TBI

• Cognitive/Behavioral
• Affective (mood)
• Physical (motor, sensory, autonomic)
• Social

Emotional & Behavioral Changes

• Reduced Insight
• Lack of control
• Social Behavior (loss of social skills, withdrawal from social interactions)
• Apathy
• Lack of initiative, poor motivation
• Depression and anxiety (60% of TBI survivors contemplate suicide during the first 5 years).

Cognitive Impairments (During & After PTA)

• Inappropriate responses to the environment
• Discipline-specific goals
• Re-orient to the environment (using calendars, schedules, etc.)
• Compensatory strategies
• Focus on specific areas of deficits
• Carry-over learning

Maximizing Cognition

• Rule out correctable biological etiologies.
• Cognitive rehabilitation.
• Cognitive enhancing medications.

Cognitive Rehabilitation

• Post-acute rehabilitation in structured settings to manage challenges in novel environments.
• Adaptive strategies and cognitive techniques on an outpatient basis.
• Community integration and addressing adjustment issues.

Case 1

• 19-year-old male in a single-vehicle collision with a rock thrown onto the car from an overpass.
• Traumatic Brain Injury
• GCS 3/15
• ICU admission
• Coma for 2 months
• Facial surgeries.
• Blind.
• Damage to frontal lobes.
• Seizures.
• Hemiplegic
• Pituitary gland non-functioning.
• Emerged from coma and achieved partial recovery, becoming partially independent in ADLs over 2 years.
• Neuropsychology testing revealed profound memory and attentional deficits.
• Unable to resume previous hobbies, driving, or schooling, but engages in array of activities including college courses.

Agitation in TBI

• Rule out other causes (e.g., Drugs, Alcohol withdrawal, Pain, Infection, Metabolic derangement, Seizures (temporal/occipital), Sleep disturbance, Vasospasm, Space-occupying lesion)
• De-escalate the situation via simple directions
• Avoid scolding and control voice
• Consider short-term memory deficits and redirect attention.

Stages of Recovery post TBI

• Ranchos Los Amigos Scale-describes stages of recovery post-TBI. Stages include: No Response, Generalized Response, Localized Response, Confused and Agitated, Confused and Non-agitated, Confused and Appropriate, Appropriate and Automatic, Appropriate

Agitation in TBI - Physical Interventions

• Quiet, private, safe, structured room
• Observation of triggers
• Video camera
• Alarms
• Sleep log
• Restraints (use only when other measures fail).

Depression post TBI

• Interferes with recovery and potentially produces further cerebral damage.
• Treatment may include antidepressants to reduce depression and/or protect against further cell death.

Medical Considerations

• Systems approach to medical considerations. e.g., Cardiovascular, Gastrointestinal, Genitourinary, Integumentary, Respiratory, Metabolic, Neurological, Musculoskeletal

Hydrocephalus

• Dilation of the cerebral ventricular system.
• Occurs when normal CSF flow is impaired, leading to fluid accumulation.
• Limits blood flow to the brain.
• Obstructive and non-obstructive subtypes.
• Symptoms may include headaches, nausea/vomiting, lethargy, decreased mental status, and gait ataxia, dementia, incontinence.

Medical Considerations (Neurological)

• Communicating hydrocephalus - headache, nausea/vomiting, lethargy, decreased mental status
• Non-communicating hydrocephalus - obstructed cerebrospinal fluid (CSF) backs up, resulting in increased intracranial pressure, headache, nausea/vomiting, lethargy, decreased mental status, and gait ataxia, dementia, and incontinence

Fatigue post TBI

• 21% of patients experience fatigue a year after injury.
• Reduced sleep amount, increased sleep interruptions, reduction/absence of deep sleep and sleep wake reversal decrease in growth hormone and testosterone levels.

Treatment

• Education (prioritizing, pacing, delegating, scheduling, structured routines, one activity at a time, scheduled rest times).
• Exercise (regular, graded physical activity, adaptive devices, social activities, biofeedback, relaxation techniques, meditation, music, pet/horticulture therapy).
• Stimulant therapy.

Reintegrate to Community

• Accessible environment (home and work).
• Attendant care.
• Transportation.
• Vocational goals.
• Sexuality.
• Parenting.
• Injury prevention counseling.
• Pacing.

Summary

• Neurologic impairment is common and can be life-altering.
• Location of damage results in a pattern of impairment.
• Severity can be classified by outcome measures.
• Team approach to treatment is essential.

Stroke and Its Management

• Objectives include understanding stroke, etiology, pathophysiology, presentation based on location, secondary prevention, intracerebral hemorrhage, factors affecting stroke prognosis, and time course of clinical improvement.
• Every 45 seconds, someone experiences a stroke. Every 3-4 minutes, someone dies from a stroke.
• A stroke survivor has a 20% chance of another stroke within two years.
• For every 10 stroke patients, 2 die, 2 recover, and 6 are left with disability.
• Leading causes: physical disability, death, cognitive impairment, depression, epilepsy, falls, long hospital stays, and institutionalization.

Stroke Definition

• Rapid development of focal symptoms and/or signs of cerebral function loss due to vascular malfunction.

Five Warning Signs

• Weakness (sudden loss of strength/numbness in face, arm, or leg).
• Trouble speaking (sudden difficulty speaking/understanding/confusion).
• Vision problems (sudden trouble with vision).
• Headache (sudden severe and unusual).
• Dizziness (sudden loss of balance, especially with above signs).

Stroke Non-Modifiable Risk Factors

• Age
• Gender (men > women)
• Prior stroke history
• Family history

Modifiable Stroke Risk Factors

• Carotid artery disease
• Hypertension
• Hypercholesterolemia
• Diabetes mellitus
• Cigarette smoking
• Atrial fibrillation
• Other cardiac causes (valvular heart disease, cardiomyopathy)
• Dietary factors
• Physical inactivity
• Obesity
• HRT and oral contraceptive pill
• Sickle cell disease

Stroke Types

• Ischemic stroke (blood clot blocks blood flow to the brain).
• Hemorrhagic stroke (blood vessel ruptures resulting in leakage of blood into the brain tissue).

Differentiation Between Ischemic and Hemorrhagic Strokes

• Ischemic stroke: blood clot stops blood supply.
• Hemorrhagic stroke: blood leaks into the brain tissue.

Ischemic Stroke Syndromes: Middle Cerebral Artery Occlusion

• Middle cerebral artery (MCA) occlusions result in specific neurological symptoms. Affected area of brain. Anterior and posterior communicating arteries and vertebral and internal carotid arteries.

Middle Cerebral Artery

• Contralateral hemiparesis (face, arm>leg).
• Contralateral hemisensory impairment.
• Contralateral homonymous hemianopsia.
• Gaze deviation away from hemiparetic side.
• Specific hemispheric signs (Left - Aphasia (expressive, receptive, global), Right - Dysarthria, Neglect).

Anterior Cerebral Artery

• Contralateral weakness of leg >> arm .
• Contralateral hemisensory impairment in the same distribution.
• Mood and cognition disturbances (Depression, Agitated confusion, Emotional lability).

Posterior Circulation Strokes

• Symptoms include slurred speech, trouble swallowing, double vision, vertigo, contralateral weakness, crossed sensory signs, cranial nerve palsies, ipsilateral incoordination, unsteady gait, fluctuating LOC, and hearing loss.

Ischemic Stroke Syndromes: Posterior Cerebral Artery

• Contralateral hemianopsia (visual field loss on one side).

Lacunar Syndromes

• Small vessel ischemic disease results in 5 main clinical syndromes: Pure motor, Pure sensory, Ataxic hemiparesis, Clumsy hand-dysarthria, Mixed motor-sensory.

Transient Ischemic Attack (TIA)

• Sudden onset focal neurological symptoms due to vascular etiology resolving within 24 hours.
• Most TIAs last between 10-60 minutes
• Warning sign for stroke.
• 15-20% of stroke patients have a preceding TIA.

Hypertension

• Most important modifiable stroke risk factor.
• 2-5x increased risk associated with stroke.
• Intracranial hemorrhage.
• Silent strokes.
• BP reduction of 10-5mmHg results in a 30-40% risk reduction in stroke.

Impact of Lifestyle Therapies on Blood Pressure in Hypertensive Adults

• Studies demonstrate that lifestyle changes like reducing sodium and alcohol intake, exercising regularly, and following a DASH diet can significantly reduce blood pressure for hypertensive adults..

Diabetes Mellitus

• Diabetes affects 8% of the population.
• 15-33% of stroke patients are diabetic.
• Diabetes is a clear risk factor for stroke.
• Higher incidence of atherosclerosis and higher prevalence of HT, hyperlipidemia, and obesity.

Hyperlipidemia

• Statin treatment provides 25% relative risk reduction.

Cigarette Smoking

• 1.5-4x increased risk of stroke.
• 33% risk reduction after 5 years of quitting.

Antiplatelet Therapy

• ASA 81-325 mg/day for patients with TIA/stroke.

Atrial Fibrillation

• 2-year stroke risk is 20% with no therapy, 16% with ASA, and 7% with warfarin.

Treatment Strategies

• Multidisciplinary team approach (Physical Therapy (PT), Occupational Therapy (OT), Speech Language Pathology (SLP), Social Work (SW), Psychology, Psychiatry, Nursing, Physiatry, Family Doctor).
• Medications.
• Targeting symptoms (spasticity management, fatigue, depression, ataxia).
• Neurogenic bladder and bowel management.

Multiple Sclerosis

• Most common acquired neurological disease.
• 50-100 per 100,000 (0.1%).
• Female-to-male ratio is 2:1.
• Onset between 15-45 years old (mean is 30).
• Higher socioeconomic status.
• Life expectancy is around 40 years from onset.

Multiple Sclerosis Pathophysiology

• Autoimmune disease where the body's immune system attacks the myelin sheath surrounding nerve fibers in the central nervous system (brain and spinal cord).
• Results in demyelination, with axon sparing or damage.

Multiple Sclerosis Pathophysiology (cont.)

• Periventricular white matter of the cerebellum, brainstem, and spinal cord are affected.
• Patient is susceptible to microenvironmental changes resulting in conduction block

Multiple Sclerosis Types

• Benign
• Relapsing-remitting
• Secondary chronic progressive
• Primary progressive
• Malignant

Multiple Sclerosis Course of Illness

• Symptoms at onset can vary (physical or cognitive/behavioral).
• Physical symptoms may include weakness, altered sensation, gait disturbances, visual problems (vertigo), spasticity, bladder difficulties, seizures, impaired coordination, Lhermitte's sign, Uhthoff's phenomenon.
• Most cases begin with a relapsing-remitting course, progressing to second attacks within 5-10 years, and then decreasing frequency of attacks.
• May stabilize or progress slowly.
• Exacerbations are associated with infections, pregnancy, fatigue, heat, stress, trauma, heavy metals, dietary issues, other autoimmune diseases.

Multiple Sclerosis Medications

• Disease-modifying agents for chronic progressive MS.
• Immune suppression therapies.
• Acute attacks are treated with high-dose steroids (severe relapse) or low-dose steroids (moderate relapse).

Multiple Sclerosis Treatment Strategies

• Multidisciplinary team approach (PT, OT, SLP, SW, Psychology, Psychiatry, Nursing, Physiatry, family doctor).
• Medications.
• Managing symptoms (spasticity management, fatigue, depression, ataxia).
• Neurogenic bladder and bowel management.

Parkinson's Disease

• Progressive neurodegenerative illness caused by dopamine deficiency in the substantia nigra.
• Dopamine is critical for nerve cell communication that allows normal muscle movement.
• Characterized by TRAP (Tremor, Rigidity, Akathesia, Postural instability).
• Prevalence increases with age (16/1000 aged > 65).
• 100,000 Canadians affected.
• Equal distribution between men and women.
• Drug therapy is used to replace dopamine in the brain.
• Rehabilitation efforts aim to maintain optimal function for as long as possible.

Approach to Parkinson's Rehabilitation

• Goal is to maximize function.
• Multidisciplinary approach involves communication between team members.
• Rehab goals should be concise and generated in collaboration with the patient and their family.

Parkinson's Disease Team Members

• Physiotherapist
• Occupational therapist
• Speech therapist
• Social worker
• Neuropsychologist
• Physician/Medicine
• Support workers.

Parkinson's Disease - Others

• Nurses
• Recreational therapists
• Psychologists
• Dietician
• Pharmacist
• Kinesiologist

Parkinson's Disease - Reintegrating to Community

• Accessible environment
• Attendant care
• Transportation
• Vocational goals
• Sexuality
• Parenting
• Injury prevention
• Pacing strategies

Test your knowledge on traumatic brain injuries with this quiz. From definitions and types of injuries to demographics and statistics, explore the various aspects of TBI and how it impacts individuals. Challenge yourself to identify key concepts related to brain injury mechanisms and classifications.