Traumatic Brain

Injury
Ma. Corazon D. Acosta, MD.,
FPARM
University of La Salette
College of Medicine and Allied
Medical Programs

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 Traumatic Brain Injury
 Epidemiology
 Bimodal age distribution
 Peak age at 15 – 24 and 65 – 75 years

old
 M > F (2:1)

 Due to VA, falls, assaults, sports injuries

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 Causes of TBI
General
Population
Other 7%

Sports/Recreation
10%

Vehicle
Firearms
Crashes
12%
50%

Falls
21%
 TBI Gender

Males are two times more

likely than females to sustain
a brain injury.
The highest rate of injury is
for males age 15-24.
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 Types of Head Injury
 Closed head injury
 Dura is intact
 Open head injury
 Dura is open
 Penetrating head injury

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Closed Head Injury

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Penetrating Head Injury

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Most common risk
factor is
ALCOHOL
INTAKE

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 Primary Injury in TBI

 Cortical contusions and lacerations

 Common in the frontal and temporal
lobes
 Cortical bruises that occur at the crests

of the gyri extending to variable depths

 Due to “coup” and “counter-coup”

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Cerebral Contusions and
Lacerations

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Cerebral Contusions and
Lacerations

Contusi
on

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 Diffuse Axonal Injury
 Occurs as a result of mechanical
deceleration, causing disruption
following shearing and tearing of
axons

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 Diffuse Axonal Injury

 Areas involved
 Corpus callosum
 Dorsolateral
quadrant of the
midbrain
 Midbrain at the
level of the
superior cerebellar
peduncle

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Diffuse Axonal Injury

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Diffuse Axonal Injury

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 Secondary Brain Injury
1. Intracranial Hematoma
2. Cerebral swelling
3. Herniation
4. Cerebral ischemia
5. Infection

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 Secondary Brain Injury
 Intrscranial hematoma
 May be extradural (epidural) or
intradural (subdural) hematoma

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 Epidural Hematoma
 Acute in presentation
 Associated with skull fractures
 Bleeding from meningeal vessels
and dural sinuses
 Lucid interval
 May lead to herniation, coma or
death

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Epidural Hematoma

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Epidural Hematoma

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 Subdural Hematoma
 Bleeding from bridging veins
 Due to acceleration-deceleration
 Dissection into subdural space
 Acute (0 – 7 days)
 Subacute (7 – 22 days)

 Chronic (> 22 days)

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Subdural Hematoma

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Subdural Hematoma

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 Cerebral Edema
 Due to either vasodilatation or an
increase in intra or extracellular
fluid
 May lead to increased intracranial
pressure (ICP)
 Increased ICP
 Headache
 Vomiting

 Papilledema

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 Papilledema

Normal Optic Papilledem

cup
a

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 Herniation
1. Central herniation
> Protrusion of the midbrain and pons
through the tentorial notch
2. Tonsillar herniation
> Protrusion of the medulla and
cerebellar tonsils through the foramen
magnum
3. Uncal herniation
> Protrusion of the uncus and
hippocampal gyrus of the brain
through the tentorial notch
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 Cerebral ischemia
 Caused by hypoxia or impaired cerebral
perfusion
 Infection
 May occur in the presence of dural
tears

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 Clinical Assessment
 Lacerations and bruising
 Basal skull fracture
 Level of consciousness
 Pupil response
 Limb weakness
 Eye movements
 Vital signs
 Cranial nerve lesions

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 Basal skull fracture

 Look for:
 1. CSF rhinorrhea
 2. Bilateral periorbital hematoma
 3. subconjunctival hemorrhage
 4. CSF otorrhea
 5. Battle’s sign

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 Level of Consciousness
 Glasgow Coma Scale
 Eye opening
 Best verbal response

 Best motor response

 Score : 3 - 15

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 Glasgow Coma Scale
 Best Eye Response. (4)
1 - No eye opening.
2 - Eye opening to pain.
3 - Eye opening to verbal command.
4 - Eyes open spontaneously.

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 Glasgow Coma Scale
 Best Verbal Response (5)
1 - No verbal response
2 - Incomprehensible sounds.
3 - Inappropriate words.
4 - Confused
5 - Orientated

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 Glasgow Coma Scale
 Best Motor Response. (6)
1 - No motor response.
2 - Extension to pain.
3 - Flexion to pain.
4 - Withdrawal from pain.
5 - Localising pain.
6 - Obeys Commands.

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 Modified Glasgow Coma
Scale
 Nonverbal Child's Best Verbal
Response Score
smiles, oriented to sound, follows objects,
interacts oriented and converses (5)
consolable when crying and interacts
inappropriately disoriented and converses
(4)
inconsistently consolable and moans;
makes vocal sounds inappropriate words
(3)
inconsolable, irritable and restless; cries
incomprehensible sounds (2)
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 Glasgow Coma Scale
 GCS 13 – 15 mild TBI
 GCS 9 – 12 moderate TBI
 GCS ≤ 8 severe TBI
 comatose

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 Pupil Response

 Light reflex tests CN II and III

 Test both direct and consensual light
reflex
 Pupil dilates on the side of the lesion
 “anisocoria”

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 Eye Movements

 Provide prognostic guide

 Doll’s eye reflex
 Oculovestibular reflex (ice water caloric

test)
 Spontaneous eye movements

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 Vital Signs
 Look for Cushing’s triad
 Hypertension
 Bradycardia

 Abnormal respiration

 Due to increased ICP

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 Measures of Injury
Severity
 Depth and duration of coma
 GCS of 8 or less
 Coma ≥ 6 hours (severe injury)

 Post – traumatic amnesia

 Period of time in which the brain is
unable to lay down continuous day-to-
day memory
 Measured using Galveston Orientation

Amnesia Test (GOAT)

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 Outcome after TBI
 Deficits
 Physical or neurobehavioral
 Vary from one person to another

 Behavioral problems
 Minor irritability or passivity to
disinhibited, bizarre or aggressive
behavior

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 Cognitive Impairment
 Common after moderate to severe
TBI
 Attention and arousal
 Memory

 Sensory/perceptual dysfunction

 Language and communication

 Intellect and executive function

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Outcomes Measurement
 Glasgow Outcome Scale
 Disability Rating Scale
 Rancho Los Amigos Level of
cognitive functioning
 Functional Independence Measure

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 Glasgow Outcome Scale

Scor Category Definition

e
1 Death As a direct result of brain trauma.
Patient regained consciousness and died
thereafter from secondary complications
or other causes
2 Persistent Unresponsive and speechless for an
Vegetative State extended period of time. (+) eye
(PVS) opening and sleep-wake cycle but
absence of function in the cerebral
cortex judged behaviorally.
3 Severe Disability Dependent for daily support due to
(conscious but mental or physical disability or both
disabled)
4 Moderate (disabled Can travel by public transport and work
but independent) in sheltered environment. Independent
in ADL. (+) impairments
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5 Good recovery Resumption of normal life even though
 Rancho Los Amigos
(Revised)
 Level I - No Response: Total Assistance
 Level II - Generalized Response: Total
Assistance
 Level III - Localized Response: Total
Assistance
 Level IV - Confused/Agitated: Maximal
Assistance
 Level V - Confused, Inappropriate Non-
Agitated: Maximal Assistance
 Level VI - Confused, Appropriate: Moderate
Assistance
 Level VII - Automatic, Appropriate: Minimal
Assistance for Daily Living Skills
 Level VIII - Purposeful, Appropriate: Stand-
By Assistance
 Level IX - Purposeful, Appropriate: Stand-By47
 Prediction of Outcome
 GCS taken at 2-3 or 4-7 days post-
injury is highly predictive of
outcome at 6 months (GOS)
 PTA > 14 days is correlated with
moderate to severe disability
 Bulk of recovery after TBI occurs
during the 1st 6 months
 Certain areas of dysfunction recover
more quickly than others
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 Possible Mechanisms of
Functional Recovery
 Resolution of temporary factors – eg.
Edema
 Neuronal regeneration – fiber
sprouting
 Functional reorganization –
“reassignment”
 Synaptic alterations
 Functional substitution
 Learning of specific skills
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 Medical Complications
After TBI
 Posttraumatic seizures
 may be generalized, partial and

absence seizures
 patients given prophylactic

phenytoin in the first week

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 Medical Complications
After TBI
 Hydrocephalus
 May be communicating (within the ventricular
system) or non-communicating (obstruction in
the subarachnoid space)
 Symptoms include
 Nausea
 Vomiting
 Headache
 Papiledema
 Obtundation
 Dementia
 Ataxia
 Urinary incontinence
 Treatment – shunting procedure or lumbar
puncture
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 Medical Complications
After TBI
 Deep Venous Thrombosis
 Patients should be given prophylaxis
as early as possible
 Prophylaxis include:
 Elastic compression
 Intermittent pneumatic compression
 Vena cava filters
 Anticoagulants

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 Medical Complications
After TBI
 Heterotopic Ossification
 Ectopic bone formation
 Common in the hips, knees, elbows,
shoulders, hands and spine
 Risk factors include coma lasting > 2
weeks, limb spasticity and decreased
mobility
 Spasticity
 Velocity dependent increase in tone

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 Medical Complications
After TBI
 GI and GU complications
 Include stress ulcers, dysphagia,
bowel incontinence and elevated liver
functions tests
 GU complications include urethral
strictures, UTI and urinary
incontinence

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THERAPEUTIC INTERVENTIONS FOR
THE COGNITIVE AND BEHAVIORAL
SEQUELAE IN TBI

 The goals of cognitive and

behavioral rehabilitation are to
enhance the person’s capacity to
process and interpret
information and to improve the
person’s ability to function in all
aspects of family and community
life 55
 Therapeutic
Interventions
 Restorative training focuses
on improving a specific
cognitive function
 used to improve specific

neuropsychological
processes, predominantly
attention, memory, and
executive skills
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 Therapeutic
Interventions
 Compensatory training focuses
on adapting to the presence of
a cognitive deficit.
Compensatory devices, such

as memory books and

electronic paging systems,
are used both to improve
particular cognitive functions
and to compensate for 57
 Therapeutic
Interventions
 Psychotherapy
 used to treat depression and loss of
self-esteem associated with
cognitive dysfunction
 Specific goals for this therapy
emphasize emotional support,
providing explanations of the injury
and its effects, helping to achieve
self-esteem in the context of
realistic self-assessment, reducing
denial, and increasing ability to 58
 Therapeutic
Interventions
 Pharmacological agents
 may be useful in a

variety of affective and

behavioral disturbances
associated with TBI

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 Therapeutic
Interventions
 Behavior modification
used to address the

personality and behavioral

effects of TBI
used in retraining persons

with TBI in social skills

 Vocational rehabilitation
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 Therapeutic
Interventions
 Other interventions, such as
structured adult education,
nutritional support, music and art
therapy, therapeutic recreation,
acupuncture, and other alternative
approaches, are used to treat
persons with TBI

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 RECOMMENDATIONS REGARDING
REHABILITATION OF PATIENTS WITH
TBI
 Rehabilitation services should be matched

to the needs, strengths, and capacities of

each person with TBI and modified as
those needs change over time.
 Rehabilitation programs for persons with

moderate or severe TBI should be

interdisciplinary and comprehensive.
 Rehabilitation of persons with TBI should

include cognitive and behavioral

assessment and intervention.
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 RECOMMENDATIONS REGARDING
REHABILITATION OF PATIENTS WITH
TBI
 Persons with TBI and their families should

have the opportunity to play an integral

role in the planning and design of their
individualized rehabilitation programs
and associated research endeavors.
 Persons with TBI should have access to

rehabilitation services through the entire

course of recovery, which may last for
many years after the injury.
 Substance abuse evaluation and

treatment should be a component of

rehabilitation treatment programs.
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 RECOMMENDATIONS REGARDING
REHABILITATION OF PATIENTS WITH
TBI
 Medications used for behavioral
management have significant side
effects in persons with TBI, can
impede rehabilitation progress, and
therefore should be used only in
compelling circumstances.
 Medications used for cognitive
enhancement can be effective, but
benefits should be carefully
evaluated and documented in each 64
 RECOMMENDATIONS REGARDING
REHABILITATION OF PATIENTS WITH
TBI
 Community-based, nonmedical
services
 clubhouses for socialization
 day programs and social skill

development program
 supported living programs and

independent living centers

 supported employment programs

 formal education programs at all levels

 consumer, peer support programs.

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 RECOMMENDATIONS REGARDING
REHABILITATION OF PATIENTS WITH
TBI
 Families and significant others provide

support for many people with TBI. To do

so effectively, they themselves should
receive support. This can include in-home
assistance from home health aides or
personal care attendants, daytime and
overnight respite care, and ongoing
counseling.
 Rehabilitation efforts should include

modification of the individual's home,

social, and work environments to enable
fuller participation in all venues. 66
 RECOMMENDATIONS REGARDING
REHABILITATION OF PATIENTS WITH
TBI
 Specialized, interdisciplinary, and
comprehensive treatment programs
are necessary to address the
particular medical, rehabilitation,
social, family, and educational needs
of young and school-age children
with TBI.

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