Traumatic Brain Injury

Grand Rounds Susan Kartiko MD PhD 10/30/13

Traumatic brain injury

The most common cause of disability and death among young people. 1.7 million people annually seek help to ED for TBI

52000 deaths and 80000 with permanent neurologcal disabilities.

In both more or less developed countries motor vehicles are the major cause deaths and disabilities , particularly among young people.

Falls are the major cause of death and disabilities for people age >65 yo.
Estimated 2% of US population is living with TBI related disabilities

Ghajar, Lancet 2000: 356: 923-29.

Ghajar, Lancet 2000: 356: 923-29.

Classifications of TBI

Mild TBI
Defn: an acute alteration in brain function caused by a blunt external force and is characterized by
a GCS score of 13 to 15, loss of consciousness for 30 minutes or less, duration of posttraumatic amnesia of 24 hours or less. If a brain CT scan has been performed, its result must be normal. The terms mild traumatic brain injury and concussion may be used interchangeably.

Estimated 1.1 million suffered from mild TBI, 75% from total TBI

East Guideline, J Trauma. 73(5):S307-S314, November 2012

Mild TBI: criteria for discharge

Holmes et al 2011: children GCS 14-15 with negative CT scan can be safely discharged home Livingstone 2000: CT scan have a 99.7% negative predictive value in GCS 14-15 patients Kaen 2009: 1.4% patients with therapeutic INR and a negative CT scan have a positive CT scan in 24hr. Cohen 2006: patient with GCS13-15, supratherapeutic INR, and negative CT scan should be admitted and have their INR reversed at least to a therapeutic range.

East Guideline, J Trauma. 73(5):S307-S314, November 2012

Mild TBI: post discharge

Studies shows most have a complete recovery between 3-12 months.

Symptoms that are seen to be present post TBI: headache, dizziness, fatigue, anxiety, depression, irritability, and personality changes
Driving recommendations: patients with mild TBI has longer reaction time and lower tactical control while driving compared to patients with mild orthopedic injury

Lundqvist A, Alinder J. Brain Inj. 2007; 21: 11091117.

Moderate/Severe TBI
Long lasting effects: cognitive defects, psychiatric disorders (ie. Depressive and behavioral disorders, PTSD), social functional disorder Cognitive: attention, memory, speed of processing, confusion, preseveration impulsiveness, language processing, executive functioning Speech and language: reactive and expressive aphasia, slurred speech, problems writing/ reading Vision/hearing/smell/taste Seizures Physical changes: chronic pain, control of bowel and urinary function, loss of stamina Social/ emotion: aggression, depression, disinhibition, irritability, lack of motivation, denial/lack of awareness
Maas, et al Lancet Neurology vol7: 728-741

Moderate/Severe TBI
Primary damage: brain damage result from external force
Macroscopic level: shearing of white matter tracts, focal contusions, hematoma, diffuse swelling Cellular level: microporation of membrane, leaky ion channels, stearic conformation of protein, microhemorrhage from torn blood vessels

Secondary damage
Develop over hours and days, include neurotransmitter release, free radical generation, calcium-mediated damage, gene activation, mitochondrial dysfunction and , inflammatory response
Inflammatory response causes brain swelling, and brain cell necrosis

Maas, et al Lancet Neurology vol7: 728-741

Management of Moderate/Severe TBI

Pre hospital
Aim: reduce hypotension and hypoxia to prevent secondary brain injury Odds ratio 2.1 and 2.7 respectively to poor outcome Keep SBP >90 mmHg Keep PaO2 > 60, or O2 sat >90.

Admission
To neurosurgical facilities (2-15 odds of death if treated in non-neurosurgical facilities) Aim: early detection and intervention if needed (ie. STAT CT) In penetrating injury: dural closure with debridement or simple wound closure and antibiotic treatment
Maas, et al Lancet Neurology vol7: 728-741

Management of Moderate/Severe TBI

NeuroICU
Aim: limit ongoing brain damage and provide best environment for brain recovery by reducing brain swelling and raised ICP Prophylactic anti-seizure DVT prophylaxis
20% TBI patients develop DVT with no ppx SCD vs pharmacological (32 vs 17%)

Nutrition:
Full nutrition by day 7, starting 72 hours post injury Under nutrition for 2 weeks increased mortality vs full nutrition by 1 week TBI patients require an average 160% vs normal When paralysed require 100-120%
Maas, et al Lancet Neurology vol7: 728-741

Management of Moderate/Severe TBI

ICP monitoring
Cerebral hypertension occur in 77% of patients Raised ICP is correlated to poorer outcome 0.5% risk of hemorrhage, 2 % risk of infection Intraventricular catheter is prefered because can be therapeutic vs intraparenchymal Maintenance of CPP> 70 with vaso-pressors and fluid boluses increased the risk of ARDS

Chestnut et al , NEJM 2012 (367): 2471-81; Maas, et al Lancet Neurology vol7: 728-741

Management of Moderate/Severe TBI

NeuroICU
NO steroids!!!
Increased mortality

Osmotherapy
Mannitol and hypertonic saline

Sedation and artificial ventilation to prevent high ICP

Propofol, barbiturates, paralytic

Decompressive creniectomy
Controversial on what is the indication. Needs to be large enough (ie. 15x15 cm) DECRA, RescueICP
Maas, et al Lancet Neurology vol7: 728-741

DECRA

Prognosis of moderate to severe TBI

Outcome is usually assessed at 6 mo
85% of recovery occur during this time period

Medical complication after TBI prevents early rehab

UTI, pulmonary complications, electrolytes derangement, liver function derangement, hydrocephalus, seizure Happen to 60-70% of TBI patients.

Maas, et al Lancet Neurology vol7: 728-741

Rehabilitation in TBI
WHO International classifications:
Impairment: any loss or impairment of psychological, physiological or anatomical structure or function Disability: any restriction or lack of activity resulting from an impairment to perform an activity in the manner or in the range considered normal for the people of similar age, sex, or culture. Handicap: a disadvantage of a given individual resulting from an impairment or disability that limits or prevents the fulfillment of a role that would otherwise be normal for that individual

Components of rehabilitation
Goal setting
Short and long term goals Attainable goals to build confidence

Outcome measurements
Ie. timed 10 m tests, nine hole peg test

Setting of rehab
Recovery curve is steepest in the 3-4 months post trauma- needs to be capitalized Inpatient vs day-center rehab

Barnes, British Medical Bulletin 1995. 55 (4): 927-943

Rehabilitation in TBI
McKay 1992: rehab vs no rehab on matched groups of severe TBI showed coma length, rehab stay and lengths of stay is better in rehab
Rehab: PT, OT, speech therapy 94% rehab group went home vs 57% no rehab group

Blackerby 1990: increased intensity of rehab (5-8 h/day) decreases length of stay in the hospital and rehab setting

Barnes, British Medical Bulletin 1995. 55 (4): 927-943

From: Cognitive Rehabilitation for Traumatic Brain Injury: A Randomized Trial

JAMA. 2000;283(23):3075-3081. doi:10.1001/jama.283.23.3075

Rehabilitation in TBI

Ghua et al, Annal Acad of Singapore 2007; 36: 31-42

Rehabilitation in TBI

Ghua et al, Annal Acad of Singapore 2007; 36: 31-42

Issues during rehab period

Pressure sores Spasticity Nutrition Cognitive problem

Behavioral issues

Barnes, British Medical Bulletin 1995. 55 (4): 927-943

Return to work/ society

GCS and classifications