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traumatic brain injury (TBI)

also see cerebral concussion for sports-related traumatic brain injury Etiology: - blunt trauma - penetrating trauma - sound wave trauma from explosions - risk facture for traumatic brain injury a) prior mild traumatic brain injury b) low education level c) low socioeconomic status Epidemiology: - 16 of 40 retired National Football League players show MRI evidence of traumatic brain injury [40] Pathology: 1) a blow to a resting, movable head produces maximal injury beneath the point of impact (coup injury) 2) a moving head contacting an immobile object results in maximal brain injury opposite the side of impact (contrecoup injury) 3) amyloid beta peptide (Abeta) accumulates in brain rapidly after traumatic brain injury [7] - beta-amyloid deposition may be more common after traumatic brain injury associated with cognitive impairment [22] - distribution of amyloid pathology in Alzheimer's disease differs from that of traumatic brain injury [11] 4) sound wave trauma may result in axonal injury [10] 5) even without concussion, college athletes who play contact sports still have white-matter changes that may have some functional significance [20] 6) severity & location of diffuse axonal injury predict white-matter degeneration after traumatic brain injury [60] Clinical manifestations: 1) loss of consciousness: - mild TBI associated with brief or no loss of consciousness - immediate & prolonged (> 5 minutes) with severe head injuries - 25% of patients show MRI &/or EEG evidence of awareness despite coma (see cognitive-motor dissociation) [67] 2) postconcussion syndrome (persistence of TBI symptoms beyond several weeks) [8] a) headache (migraine or tension headache) [8] b) amnesia, memory impairment, learning impairment [8] c) dizziness d) irritability, depression, anxiety [8] e) confusion f) inability to concentrate 3) abnormal Glasgow coma score 4) gait disturbance 5) abnormal pupillary response 6) other [8] - photophobia, phonopobia - nausea/vomiting - visual disturbance - dysarthria - altered state of consciousness [8] - focal neurologic deficits [8] - seizure (within 1 week) [8] - delayed reaction time - sleep disorder - fatigue, insomnia, hypersomnia, drowsiness, vivid dreams - emotional distress* [51] 7) symptoms of mild TBI generally resolve within 10 days * predictor of poor recovery (see complications) Laboratory: - ubiquitin C-terminal hydrolase in blood & GFAP in blood FDA-approved to assess need for CT of brain in adults with mild traumatic brain injury (concussion) [48] - neurofilament light chain in serum may be elevated in the early chronic phase of traumatic brain injury [64] - GFAP in blood normal 8 months after TBI, but may show elevation at 5 years [64] Special laboratory: 1) electroencephalography (EEG): - post-traumatic seizure - unresponsive to verbal commands - a small proportion of patients show cerebral responses but not physical responses to commands [56] - these patients fare better than their peers without brain activation - may represent 'locked in syndrome' 2) auditory brainstem response: value uncertain 3) neuropsychiatric testing Radiology: 1) see New Orleans criteria &/or Canadian CT Head Rule for appropriateness of neuroimaging [12] 2) for mild traumatic brain injury, neuroimaging recommended if: - worsening headache, repeated vomiting, drowsiness, persistent confusion, dysarthria, focal neurologic deficits [8] 3) computed tomography (head CT) imaging modality of choice in acute setting [8] a) Glasgow coma scale < 15 b) focal neurologic deficits c) coagulopathy, anticoagulation d) persistent severe headache > 71 hours e) suspected skull fracture f) post-traumatic seizure g) post-traumatic amnesia h) post-traumatic gait disorder i) recurrent vomiting j) age > 60 years with loss of consciousness; age > 65 years k) drug toxicity or alcohol intoxication l) dangerous mechanism of injury - pedestrian struck by motor vehicle - occupant ejected from motor vehicle - fall from > 3 feet or > 5 stairs m) children with minor blunt head trauma presenting to the emergency department with isolated loss of consciousness are at very low risk for traumatic brain injury & do not routinely require computed tomography [26,53] n) in patients with mild head trauma, a second CT scan is unnecessary [46] 4) magnetic resonance imaging (MRI neuroimaging) 5) flortaucipir & florbetapir PET scan - may be useful for predicting outcome [23] - tau-related changes in symptomatic former NFL players but a relative absence of amyloid deposition [55] Differential diagnosis: 1) minor head injury a) migraine headache b) psychiatric disorder c) drug & alcohol abuse d) learning disorder 2) comatose individuals a) subdural hematoma, epidural hematoma b) subarachnoid hemorrhage c) intracerebral hematoma d) drug or alcohol overdose e) metabolic disease Complications: 1) seizures (17% with severe injury) 2) spasticity 3) hydrocephalus 4) visual impairment 5) vesibular impairment 6) sleep disturbance noted for as long as 18 months [41] - increased sleep needs (8.1 vs 7.1 hours) - chronic excessive daytime sleepiness (67% vs. 19%) 7) 14% if children wuth mild traumatic brain injury symptomatic 3 months after injury [9] a) symptoms persist for at least 12 months in some children b) 3 months predict worse quality of life & need for educational intervention [14] c) greater risks later for premature mortality, psychiatric inpatient admissions & outpatient visits, being on disability & welfare, & lower education [44] - risks stronger with greater severity of injury, multiple injuries, & older age at first injury 8) no clear cognitive effect of sub-concussion head impact [15] 9) with moderate-severe TBI, increased risk of a) psychiatric disease b) medical morbidity c) mortality d) dementia [25,47] 10) TBI with loss of consciousness is associated with - risk for Lewy body accumulation - progression of parkinsonism & Parkinson's disease - not associated with dementia, Alzheimer's disease, neuritic plaques, or neurofibrillary tangles [43] - hospitalization with major traumatic brain injury associated with increased risk for dementia (RR=1.3) [63] 11) veterans especially at risk - prevalence of PTSD higher in veterans with mild TBI than in civilians [8] - depression often comorbid with PTSD [8] - even mild TBI without loss of consciousness is associated with increased risk for dementia in veterans [50] 12) traumatic brain injury in older adults increases risk of Parkinson's disease [30] 13) elderly (> 75 years of age) have highest risk of morbidity, hospitalization & mortality after traumatic brain injury - avoid overmedication - encourage physical activity - home safety 14) olfactory impairment [31] 15) increased risk for attention-deficit hyperactivity disorder (ADHD) among children 3-7 years of age at the time of TBI with ADHD manifesting as late as 7 years [49] - more severe cases of ADHD occur within 18 months [49] 16) increased risk for suicide [52] - screen for depression [8] 17) predictors for poor recovery - emotional distress - maladaptive coping early after injury - preinjury mental health problems - lower education - age 40-60 years versus younger or older age [51] 18) gaps in care hospital discharge even in symptomatic patients & those with positive brain CT [51] Management: 1) initial assessment: a) Airway, breathing, circulation b) cervical spine evaluation c) Glasgow coma scale/AVPU system head abbreviated injury scale [5] d) history - previous head injury - headache - tinnitus - blurred vision - nausea - emotional lability e) physical examination - pupillary response - Romberg's test - tandem walk (heel-to-toe) - finger to nose - extraocular movements - concentration - memory f) serial evaluation 5, 10, & 20 minutes post injury - provocative testing (physical stressors) g) also see cerebral concussion 2) avoid hypotonic fluids a) D5W-1/2 normal saline 1st line treatment after head trauma b) add IV desmopressin if urinary output is excessive or electrolyte abnormalities develop [8] 3) monitor for increased intracranial pressure - no benefit from therapy guided by intracranial pressure monitoring rather than clinical and radiographic signs [16] 4) tranexamic acid within 3 hours of a mild-moderate TBI may reduce head injury-related mortality (but not overall mortality) [58] 5) glucocorticoids may increase early mortality - attention to glycemic control 6) beta-blocker may be of benefit for hospitalized patients (NGC, EAST) 7) near-infrared light pulsing may enhance recovery in patients in acute (within 1 week), subacute (2-3 weeks)& late-subacute (3 months) recovery phases [66] 8) of no benefit a) progesterone infusion begun 4-8 hours after injury & continued for 96-120 hours of no benefit [29] b) continuous infusion of 20% hypertonic saline solution for 48 hours [62] c) hypothermia of no value [54] 9) children with blunt head injury who have normal Glasgow coma scale & normal head CT a) can be safely discharged home with postconcussive follow-up care instructions (signs of deterioration) b) outpatient follow-up before resuming physical activities [11] 10) treat postconcussion syndrome 11) athletes suspected of traumatic brain injury should be immediately removed from game & should undergo sideline assessment - avoid contact sports in symptomatic patients [8] (see cerebral concussion & postconcussion syndrome) 12) amantadine a) accelerates recovery loss of consciousness; however, the benefit disappears after amantadine is stopped [13] b) reduces irritability in outpatients with chronic, moderate traumatic brain injury [21] 13) patients should be advised to limit physical & cognitive activity in first several days post-injury, then, graduallyincrease activity, as long as symptoms do not worsen [53] 14) NSAIDS or triptans may be used for mild TBI headaches - avoid opiates & barbiturates [8] - SSRIs, SNRIs, & TCAs can also be used for post-traumatic headache, mood disorders & anxiety disorders [8] 15) methylphenidate may improve cognition after TBI in children [57] 16) DVT prophylaxis, seizure prevention, fever control for severe TBI [8] 17) prognosis: - mild TBI typically resolves spontaneously within 7-10 days [8] - 98% of moderate-severe TBI patients recover consciousness [61] - most achieve either full or partial functional independence after inpatient rehabilitation [61] - screen for depression if symptoms persist 18) prevention - Q-collar for prevention of repetitive sub-concussive traumatic brain injury in athletes >= 13 years of age * also see severe head injury Comparative biology: - continuous transcranial application of glutathione within 3 hours of traumatic brain injury reduced brain injury by >= 50% in mice [23] - monoclonal antibodies against cis P-tau following TBI in mice block pathological changes & some of the behavioral effects associated with TBI [32] - treatment of mice with experimental compound P7C3-A20 one year after TBI repairs blood-brain barrier, arrests chronic neurodegeneration, & restores cognition [59]

Related

anoxic/hypoxic encephalopathy Mayo Portland Adaptability Inventory severe head injury

Specific

brainstem contusion cerebellar contusion cerebral concussion cerebral contusion cerebral laceration chronic traumatic encephalopathy (CTE) contrecoup injury coup injury dangerous mechanism of injury dementia pugilistica gunshot wound to the brain intracranial hematoma post concussion syndrome post-traumatic headache second impact syndrome (SIS) shaken baby syndrome

General

head injury CNS trauma disease/disorder primarily affecting brain

References

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