Traumatic Brain Injury

Traumatic Brain Injury and its management

1. TRAUMATIC BRAIN INJURY Dr. RAMNGAIHZUALA CHHANGTE

2. INTRODUCTION Traumatic Brain Injury (TBI) is defined as an insult to the brain caused by an external force that may produce diminished or altered states of consciousness, which results in impaired cognitive abilities or physical functioning * Often referred to as silent epidemic as society in general is largely unaware of the magnitude of the problem and potential chronicity of its sequelae ** * National Head Injury Foundation, 1988 ** Youmans & Winn, 8 th Ed, p.2903

3. EPIDEMIOLOGY OF TRAUMATIC BRAIN INJURY Traumatic Brain Injury (TBIs) are a leading cause of morbidity, mortality, disability and socioeconomic losses in India and other developing countries. It is estimated that nearly 1.5 to 2 million people are injured and 1 million succumb to death every year in India. Road traffic accidents (60%), Falls (20-25%), Violence (10%) are the leading cause of TBIs in India. Gururaj G. Epidemiology of traumatic brain injuries: Indian scenario. Neurol Res. 2002 Jan;(1):24-8.doi:10.1179/016164102101199503. PMID 11783750

4. SEVERITY OF TRAUMATIC BRAIN INJURY VA/ DoD Clinial Practice Guideline for management of Concussion/ mTBI (2009) CRITERIA MILD MODERATE SEVERE Imaging Normal Normal or abnormal Normal or abnormal Loss of Consciousness 0-30 min 30mins to 24 hours > 24 hours Alteration of mental state A moment upto 24 hours >24 hours, severity based on other criteria Post traumatic Amnesia 0-1 day >1 and < 7 days >7 days GCS (best score in the first 24 h) 13-15 9-12 <9

5. CLINICAL FEATURES OF TBI Vomiting Headache Confusion ENT bleeed Seizure Loss of consciousness Paralysis CSF rhinorrhoea / Otorrhoea Periorbital echhymosis Dilated pupils/ Anisocoria Bradycardia Aphasia Inappropriate emotional responses Facial paralysis Loss of bowel control/bladder control Coma ‘Traumatic Brian Injury’ - A Nitin Agarwal , MD, Rut Thakkar , Khoi Than, MD, FAANS, 2020

6. PATHOPHYSIOLOGY OF TBI TBI causes BBB dysfunction which activates ROS and cytokines/ chemokines . This causes demyelination and axonal swelling which leads to neurodegeneration . Excessive accumulation of neurotransmitters allow the influx of calcium ions which results in mitochondrial dysfunction. Mitochondrial dysfunction causes apoptosis inducing factor (AIF) to be released in cytosol. These cellular and molecular events lead to caspase dependent and independent neuronal cell death. Ray, S. K., Dixon, C. E., and Banik , N. L. (2002 ). Molecular mechanisms in the pathogenesis of traumatic brain injury.  Histol . Histopathol .  17, 1137–1152. doi : 10.14670/HH-17.1137

7. TYPES OF TRAUMATIC BRAIN INJURY PRIMARY TBI : occurs at the moment of initial trauma – skull fractures, contusions, concussions, diffuse axonal injury, etc. Primary TBI can be caused by either penetrating (open) head injury or a non penetrating (closed) head injury. SECONDARY TBI : occurs as an indirect result of the insult. It results from processes initiated by the initial trauma and typically evolves over time which include ischemia, hypoxia, cerebral edema , raised ICP, hypercapnia , meningitis, epilepsy, etc. Hegde , M.N. (2006). A coursebook on aphasia and other neurogenic language disorders (3 rd Ed).

8. TYPES OF TBI CONTD… CEREBRAL CONCUSSION Defined as head injury with a transient loss of brain function and is known to cause a variety of physical, cognitive and emotional symptoms. Most common type of head injury Headache and dizziness are the most common symptoms. Amnesia, confusion, blurring of vision, fatique are also other common symptoms. Brain scans are almost always unremarkable. Self limiting; needs only symptomatic treatment. Caused by acceleration and deceleration forces with minimal axonal stretch. Ramamurthy, (2012). Concussion Brain. Textbook of Neurosurgery (3 rd Ed). (pp. 257-259)

9. TYPES OF TBI CONTD… EXTRADURAL HEMATOMA Ramamurthy, (2012). Extradural Hematomas. Textbook of Neurosurgery (3 rd Ed). (pp. 440-444) Occurs in aprox 2% of patients with head injuries. Collection of blood between inner table of the skull and the dura . It arises from injury to middle meningeal artery in over one half, from middle meningeal vein in on third and from dipolic veins in the reminder Characterized by lucid interval, but not pathognomic . Temporopariental region are most commonly effected. Commonly associated with overlying skull fracture. Usually occurs in young adults. Rare in children below 2 years or after the age of 60 years. CT scan is the investigation of choice. Treatment is mainly surgical.

10. TYPES OF TBI CONTD… SUBDURAL HEMATOMA Ramamurthy, (2012). Acute subdural Hematomas. Textbook of Neurosurgery (3 rd Ed). (pp. 432-438) Accumulation of blood within the subdural space of the brain. Occurs in 5-29% of patients with head injury. It is due to avulsion of bridging veins or rupture of small coritcal arteries. Mechanism of injury is rapid deceleration of the cranium with a relatively low magnitude of the shear force applied. Convexity of the brain is most commonly affected Usually occurs in the fifth and sixth decades (mean age 31-47 years). 50% of acute SDH is associated with intracranial injuries

11. TYPES OF TBI CONTD… SUBARACHNOID HEMORRHAGE Ramamurthy, (2012). Subarachnoid Hemorrhage. Textbook of Neurosurgery (3 rd Ed). (pp. 849-857) SAH is hemorrhage into the subarachnoid space. Trauma is the most common cause of SAH Classical presentation of SAH is severe headache. CT scan is the investigation of choice for traumatic SAH More commonly seen in the cerebral sulci than in the Sylvian fissure and in the basal cisterns. Has better prognosis than aneurysmal SAH.

12. TYPES OF TBI CONTD… CEREBRAL CONTUSIONS Ramamurthy, (2012). Cerebral contusions. Textbook of Neurosurgery (3 rd Ed). (pp. 361-367) Cerebral contusion is a bruise of the brain parenchyma, which can be localized or diffuse. Caused by the brain being striked or squeezed against dural partitions. Commonest traumatic lesion visualized on CT scans. Clinical features ranges from LoC , seizures, hemiparesis, confusions, etc , depending upon its size, location, extent of associated edema and hemorrhage . Can be fatal if vital areas like hypothalamus, pons or medulla are effected.

13. TYPES OF TBI CONTD… DIFFUSE AXONAL INJURY Ramamurthy, (2012). Diffuse Axonal Injury. Textbook of Neurosurgery (3 rd Ed). (pp. 370-375) Characterized by reactive axonal ‘retraction’ balls, hemorrhagic necrosis in the dorsolateral quadrant of the brainstem and in the corpus callosum. It is caused by angular or rotational acceleration forces. Should be suspected when a patient demonstrates clinical symptoms disproportionate to his/her CT findings. Patient presents with immediate loss of consciousness with extensor or flexion posture. Most patients remain in persistent vegetative state. MRI is preferred over CT scan for demonstrating DAI

14. TYPES OF TBI CONTD… SKULL FRACTURE https://operativeneurosurgery.com/doku.php?id=skull_fracture Skull fracture is a fracture or break in the cranial bones There are four major types of skull fractures : Linear Skull fracture Depressed Skull fracture Diastatic fracture Basilar fracture Linear fractures are the most common type of skull fracture and usually require no intervention. Depressed fractures are usually comminuted , with broken portions of bone displaced inwards and often need surgical intervention. Diastatic fractures widen the sutures of the skull and usually affect children under three Basilar fractures are in the bones at the base of the skull CT scan is the investigation of choice.

15. CLINICAL ASSESSMENT OF TBI GENERAL EXAMINATION : Airway Breathing Circulation CLINICAL HISTORY : Ask for history of.. Loss of consciousness Seizure ENT bleed Vomiting Ramamurthy, (2012). Clinical Assessment of a Head Injury Patient. Textbook of Neurosurgery (3 rd Ed). (pp. 406-410)

16. CLINICAL ASSESSMENT OF TBI CONTD.. NEUROLOGICAL ASSESSMENT : The single most important parameter of neurological examination is the state of consciousness which is to be recorded as per Glasgow Coma Scale. Ramamurthy, (2012). Clinical Assessment of a Head Injury Patient. Textbook of Neurosurgery (3 rd Ed). (pp. 406-410)

17. CLINICAL ASSESSMENT OF TBI CONTD.. PUPILLARY STATUS AND OPTIC NERVE FUNCTION Size, shape, position, reaction to light and the pupillary reflexes should be thoroughly examined. The pupillary status and their changes are related to the brainstem and both Optic Nerve and oculumotor Nerve activity. Pupil is dilated ipsilateral to the side of lesions in 85% cases. i.e can be used for determination of the side of lesion. Bilaterally dilated pupils are indicators of a poor prognosis and are early prequel of brain death Ramamurthy, (2012). Clinical Assessment of a Head Injury Patient. Textbook of Neurosurgery (3 rd Ed). (pp. 406-410)

18. CLINICAL ASSESSMENT OF TBI CONTD.. MOTOR EXAMINATION AND REFLEXES The Medical Research Council Grading is used for grading muscle power in conscious and alert patients. Superficial and Deep tendon reflexes should also be examined including biceps, supinator, triceps, knee and ankle jerks. Ramamurthy, (2012). Clinical Assessment of a Head Injury Patient. Textbook of Neurosurgery (3 rd Ed). (pp. 406-410)

19. RADIOLOGICAL ASSESSMENT OF TBI CT SCAN Non contrast CT scan is the investigation of choice for Traumatic Brain Injury mainly because :- Rapid : Takes only few minutes for brain scan Very sensitive to calvarial injury : Can detect scalp hematoma, skull fracture with high accuracy Radio opacity to foreign body : For detecting gunshot fragments, penetrating injury, etc Sensitivity and accuracy for detecting hemorrhage , herniation and hydrocephalus requiring emergent neurosurgical attention. For predicting clinical outcomes : NCCT findings have been incorporated into a number of outcome prediction rules. Mutch CA, Talbott JF. Imaging Evaluation of Acute Traumatic Brain Injury. Neurosurg Clin N Am. 2016 Oct;27(4):409-39. doi : 10.1016/j.nec.2016.05.011. Epub 2016 Aug 10. PMID: 27637393; PMCID: PMC5027071

20. RADIOLOGICAL ASSESSMENT OF TBI WHEN TO ADVISE CT SCAN ? According to NEW ORLEANS CRITERIA (NOC) … https://www.researchgate.net/publication/318853717/figure/fig2/AS:631662765424651@1527611547216/New-Orleans-criteria.png

21. RADIOLOGICAL ASSESSMENT OF TBI WHEN TO ADVISE CT SCAN ? According to CANADIAN CT HEAD RULE … https://ars.els-cdn.com/content/image/1-s2.0-S0196064401024623-gr1.jpg

22. RADIOLOGICAL ASSESSMENT OF TBI MRI MRI is more sensitive for the detection of certain intracranial injuries especially axonal injuries It is also more sensitive in detecting blood products 24-48 hours after injury. Therefore MRI is advised when CT findings are normal and there are persistent unexplained neurological findings or at subacute or chronic periods. Limitations of MRI include.. :- Accessibility Sensitivity to motion Cost Andrew D. Schweizer , Sumit N. Niogi , Christopher T. Whitlow, A. John Tsiouris . Traumatic Brain Injury: Imaging Patterns and Complications. 2019 Oct 7. https://doi.org/10.1148/rg.2019190076

23. MANAGEMENT OF MILD TBI Mild traumatic brain injury (TBI) is common and associated with a range of diffuse, non-specific symptoms including :- headache , nausea , dizziness, fatigue , hypersomnolence , attentional difficulties, photosensitivity and phonosensitivity , irritability and depersonalisation . These symptoms usually resolve within 3 months. However, 5-15% patients have persistent symptoms beyond 3 months. Nevertheless, treatment of Mild TBI is mainly symptomatic including analgesic, anti-depressant, etc. van Gils A, Stone J, Welch K , et al Management of mild traumatic brain injury Practical Neurology   2020; 20: 213-221

24. PRE HOSPITAL MANAGEMENT OF SEVERE TBI PROTOCOLS Airway repositioning maneuvers are performed Bag-valve-mask (BVM) ventilation is performed using airway adjuncts (e.g., an oropharyngeal airway ). Endotracheal intubation is performed if an experienced ALS provider is available . Management of ventilation :- M aintain ETCO 2  between 35 and 45 mmHg. M ild therapeutic hyperventilation, ETCO2 between 30 to 35 mmHg is recommended only  for  obvious  signs of herniation. Maintain SBP between 90mmHg and 140mmHg. Dash HH. Prehospital care of head injured patients.  Neurol India.  2008;56:415–419

25. MANAGEMENT PROTOCOL FOR RAISED ICP Nathens AB, Cryer HG, Fildes J. The American college of surgeons trauma quality improvement program.  Surg Clin North Am.  2012;92:441–454.

26. MANAGEMENT PROTOCOL FOR RAISED ICP Nathens AB, Cryer HG, Fildes J. The American college of surgeons trauma quality improvement program.  Surg Clin North Am.  2012;92:441–454.

27. POST TRAUMATIC EPILEPSY Post-traumatic seizures are classified as :- I mmediate (at the moment of injury, or within minutes), E arly (within the first 7 days), and L ate (beyond the first week after injury ) Patients with clinically severe TBI (GCS score, 3 to 8), penetrating brain injury, and a history of alcohol abuse are at higher risk for developing post-traumatic seizures. Incidence of immediate seizure following TBI is 1-4% Incidence of early seizure following TBI is 2-9% Incidence of Late seizures in persons who developed early seizures is as high as 25-75% H. Gordon Deen , ( 2007). Head Trauma. Neurology and Clinical Neuroscience . (pp. 1386-1396)

28. ANTICONVULSANT THERAPY FOR PTE Prophylactic anticonvulsant therapy lower the risk of Early seizures but do not improve the outcome. Prophylactic anticonvulsants however, do not lower the risk of Late seizures . Prophylaxis, when prescribed, is usually  phenytoin, and the usual duration of therapy is 1 week . In patients who have had a seizure, anticonvulsants are continued for at least a year . If late seizures occur, long-term anticonvulsant therapy is needed, usually starting with phenytoin or  carbamazepine  and progressing to other agents in the event of therapeutic failure or toxicity . H. Gordon Deen , ( 2007). Head Trauma. Neurology and Clinical Neuroscience . (pp. 1386-1396)

29. INDICATIONS OF SURGERY IN TBI PATIENTS EXTRADURAL HEMATOMA Any acute symptomatic EDH Any asymptomatic EDH with.. Midline shift >5mm EDH thickness >10mm EDH volume >40cc GCS less than 9 with pupillary abnormalities EDH in pediatric patients (low threshold for sudden deterioration) Failure of non-surgical management Ramamurthy, (2012). Extradural Hematomas. Textbook of Neurosurgery (3 rd Ed). (pp. 440-444)

30. INDICATIONS OF SURGERY IN TBI PATIENTS SUBDURAL HEMATOMA Regardless of the patient’s GCS, any acute S DH with.. Midline shift >5mm S DH thickness > 10mm SDH with midline shift <5mm and thickness <10mm should undergo surgery if.. GCS score decreased by 2 points or more from the time of injury and hospital admission Asymmetric or fixed and dilated pupils Intracranial pressure exceeds 20 mmHg. Ramamurthy, (2012). Acute subdural Hematomas. Textbook of Neurosurgery (3 rd Ed). (pp. 432-438)

31. INDICATIONS OF SURGERY IN TBI PATIENTS CONTUSIONS Progressive neurological deterioration Signs of mass effect on brain CT Unresponsive increased ICP Midline shift >5mm Cistern compression evidenced on brain CT Temporal or frontal contusions >20cc Any contusions >50cc Ramamurthy, (2012). Cerebral contusions. Textbook of Neurosurgery (3 rd Ed). (pp. 361-367)

32. INDICATIONS OF SURGERY IN TBI PATIENTS SKULL FRACTURES Depressed skull fracture > thickness (8-10mm) of the calvaria Dural penetration CSF fistula Intradural Pneumocephalus Significant intracranial hematoma Frontal sinus involvement Wound infection or gross contamination Cosmetic deformity Stein SC. The Evolution of Modern Treatment for Depressed Skull Fractures. World Neurosurg . 2018 Oct 13. pii : S1878-8750(18)32341-6. doi:10.1016/j.wneu.2018.10.045.

33. SEQUELAE OF TBI Post-traumatic amnesia Post-concussion syndrome Neurobehavioural sequele Post-traumatic epilepsy Infections – meningitis, osteomyelitis, abscess Normal Pressure Hydrocephalus Metabolic abnormalities Vascular abnormalities Ramamurthy, (2012). Complications and Sequelae of Head Injuries. Textbook of Neurosurgery (3 rd Ed). (pp. 458-470)

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