Traumatic Brain Injury (TBI): A Clinical Overview

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1. Sayan pratihar mpt (Neurology) TRAUMATIC BRAIN INJURY

2. Definition A traumatic brain injury (TBI) is defined as “an alteration in brain function, or other evidence of brain pathology, caused by an external force. ( Menon , DK, et al: 2010)

3. PREVALENCE AND IMPACT Falls are the leading cause of TBI (32%) followed by motor vehicle/traffic accidents (19%), struck by/against events (18%), and assaults (10%). Children, older adolescents/young adults (less than 25 years old), and older adults are most at risk for experiencing TBI. Traumatic brain injuries are most common in young children (0 to 4 years old). However, hospitalization and death as a result of TBI is most common in older adults (65 years old and over)………..( Faul M. et al. 2006)

4. MECHANISM OF INJURY AND PATHOPHYSIOLOGY Primary Injury: Primary TBI results from either brain tissue coming into contact with an object (e.g., bony skull or external object such as a bullet or sharp instrument creating a penetrating injury) or rapid acceleration/deceleration of the brain. Contact injuries often result in contusions, lacerations, and intracerebral hematomas .

5. cont. Acceleration and deceleration cause shear, tensile, and compression forces within the brain, which causes diffuse axonal injury (DAI), tissue tearing, and intra-cerebral hemorrhages.( Kochanek et al. 2007 ) The mechanism of DAI is microscopic, so often there are minimal initial findings on computed tomography (CT) and magnetic resonance imaging (MRI). he acceleration/deceleration forces cause disruption of neuro -filaments within the axon leading to Wallerian -type axonal degeneration. (JM et al. 2001)

6. Blast Injury When an explosive device detonates a transient shock wave is produced, which can cause brain damage. Primary blast injury results from the direct effect of blast overpressure on organs (in this case the brain). secondary injury results from shrapnel and other objects being hurled at the individual, and tertiary injury occurs when the victim is flung backward and strikes an object .

7. Secondary Injury Secondary cell death occurs as a result of a chain of cellular events that follow tissue damage in addition to the secondary effects of hypoxemia, hypotension, ischemia, edema, and elevated ICP.

8. Impairments Commonly Associated With Traumatic Brain Injury Neuromuscular • Paresis • Abnormal tone • Motor function • Postural control Cognitive • Arousal level • Attention • Concentration • Memory • Learning • Executive functions

9. Cont. Neurobehavioral Communication: Swallowing Agitation/Aggression Disinhibition Apathy Emotional lability Mental inflexibility Impulsivity Irritability

10. Dysautonomia Elevated sympathetic nervous system activity occurs as a normal response to trauma; following TBI this response may become overactive. Post-traumatic Seizures Between 12% and 50% of people with severe TBI develop post-traumatic seizures.

11. Secondary Impairments and Concomitant Injuries Deep vein thrombosis • Heterotopic ossification • Pressure ulcer • Pneumonia • Chronic pain • Contractures • Decreased endurance • Muscle atrophy • Fracture • Peripheral nerve damage

12. DIAGNOSIS AND PROGNOSIS Traumatic brain injury is generally categorized as severe, moderate, or mild using the Glasgow Coma Scale (GCS). T he scores from the separate responses are summed to provide a score between 3 and 15. Scores of 8 or less are classified as severe, scores between 9 and 12 are defined as moderate, and scores of 13 to 15 are classified as mild brain injury.

13. post-traumatic amnesia (PTA) The length of time between the injury and the time at which the patient is able to consistently remember ongoing events, is also an important factor in predicting recovery. Brown et al. found that duration of PTA as measured by the Galveston Orientation and Amnesia Test (GOAT), during inpatient rehabilitation is able to predict functional independence, employment, good overall recovery, and independent living 1 year after injury.

14. Characteristics of Mild, Moderate, and Severe Traumatic Brain Injury MILD TBI MODERATE TBI SEVERE TBI LOC: 0–30 min >30 min and <24 hr >24 hr AOC: brief >24 hr >24 hr >24 hr PTA: 0–1 day >1 and <7 days >7 days GCS: 13–15 9–12 <9 Neuro -imaging: Normal Normal or abnormal Normal or abnormal TBI = traumatic brain injury, LOC = loss of consciousness, AOC = alteration of consciousness, PTA = post-traumatic amnesia, GCS = Glasgow Coma Scale.