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Brain injury


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Brain injury

  1. 1. The following lecture has been approved for University Undergraduate StudentsThis lecture may contain information, ideas, concepts and discursive anecdotes that may be thought provoking and challenging It is not intended for the content or delivery to cause offence Any issues raised in the lecture may require the viewer to engage in further thought, insight, reflection or critical evaluation
  2. 2. Introduction to Brain Injury Dr. Craig Jackson Senior Lecturer in Health Psychology School of Health and Policy Studies Faculty of Health & Community Care University of Central England
  3. 3. What was Michael Angelo’s Hidden Message? Michelangelo. The Creation of Adam (detail, Sistine Chapel). 1510. Fresco. Sistine Chapel, Vatican, Rome.
  4. 4. ObjectivesList major structures and function of nervous systemName types of head and spine injuries; describe clinical featuresDescribe mechanisms of neurologicalinjuryDescribe assessment of head injuriesDescribe functional affects and symptomsDescribe imaging techniques
  5. 5. Neurological Injuries Responsible for 50+% of trauma deaths Approx. 1,000,000 patients in UK attend A&E with head injury per year Can be prevented (some extent) by helmets and PPE Major cause of chronic disability Mostly from Falls, RTAs and AssaultsFlannery & Buxton, 2001
  6. 6. Anatomy PrinciplesNeuronspecialized nerve cellDendrites and Axonsshort and long processes of neuronsPeripheral neurons sheathed with myelinImpulses transmitted from synapses to dendrites
  7. 7. Anatomy Principles 2Central Nervous System = brain, spinal cordPeripheral Nervous System = nerves, branchesMeninges = protective triple layer cover Dura matter = outer layer Arachnoid = middle layer Pia matter = inner layerCerebral Spinal Fuid (CSF) circulates in middle layer
  8. 8. Anatomy Principles 3Cerebrum (hemispheres)Cerebellum, brainstemCranial nervesoriginate at base of brainSensory / motor supply to head and faceMotor nerves = brain to muscle unitsSensory nerves = skin back to brainSomatic Nervous System = voluntary actionAutomatic Nervous System = involuntary action
  9. 9. Anatomy Principles 4
  10. 10. Traumatic Brain InjuryPhysical force causes nerve cells to stretch, tear and pull apartUnable to relay messages through brainForce causes brain to slam against skull interior: “Traumatic Brain Injury”Injury to brain cells affects processing: thinking remembering seeing control & coordination mood
  11. 11. Traumatic Brain InjuryTBI ranges from mild to severe: degree of force multiple trauma neurological complications speed of assistance
  12. 12. Head InjuriesSeverity depends on amount of Primary and Secondary brain injuryMain cause of Secondary injury = hypoxiaCategories: Open or ClosedForces: Shearing and Compression
  13. 13. Non Loss of Function41 yr old Mike HillAttacked from behindFull recovery after removalNo infectionLeft hospital 1 week after removalEpileptic medication and some memory problems
  14. 14. Functional StatusSPECT image with Technetium (T99)
  15. 15. Pathophysiological DisturbanceInvolve scalp, cranium, or underlying brainDepends on mechanism of injuryScalp: lacerations, contusions, abrasionsSkull fractures: vault / base, simple or compound, depressed or planarPrimary Brain Injury: Focal (intra-cranial haematoma, contusion) Diffuse (diffuse axonal injury)Categories: Open or ClosedForces: Shearing and Compression
  16. 16. “Closed” or “Open” Head InjuryClosed Head Injury (CHI): No penetration of the skull Usually a TBI Not always thoughOpen head Injury (OHI): Bullet, Knife, or Fracture Skull breechedBrain injury depends on power of physical force injuryIf great enough, forces radiates through skull, causes sudden brain movementResults in damaged nerve cellsMay result in “soft tissue” injury - cervical strain myofascial trauma
  17. 17. “Mild” Traumatic Brain InjuryHead injury graded on: (i) length of unconsciousness (ii) length of amnesiaBoth caused by sudden trauma and nerve cell tearingBrain cannot maintain functioning and shuts down either: fully (unconsciousness) or partially (dazed)MBI refers to loss of consciousness for 30 mins or lessUnconsciousAmnesia Any of these Diffuse AxonalAltered consciousness indicates MBI Injuryneurological deficitsMBI can result in life changing consequences
  18. 18. Diffuse Axonal InjuryThinking slows downMemory poor Mild Brain Injury Processing slowerConcentration haphazard“Roadblocks of damaged unconnected neurons”Individual feels: Incomplete emotional problems Unconfident Frustrated Described as “ mental fog” Irritable Struggling cognitive problems
  19. 19. Brain Injury without Direct TraumaWhiplash & ShakingSudden movement inside cranium damages neuronsAcceleration – DecelerationRTAs – even with airbag deployment –can cause brain injuryBrain is torn, squashed, bruisedRollercoasters
  20. 20. Types of Head InjuriesConcussion: Temporary alteration in neurological function or LORCerebral Contusion: Bruised brainCerebral Haemotoma or bleed epidural sub-dural sub-arachnoid intra-cerebral
  21. 21. Signs and SymptomsHeadacheDizzinessNausea / VomitingAmnesiaDecreased responsivenessConfusionCombativenessLoss of responsiveness
  22. 22. AssessmentFirst impression: Responsive or UnresponsiveUrgent Survey: LOR ABC’sOpen airway with C-spineCheck breathing: Ventilate; Oral airway; O2 when availableCheck carotid artery pulse – CPR if indicatedControl any major bleeding
  23. 23. Assessment continuedRapid Body Survey Sample, DCAP-BTLSStabilize head between kneesCall for equipment, assistance, transportMaintain body temp.Transport (head uphill)Non-Urgent SurveyOngoing Survey – seizures, vomiting, change in LOR
  24. 24. Assessment continued Brain Swelling  Increased Intracranial Pressure (ICP)  Hypoxia  Further Secondary Brain Injury  More Swelling  Increased ICP
  25. 25. Localised Neurological Signs (ICP)GENERAL SIGNS + PLUS +Change in pupil size / light reactivitySlowing pulseRising BP.Change in respirationUnilateral weaknessIncontinenceSeizure
  26. 26. Urgent Interventions - ATLSPresume C-Spine injuryImmobilize neckOpen airway: administer oxygenTreat bleeding and shockPrevent aspiration of vomit / secretionsTransport immediatelyElevate head 6”Transport head uphill
  27. 27. ImagingXray, MRI and CT cannot show traumaticbrain injuryTechniques rely on tissue densityDiffuse damage will not show on thesetechniquesSPECT or PET measure brain cell metabolismCan detect changes in function due brain injury
  28. 28. Behavioural ChangesSpeechCognitionMemoryMoodMental health psychoses deliriumTremorGaitSymmetry of function Gross over-simplificationVisualAuditoryPositive and negative symptoms
  29. 29. Other Causes of Brain InjuryDrug effectsTumorMetastasesPhysical assaultSurgeryTraumatic birthHypoxia
  30. 30. Glasgow Coma ScaleScores 8 or less = needs urgent anaesthetic assessment.Danger of airway compromise13-15 = mild 9-12 = moderate 3-8 = severe
  31. 31. Queen’s Medical Centre
  32. 32. Cerebral Asymmetry of FunctionHemispheric asymmetry of function is relativeAsymmetries have been overblown by popular media into fads(e.g. golf with your right brain)Anterior-posterior differences far outweigh left-right differencesAsymmetry is not uniquely human
  33. 33. Cerebral Asymmetry of FunctionLEFT HEMISPHEREConvolutions mature more rapidlyExtends further posteriorlyHigher in density (more gray matter; more neurons)Planum temporale larger on left (in 60-90%) of casesLarger insulaLonger Sylvian fissure (gentler slope)Double cingulate gyrusLarger lateral posterior nucleus (to parietal cortex)Wider occipital lobeLarger total area of frontal operculum (much buried in sulci)Larger inferior parietal lobule
  34. 34. Cerebral Asymmetry of FunctionRIGHT HEMISPHEREConvolutions mature less rapidlyExtends further anteriorlyLarger and heavierPrimary auditory (Heshls gyrus) larger on rightShorter (steeper slope)SingleLarger medial geniculate nucleusNarrowerLarger area of convexity in frontal lobe; wider frontal lobe
  35. 35. Cortical LesionsHuman cognitive and sensory dysfunction different following lesions(due to strokes, surgery, accident, etc.)Differences noted in lesions to left and right hemispheresLesions can provide clues about brain organization Do specific areas possess special unique functions? Does a lesion to a specific area demonstrate a dysfunction + Lesions to other brain locations do not cause a similar dysfunction
  36. 36. DissociationLesion site Reading Writing Speaking100 normal normal impaired102 impaired normal normal104 normal impaired normalAllows understanding of specific sites and impairments
  37. 37. Hemispherical Function Left RightVision linguistic stimuli patterns faces steropsisAudition language sounds rhythmSomatosensation tactile recognitionMotor complex movement spatial movementMemory verbal memory non-verbal memoryLanguage speech reading prosody writing arithmeticEmotion social emotions primary emotionsSpatial processes geometry spatial images orientation
  38. 38. Split Brain and CommissurotomyCorpus Callosum joins hemispheresSever corpus callosumTwo hemispheres cannot communicate
  39. 39. Brain Injury - Summary1. The main cause of secondary damage to the brain is _ _ _ _ _ _ _ ?2. Head injury alone rarely causes damage. T / F?3. Temporary loss of consciousness or function from a head trauma is a__________?4. Brain injury can occur without any impact trauma. T / F5. Axons being damaged / shredded is the simple reason for cognitiveproblems in head injury patients. T / F
  40. 40. Hemispherical test I always wear a watch 1
  41. 41. Hemispherical test I keep a journal 2
  42. 42. Hemispherical test I believe there is a right and wrong way to do everything 3
  43. 43. Hemispherical test I hate following directions 4
  44. 44. Hemispherical test The expression "Life is just a bowl of cherries" makes no sense to me 5
  45. 45. Hemispherical test I find that sticking to a schedule is boring 6
  46. 46. Hemispherical test Id rather draw someone a map the tell them how to get somewhere 7
  47. 47. Hemispherical test If I lost something, Id try to remember where I saw last 8
  48. 48. Hemispherical testIf I dont know which way to turn, I let my emotions guide me 9
  49. 49. Hemispherical test Im pretty good at math 10
  50. 50. Hemispherical test If I had to assemble something, Id read the directions first 11
  51. 51. Hemispherical test Im always late getting places 12
  52. 52. Hemispherical test Some people think Im psychic 13
  53. 53. Hemispherical test Setting goals for myself helps keep me from slacking off 14
  54. 54. Hemispherical test When somebody asks me a question, I turn my head to the left 15
  55. 55. Hemispherical testIf I have a tough decision to make, I write down the pros and the cons 16
  56. 56. Hemispherical test Id make a good detective 17
  57. 57. Hemispherical test I am musically inclined 18
  58. 58. Hemispherical testIf I have a problem, I try to work it out by relating it to one Ive had in the past 19
  59. 59. Hemispherical test When I talk, I gesture a lot 20
  60. 60. Hemispherical test If someone asks me a question, I turn my head to the right 21
  61. 61. Hemispherical test I believe there are two sides to every story 22
  62. 62. Hemispherical test I can tell if someone is guilty just by looking at them 23
  63. 63. Hemispherical test I keep a to do list 24
  64. 64. Hemispherical test I feel comfortable expressing myself with words 25
  65. 65. Hemispherical test Before I take a stand on an issue, I get all the facts 26
  66. 66. Hemispherical testIve considered becoming a poet, a politician, an architect, or a dancer 27
  67. 67. Hemispherical test I lose track of time easily 28
  68. 68. Hemispherical testIf I forgot someones name, Id go through the alphabet until I remembered it 29
  69. 69. Hemispherical test I like to draw 30
  70. 70. Hemispherical test When Im confused, I usually go with my gut instinct 31
  71. 71. Hemispherical test I have considered becoming a lawyer, journalist, or doctor 32
  72. 72. Hemispherical test1. L2. L3. L4. R5. L6. R7. R8. L9. R10. L11. L12. R
  73. 73. Hemispherical test13. R14. L15. R16. L17. L18. R19. R20. R21. L22. R23. R24. L
  74. 74. Hemispherical test25. L26. L27. R28. R29. L30. R31. R32. L