TBI – Traumatic Brain Injury/Concussion •What is TBI? •Means of TBI •Case Study •Neurology & Diagnostics •Recovery Compiled: Seth Premo
TBI – Traumatic Brain Injury/Concussion What – the results of a moderate or severe force to the head, where physical portions of the brain are damaged and functioning is impaired. • Falls and car accidents account for nearly half of all cases. • Most likely to occur to children, adolescents, and those over 65 yrs. • 1.7 million TBI’s occurring each year in the U.S. 80.7% were emergency department visits, 16.3% were hospitalizations, and 3.0% were deaths. How – three primary methods: • Blunt force trauma (coup-contrecoup; bilateralism). • Penetrating trauma (gunshot wound, puncture). • “Whiplash”/Shaken Baby Syndrome: neuronal detachment & damage to brainstem from trauma-induced stretching. Effects – secondary injury: • Tissue damage and death via ischemia & ICP (intra-cranial pressure). • Pathogens (from penetrating trauma); Viruses and bacteria can now bypass the blood-brain barrier due to the wound. • Physical (paralysis, ataxia, dysphasia, depending on location of injury). • Cognitive (permanent altered mental status; loss of computational ability). • Emotional, and behavioral (personality changes). Centers for Disease Control (2010)
Blunt Force Trauma Blunt force trauma can cause many issues, many of which are related to swelling (ICP): Hydrocephalus: Blockage of CSF output causes swollen ventricles and increased pressure Hematoma: Broken blood vessels leak and are trapped causes pressure Contusion: Broken blood vessels leak into immediate area Pressure in the upper brain can cause brain damage; but pressure on brainstem (medulla) can cause more urgent issues like cardiac arrest & uncontrolled respiration, as it controls autonomic functions like heart rate, blood pressure, and breathing.Hematoma: Midline Shift (MRI) Hydrocephalus (MRI) Medulla
Penetrating Trauma: Phineas Gage - Cause Gage was a railroad worker in the early 1800’s. Working with explosive to clear rock, premature detonation caused an iron bar to project cleanly through his skull. He was conscious enough immediately afterward to tell his doctor the manner of which he incurred the injury. Damage: L. Frontal lobe; L. facial paralysis. Function:Frontal lobes are considered our emotional control center andhome to our personality; involved in motor function, problemsolving, spontaneity, memory, language, initiation, judgment, impulse control, social behavior, and sexual behavior. It is miraculous that Mr. Gage did not die from both secondary complications (infection), and the standard medical practices during that era.
Penetrating Trauma: Phineas Gage – Behavioral Effect Presentation: “The equilibrium or balance, so to speak, between his intellectual faculties and animal propensities, seems to have been destroyed. He is fitful, irreverent, indulging at times in the grossest profanity (which was not previously his custom), manifesting but little deference for his fellows, impatient of restraint or advice when it conflicts with his desires, at times pertinaciously obstinate, yet capricious and vacillating, devising many plans of future operations, which are no sooner arranged than they are abandoned in turn for others appearing more feasible. A child in his intellectual capacity and manifestations, he has the animal passions of a strong man. Previous to his injury, although untrained in the schools, he possessed a well-balanced mind, and was looked upon by those who knew him as a shrewd, smart businessman, very energetic and persistent in executing all his plans of operation. In this regard his mind was radically changed, so decidedly that his friends and acquaintances said he was ‘no longer Gage.’” --Dr. John Martin Harlow, 1868.
Diagnosis & Treatment Neuropsychology relates to today’s world during medical examination and treatment. Understanding the pathways of nerves and its respective locale in the brain became the basis for developing tests. One way to diagnose neurological damage in TBI is through a cranial nerve exam. This exam systematically tests the function of the senses, as they relate to the nerves. I Olfactory (smell) The Roman numerals indicate the nerves, and point into the holes (foramen) where the nerve II Optic (visual info) leave the skull.III, Oculomotor, Trochlear,IV, Abducens (eye muscleVI movement) V Trigeminal (face sensation)VII FacialVIII Vestibulocochlear (hearing)IX, X Glossopharyngeal, Vagus (throat) XI Accessory (shoulders & neck)XII Hypoglossal (tongue)
TBI: IdentificationSymptoms (physical presentation) may appear minor, or may not beobvious at first. Thus, neurologists have developed systems to findwarning signs of TBI:One system for assessing a patient’s level of Symptoms of TBI:consciousness, is called the Glasgow Coma Confusion Difficulty ConcentratingScale. It classifies observations of thepatient’s eyes, verbal, and motor skills, to Headache Difficulty Rememberingrate a patient’s neurological status. The Vomiting Irritability“GCS” is usually taken by emergency Amnesia Mood Swingsmedical personnel when the victim’s is first Tinnitus Equilibrium Imbalanceencountered, and is rated on a numericalscale of 1 -15. Scores under 9 are Alterations Fatigueconsidered severe, and 9 – 13 is moderate. Insomnia NauseaA second system called MACE also involves using a number system to rate patients.It can be done in 5 minutes, and involves obtaining a history of the incident whereTBI is suspected, chronological orientation, immediate memory, delayed recall,concentration, and a neurological screening.
Recovery and NeurogenesisRecovery from TBI is very limited: Intracranial pressure is now well-monitored by machines & medication. Secondary pathogenic illness is well-controlled by medications. The full extent to which a patient may recover from TBI is not well known, even as far out as 6 months after the injury. Recovery itself is a continual process, apparent even 6 years after the injury. TBI is a heavily researched area due to both its occurrence and the limited amount we know. Neuroplasticity – a working and research-based theory that the brain’s structure (anatomy) and function (physiology) can and does change in response to experience. Although nerves do regenerate in the brain after TBI, they don’t seem to function in the same way – perhaps due to loss of integration from the old neural pathways. The pain associated with TBI is sometimes more severe than the physical injury. Neurologists hypothesize that the pain originates from the growth of new nerves. Pain management through narcotics is often prescribed.
Conclusive Statements:TBI is a condition that can occur without obvious orimmediate symptoms.Effects from traumatic brain injuries can often go under- ormis-diagnosed as personality, cognitive, and behavioral issueslater become apparent – with no link to the original incident.Survivors of brain injuries, like Mr. Gage, furthered ourunderstanding of brain function.Neuronal re-growth is a large research area, and poorlyunderstood. Scientists are working to find ways to create anoptimal environment for nerve regeneration & re-integration.