Traumatic Brain Injuries: Pathophysiology, Treatment and Prevention

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Traumatic Brain Injuries Pathophysiology,
Treatment and Prevention
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Disclaimer

• The views expressed in this presentation are
  those of the author and do not reflect the
  official policy of the Department of the Army,
  Department of Defense, or U.S. Government.

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Defense and Veterans Brain Injury Center (DVBIC)

• DVBIC, founded in 1991 as the Defense and
  Veterans Head Injury Program (DVHIP), a
  congressionally funded DoD-VA Disease Management
  Program.
• The DVBIC mission
• conduct clinical research
• ensure optimal clinical care
• education for military, veterans, and their
  families.
• Military Sites WRAMC, NMCSD, WH-BAMC
• VAMCs Richmond, Minn, Palo Alto, Tampa
• civilian community reentry programs Virginia
  Neurocare and Laurel Highlands (Western Penna)

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Mechanisms of Injury
Traumatic Brain
Injury Blunt(Closed) Penetrating
Explosion Fall GSW Stab
Blast
Fragment Motor vehicle crashes (MVC)

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Traumatic Brain InjuryDescription
GCS Glasgow Coma Scale LOC Loss of
consciousness PTA Posttraumatic amnesia
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American Congress of Rehabilitation Medicine
Mild Traumatic Brain Injury (MTBI) Definition

• A traumatically induced physiological disruption
  of brain function manifested by at least one of
  these symptoms
• Loss of consciousness lt 30 minutes
• Loss of memory for events immediately before
  (retrograde amnesia) or after the accident (Post
  Traumatic Amnesia lt24 hours)
• Any alteration in mental state at the time of the
  injury (dazed, disoriented, confused)
• Presence of focal neurological deficits
• If given, GCS score gt 13
• Kay, et al., 1993

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Relative Proportion of
Levels of Care for TBISource CDC Traumatic
Brain Injury in the United States, October 2004
50,000 Deaths
235,000 Hospitalizations
1,111,000 Emergency Department Visits
??? Other Medical Care or No Care
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Head Injury in the U.S. Military
Ommaya AK, Ommaya AK, Dannenberg AL, Salazar AM.
Causation, incidence, and costs of traumatic
brain injury in the U.S. Military Medical System.
J Trauma. 1996
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Traumatic Brain Injury (TBI)
Epidemiology Incidence
Incidence (cases/100,000)
From D. Hovda, UCLA BIRC Program (modified from
Kraus JF, et. al. 1996 and Durkin MS, et. al.
1998)
Age (years)
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Incidence of TBI-Related Hospitalizations Amon
g Active Duty US Army Personnel
(Ivins, et al,
Neuroepidemiology, 2006)
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Mechanisms of Injury
Penetrating Gun Shot Wound
Diffuse Axonal
Contra coup
From the Centre for Neuro Skills
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Pathophysiology of Injury

• Primary Injury Function of energy transmitted to
  brain
• Very little can be done by health care providers
  to influence
• Command enforcement of personal protection
• Helmets, Seatbelts
• Secondary Injury Function of damage to brain
  from systemic physiology
• Systemic
• Hypotension Acute and easily treatable
• Hypoxia Acute and easily treatable
• Fever and Electrolyte Imbalances
• Seizures
• Intracranial Pressure ? Can Lead to
  Herniation

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Neuropathology of Closed TBI

• Primary Injury
• Contusions/Hemorrhages
• Diffuse Axonal Injury (DAI)
• Secondary Injury (Intracranial)
• Blood Flow and Metabolic Changes
• Traumatic Hematomas
• Cerebral Edema
• Hydrocephalus
• Increased Intracranial Pressure

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Severe and Penetrating Brain Injury Clinical
Challenges

• Craniectomy
• Vascular Complications
• 47.4 had traumatic cerebral vasospasm. Majority
  were blast related injury (Armonda, R., Bell, R.,
  Vo,A., et al 2006. Wartime traumatic cerebral
  vasospasm Recent review of combat casualties.
  Neurosurgery, 59(6), 1215 -1225.)
• Autonomic Instability/Sympathetic Storms
• Infectious Complications
• Archives of Physical Medicine and Rehab (Invited
  Manuscript) R. Riechers, et al.

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Brain-Behavior Relationships and Regional
Cortical Vulnerability to TBI Figure adapted
from Arciniegas and Beresford 2001)
Dorsolateral prefrontal cortex (executive
function, including sustained and complex
attention, memory retrieval, abstraction,
judgement, insight, problem solving)
Orbitofrontal cortex (emotional and social
responding)
Anterior temporal cortex (memory retrieval,
sensory-limbic integration)
Amygdala (emotional learning and conditioning,
including fear/anxiety)
Hippocampal-Entorhinal Complex (declarative
memory) Viewed on coronal MRI
Ventral brainstem (arousal, ascending activation
of diencephalic, subcortical, and cortical
structures)
(
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Postconcussion Symptoms (PCS)

• SOMATIC
• Headache
• Dizziness
• Fatigue for physical and mental
• Visual Disturbances
• Sensitivity to Noise
• and Light

• COGNITIVE
• Decreased Concentration
• Memory Problems
• NEUROPSYCHIATRIC
• Anxiety
• Depression
• Irritability
• Mood Swings
• Sleep Disturbances

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Post Concussive Symptoms in Mild TBI

• Natural history is recovery within weeks/months
  (Levin 1987)
• A small percentage will have persistent symptoms
  (Alexander, Neurology 1995)
• Repeat concussions more morbidity (Collins, et
  al, Neurosurgery 2002)
• Educational interventions effective in
  reducing symptoms (Ponsford, et al. 2002)

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Cognitive Changes

• Attention/Concentration
• Speed of Mental Processing
• Learning/Information Retrieval
• Executive Functions (e. g., Planning, Problem
  Solving, Self Monitoring) May see judgment
  problems, apathy, inappropriate behaviors

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fMRI study of MTBI and Memory (McAllister, et
al, 2000)
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Neurometabolic Changes and Concussion (Hovda et
al, 1998)
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Simple Reaction Time Warden D, Bleiberg
J, Cameron K, et al, Neurology, 2001
p lt 0.05
Baseline
1 hour post
4 days post
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ConcussionTime to Recovery
Bleiberg J., et al. Neurosurgery, 2004.
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Post Deployment TBI Questions

• Did you have any injury(ies) during your
  deployment from any of the following? (check all
  that apply)
• 1. Fragment
• 2. Bullet
• 3. Vehicular (any type of vehicle, including
  airplane)
• 4. Fall
• 5. Blast (Improvised Explosive Device, RPG, Land
  mine, Grenade, etc.)
• 6. Other specify
• Did any injury received while you were deployed
  result in any of the following? (check
• all that apply)
• 1. Being dazed, confused or seeing stars
• 2. Not remembering the injury
• 3. Losing consciousness (knocked out) for less
  than a minute
• 4. Losing consciousness for 1-20 minutes
• 5. Losing consciousness for longer than 20
  minutes
• 6. Having any symptoms of concussion afterward
  (such as headache, dizziness, irritability, etc.)
• 7. Head Injury
• 8. None of the above (any of
  1-5 suggest a MTBI diagnosis)

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Post-Deployment TBI Screening

• DVBIC has worked with multiple sites screening
  returning war fighters
• Approximately 10-20 war fighters had a TBI while
  in theater (Army Times-Sept 5, 2005)
• Virtually all were mild TBI
• Most are now asymptomatic

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WRAMC TBI Screening Flow Chart
Involved in/exposed to/experienced Blast,
vehicular crash, fall, GSW to head/face and/or
neck, (including superficial wounds)
  Yes
 
TBI Symptom Screening/Interview Any LOC, AOC,
PTA and symptoms endorsed on the Post Concussive
Symptom Checklist
  Yes
Medical Evaluation
 
   
Cognitive, physical, and/or emotional symtoms or
findings thought to be due to PTSD or other
psychiatric disorder
Note Both may be present at this level
Cognitive, physical, and/or emotional symptoms or
findings thought to be due to TBI
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Walter Reed OIF/OEF TBI Experience (1/03 to
4/05)

• N433 Hospitalized patients with TBI
• 68 of injuries were due to explosion/blast
• 88.5 were closed TBI
• Post Traumatic Amnesia (PTA) lt 24 hours 43

Warden et al., Journal of Neurotrauma 2005
221178
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Walter Reed OIF/OEF TBI Experience (cont.)

• Complications - 14 shock 9.5 hypoxia 25
  skull fracture 18.7 subdural hematoma and 1.5
  epidurals
• 6 had seizures
• 19 had limb amputations lower extremity most
  common
• 91 reported post concussive symptoms
• headache (47)
• memory deficits (46)
• irritability/aggression (45)
• attention/concentration difficulties (41)
• Of 43 with a psychiatric symptoms noted,
  depression was the most
• common (27).

Warden et al., Journal of Neurotrauma 2005
221178
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Military Context
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Blast Wave Physics
Courtesy of Keith Prusaczyk, Ph.D.
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Evaluation of MTBI in the field

• Medic obtains history using
• Military Acute Concussion Evaluation (MACE)
• New Clinical Practice Guideline drawing on sports
  concussion and operational experts released 22
  Dec 06 includes the SAC Standard Assessment of
  Concussion (McCrea 2000)

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Conclusions Regarding PTSD in TBI Patients

• Studies suggest that PTSD following TBI does
  occur, but may be modified by the brain injury.
  
• Intrusive memories are less common in
  individuals when present, highly predictive of
  PTSD
• PTSD is more likely in mild TBI than severe TBI
• (Bombardier, C., et al. 2006. J Neuropsychiatry
  Clin Neurosci Posttraumatic Stress Disorder
  Symptoms During the First Six Months After
  Traumatic Brain Injury 184501-508)

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Treatment Areas

• Education and support for the patients family
• Rest and avoidance of another injury
• Individual and group therapies
• Medication including symptom mgt
• Rehab (acute, sub-acute, community re-entry)

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Guidelines for the Pharmacologic Treatment of
Neurobehavioral Sequelae of TBI

• Symptom Management
• Addresses 3 topic areas
• Aggression
• Cognitive disorders
• Affective disorder/Anxiety/Psychotic disorders
• Warden D., Gordon B., McAllister T., et al
  (2006). Guidelines for the pharmacologic
  treatment of neurobehavioral sequelae of
  traumatic brain injury. Journal of Neurotrauma,
  10(23),
  1468-1501.

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Guidelines for the Pharmacologic Treatment of
Neurobehavioral Sequelae of TBI

• Despite reviewing a significant number of studies
  on drug treatment of neurobehavioral sequelae
  after TBI, the quality of evidence did not
  support any treatment standards and few
  guidelines due to a number of recurrent
  methodological problems.
• Guidelines were established for the use of
  methylphenidate in the treatment of deficits in
  attention and speed of information processing, as
  well as for the use of beta-blockers for the
  treatment of aggression following TBI.
• Options were recommended in the treatment of
  depression, bipolar disorder/mania, psychosis,
  aggression, general cognitive functions, and
  deficits in attention, speed of processing, and
  memory after TBI.

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Prevention Areas

• Rest to prevent re-injury
• Education regarding risk taking behaviors
• Neurometabolic changes and concussion
• Helmets

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Questions?
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Referral to Defense and Veterans Brain Injury
Center (DVBIC)
Toll Free Referral and Information Line
1-800-870-9244 DSN 662-6345 Web Site
www.DVBIC.org
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DVBIC Headquarters, WRAMC

• Wei Lu, RN
• Lisa Moy Martin, RNC
• Silvia Massetti, MSW
• Kathryn Misner, PA-C
• Sonal Pancholi, PhD
• Glenn Parkinson, MSW, MA
• CPT Ron Riechers, MC
• Karen Schwab, PhD
• Alice Marie Stevens, MA
• Katie Sullivan, MS
• Jose Valls, LPN
• Jehue Wilkinson, LPN
• Michael Wilmore, PA-C
• Cecilie Witt, BA

• Amy Craig, MBA
• Pannakal David, MD
• COL James Ecklund, MC
• Jamie Fraser, MPH
• Louis French, PsyD
• Phil Girard, MS
• Kathy Helmick, RN, CRNP
• Maraquita Hollman, BA
• Ronnell Iandolo, RN
• Angela Ibrahim, MPA, CRA
• Brian Ivins, MA
• COL Robert Labutta, MC
• COL Geoff Ling, MC