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1 Slide 1 Eric S. Hart, Psy.D., ABPP-CN Associate Clinical Professor Director of Adult Neuropsychology Associate Chair University of Missouri-Columbia Department of Health Psychology Slide 2 A traumatic brain injury (TBI) is defined as a blow or jolt to the head or a penetrating head injury that disrupts the function of the brain. Not all blows or jolts to the head result in a TBI. The severity of such an injury may range from "mild," i.e., a brief change in mental status or consciousness to "severe," i.e., an extended period of unconsciousness or amnesia after the injury. A TBI can result in short or long-term problems with independent function. (Brain Injury Association of American). Slide 3 Falls account for 28% Motor vehicle-traffic crashes account for 20% Struck by/against account for 19% Assaults account for 11%

2 Slide 4 Direct medical costs and indirect costs such as lost productivity of TBI totaled an estimated $60 billion in the United States in (Brain Injury Association of America) Slide 5 Estimated 1.4 million sustain a TBI each year in the United States 235,000 are hospitalized 50,000 result in death 1.1 million are treated and released from an emergency department Slide 6 Males = 1.5 times as likely as females. Bimodal distribution regarding high risk age groups = 0 to 4 year and 15 to 19 year olds. African Americans = highest death rate from TBI.

3 Slide 7 CDC estimates at least 5.3 million Americans currently have a long-term or lifelong need for help to perform activities of daily living as a result of a TBI. About 40% of those hospitalized with a TBI had at least one unmet need for services one year after their injury. The most frequent unmet needs were: Improving memory and problem solving Managing stress and emotional upsets Controlling one's temper Slide 8 Improving one's job skills. TBI can cause a wide range of functional changes affecting thinking, language, learning, emotions, behavior, and/or sensation. It can also cause epilepsy and increase the risk for conditions such as Alzheimer's disease, Parkinson's disease, and other brain disorders that become more prevalent with age. (Brain Injury Association of America). Slide 9 Destructive forces not equally distributed. Concentration of force shear strains/hemorrhagic contusions occurring predominately in orbitofrontal and anterior temporal lobes. Consequently, higher concentration of extraparenchymal and parachymal lesions are apparent in these areas regardless of initial site of impact.

4 Slide 10 Slide 11 Closed Head Injury Open/Penetrating Head Injury Crushing Head Injury Blast/Percussive Injury Slide 12 CHI is by far the most common type of First Injury. In CHI, there is no penetration of skin or open wound. Created by rapid acceleration, deceleration, and rotational effects. Acceleration Injury = head is relatively motionless and is struck by a more rapidly moving object. Deceleration Injuries = head itself is moving rapidly and strikes a fixed or solid object. Linear or rotational movements can force brain to contact with bony prominences or the edges of dural membranes. damage of arteries and veins, as well as diffuse axonal injury (DAI), which causes widespread effects on white matter.

5 Slide 13 Coup = Initial point of impact Contra-Coup = The diametric rebound Slide 14 Slide 15 Object penetrates cranial vault and disrupts protective layers (e.g., meningeal tissue), blood vessels, and brain tissue. In general, PHIs result in focal lesions with associated laceration of the skull and surrounding dura mater. Higher risk for posttraumatic seizure disorder associated with PHI

6 Slide 16 Skull Fractures Contusions DAI Slide 17 Slide 18

7 Slide 19 High speed with stretch or shearing of brain tissue. Mechanism for LOC in the absence of a space occupying lesion. Initial CT scan often negative. Can cause deep coma. Mortality = 40-50% Slide 20 Slide 21

8 Slide 22 Traumatic Hematoma Excitatory Amino Acid Release Edema Increased ICP Hydrocephalus Ischemia Seizures DAI Slide 23 Slide 24

9 Slide 25 Slide 26 Slide 27

10 Slide 28 When brain is damaged, it heals with a scar. As it does, the brain tissue around the damaged area may begin to work in an abnormal way. It can become irritable and unstable and lead to bursts of uncontrolled activity. The disturbance tends to spread wide of the damaged area and involve the rest of the brain, which produces epileptic activity. Occurs more often with severe injuries, especially when there has been much bruising or bleeding into the brain, or if there has been an open injury. Slide 29 Large degree of controversy within regarding delineation. Inconsistencies makes communication with professionals complicated. Most controversial, of course, is mtbi. Slide 30 Scores range between 3 and 15. The low the score, the more severity. Three parameters include eye, verbal and motor responses.

11 Slide 31 Activity Score Response Eye Open 4 Spontaneous 3 Eye Opening to Verbal Command 2 Eye Opening to Pain 1 No Eye Opening Slide 32 Activity Score Response Verbal Response 5 Oriented x 4 4 Confused 3 Inappropriate Words 2 Sounds, but words not understandable 1 No Verbal Response Slide 33 Activity Score Response Motor Response 6 Obeys Commands 5 Localizes Pain 4 Withdraws to Pain 3 Abnormal Flexion to Pain 2 Abnormal Extension to Pain 1 No Motor Response

12 Slide 34 LOC < 30 LOC not required GCS = PTA < 24 hours Temporary of Permanently Altered Mental or Neurological State Slide 35 LOC = 30 minutes to 6 hours GCS = 9-12 PTA = 1-24 hours Some long term problems in one or more areas of life (e.g., home, work, and community) Slide 36 LOC > 6 hours GCS = 3-8 PTA = >24 hours Long term impairments in one or more areas of life.

13 Slide 37 Onsite: ABC (airway, breathing, circulation), assessment of GCS, assess for hypotension and hypoxia. ER: Imaging, control bleeding, fracture assessment. ICU: Monitor ICP Acute Rehab: Treatment of debility with team approach (physiatry, psychology, ST, PT, OT, RT, RN, and case management). Outpatient therapy often required Slide 38 Attentional disorders very common. Frequently occur rapid deceleration injuries such as MVA. Takes the form of impaired vigilance (sustained attention), distractibility, and divided attention. PT may become too distractible to benefit from treatment. Slide 39 TBI survivors show disproportionate slowing. Often, earliest to return and befitted by restorative vs. compensatory strategies. Difficulty to identify physiological substrate. Impacts many other domains on testing.

14 Slide 40 Memory impairment is one of the most common. Can be temporary, as it occurs in PTA, or more permanent. Classified as either retrograde amnesia (memory loss for events in a time period before injury) or anterograde amnesia (memory loss for events after the injury). Slide 41 Manifestation of neuropathological effects of shear strain and contusions in the anterior temporal lobes; hippocampus also vulnerable to hypoxic/ischemic changes, as well as release of excitotoxic amino acid release. Long-term/retrograde memory typically preserved, whereas anterograde/stm impacted. Slide 42 Executive functioning difficulties very common. Encompasses the abilities necessary for an individual to perform a problem-solving task from beginning to end. Includes judgment, reasoning, concept formation, abstraction, planning, organization, and behavioral control.

15 Slide 43 Presumed to be related to DAI and high concentration of parenchymal and extraparenchymal lesions in anterior cortex/frontal lobes. Not a unitary construct! Traditional testing paradigms Role of evaluator/technician as source compensation. Slide 44 Speech and language difficulties may be present, however, depends on nature, location, and severity of injury. Injuries that are focal or penetrating and involve the language-dominant hemisphere are more likely to cause language impairments. Slide 45 Often observe subclinical aphasias characterized by fluent output with preservation of repetition and comprehension (to some extent), although marked by disorganization/circumlocution, anomia/word-finding, and paraphasic errors.

16 Slide 46 Depression = most common mood disorder after TBI. Variability in prevalence rates (e.g., between 6% to 77%). Differential includes adjustment disorder with depressed mood, apathy, emotional lability, and PTSD. Slide 47 Posttraumatic depression more common in those with pre-injury psychiatric status and/or substance abuse. Most occur/resolve within first year; different etiology for early vs. late onset. Associated with left dorsolateral frontal or left basal ganglia/subcortical lesions. Serotonergic projections from brainstem to frontal lobes. Slide 48 Difficulties with differential diagnosis (e.g., abulia, other vegetative symptoms. Role of insight/emergence of neurocognition.

17 Slide 49 Less common, yet still problematic. Typically associated with R-sided lesions. Prevalence: - GAD = 8-24% - Panic Disorder = 2-7% -OCD = 1 9 % -PTSD = 0-42% *inclusion of mtbi in studies inflates percentages Slide 50 Schizophrenia = relatively uncommon after TBI (.7%) However, many SCZ = head injury before age 10 (diathesis stress model). Pathophysiology = involving left frontoparietal region. Differential = Delirium, TLE, typical disorganized thoughts with TBI, Wernicke s aphasia. Slide 51 its not only the kind of injury that matters, but the kind of head. (Symonds, 1937)

18 Slide 52 Slide 53 Pseudodepressed Personality Syndrome: Apathetic, diminished initiation, and limited emotional reactivity (dorso-medial lesions). Pseudopsychopathic Syndrome: Disinhibited, egocentric, and sexually inappropriate (associated with orbital-frontal lesions) Slide 54 Preponderance of data supports causality for depression, anxiety, and bipolar disorder. Poor support for schizophrenia and alcohol abuse. PD research is equivocal. Psychiatric disorder = risk for TBI. Severe TBI = a buffer for some psychiatric conditions?

19 Slide 55 Inpatient Comprehensive Rehab. Outpatient Rehab. (ST, OT, PT) Home Health Psychopharmacy/Neuropharmacy Rehab. Psych. -Individual -Family -Marital -Group