Mild Traumatic Brain Injury

Transcription

1 Mild Traumatic Brain Injury Concussions This presentation is for information purposes only, not for any commercial purpose, and may not be sold or redistributed. David Wesley, M.D.

2 Outline Epidemiology Anatomy/Physiology Injury Mechanisms Diagnosis & Assessment Treatment Outcomes David Wesley, M.D. 2

3 Outline Epidemiology David Wesley, M.D. 3

4 Epidemiology of Traumatic Brain Injuries 1.7 million TBIs reported each year in the United States Death 52,000 Hospitalization 275,000 Treated in ED 1,365,000 As many as 3.8 million go untreated 80 95% concussions David Wesley, M.D. 4

5 Epidemiology of Traumatic Brain Injuries North Carolina ( ) 140,234 ED visits for TBI Sex Age 39.0% falls 17.6% struck by person or object 14.1% MVA s Men: 7.9 visits per 1,000 person-years Women: 6.8% per 1,000 person-years 0 4: 13.1 visits per 1,000 person-years 15 19: 10.6 per 1,000 person-years 75 79: 11.3 per 1,000 person-years 80 84: 17.9 per 1,000 person-years Kerr ZY, Harmon KJ, etal. The epidemiology of traumatic brain injuries treated in emergency departments in North Carolina, NCMJ. 2014;75(1):8-14. David Wesley, M.D. 5

6 TBI In North Carolina Kerr ZY, Harmon KJ, etal. The epidemiology of traumatic brain injuries treated in emergency departments in North Carolina, NCMJ. 2014;75(1):8-14. David Wesley, M.D. 6

7 TBI In North Carolina Kerr ZY, Harmon KJ, etal. The epidemiology of traumatic brain injuries treated in emergency departments in North Carolina, NCMJ. 2014;75(1):8-14. David Wesley, M.D. 7

8 Rate of concussion by sport among 19,903 high school athletes : North Carolina, Schulz MR, Marshall SW, etal. Incidence and risk factors for concussion in high school athletes, North Carolina Am J Epidemiol 2004;160: David Wesley, M.D. 8

9 Concussions in Sports Football, football, football Collision sports (also women s hockey) At increased risk of repeat concussion College versus High School Bigger, faster, stronger More often, more severe Yet high school athlete recovers more poorly Cheerleaders More often in practice than in games Don t do pyramids Schulz MR, Marshall SW, etal. Incidence and risk factors for concussion in high school athletes, North Carolina Am J Epidemiol 2004;160: David Wesley, M.D. 9

10 Outline Epidemiology Anatomy/Physiology David Wesley, M.D. 10

11 Anatomy bones of the skull David Wesley, M.D. 11

12 Anatomy bones of the skull David Wesley, M.D. 12

13 Anatomy - lobes Atrain Education David Wesley, M.D. 13

14 Anatomy - neurons David Wesley, M.D. 14

15 Anatomy - neurons American Association for the Advancement of Science Science 2014;343:

16 Anatomy - matters David Wesley, M.D. 16

17 Anatomy inner brain Atrain Education David Wesley, M.D. 17

18 Cerebrospinal Fluid David Wesley, M.D. 18

19 Sub Arachnoid Space David Wesley, M.D. 19

20 Outline Epidemiology Anatomy/Physiology Injury Mechanisms David Wesley, M.D. 20

21 Coup Contracoup David Wesley, M.D. 21

22 Intracranial Pressure V intracranial (constant) = V brain + V CSF + V blood + V mass lesion David Wesley, M.D. 22

23 Intra Cranial Hemorrhage David Wesley, M.D. 23

24 INTRACRANIAL HEMORRHAGE Epidural Hematoma Damage to the middle meningeal artery blood accumulates between the skull and the dura Subdural Hematoma more common than epidural hematomas impact that damages the veins beneath the dura mater evolves rapidly if there is also a skull fracture 30% to 40% mortality rate and often residual morbidity David Wesley, M.D. 24

25 Herniation David Wesley, M.D. 25

26 INTRACRANIAL HEMORRHAGE Intracerebral Hematoma bleeding into the brain itself usually from a torn artery very high acceleration injury or congenital abnormality rapidly fatal Subarachnoid Hematoma tearing of the tiny surface brain vessels bleeding confined to the CSF headaches can also be rapidly fatal David Wesley, M.D. 26

27 Sub Arachnoid Space David Wesley, M.D. 27

28 AXONAL SHEARING Shearing forces disrupt axonal connections Not seen on CT Can be localized or diffuse Diffuse can cause deep coma Chronic neurologic deficit Often persistent vegetative state David Wesley, M.D. 28

29 AXONAL SHEARING David Wesley, M.D. 29

30 Axonal Shearing David Wesley, M.D. 30

31 Brainbow Hippocampus David Wesley, M.D. 31

32 Outline Epidemiology Anatomy/Physiology Injury Mechanisms Diagnosis & Assessment David Wesley, M.D. 32

33 Concussions a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces brain is altered at a cellular level rather than showing any evidence of structural injury Excitatory neurotransmitter activity predominates mismatch of increased brain metabolic demand and relative decreased supply of glucose A small percentage of concussions deteriorate David Wesley, M.D. 33

34 Glasgow Coma Scale Eye Opening Response Spontaneous -- open with blinking at baseline 4 points To verbal stimuli, command, speech 3 points To pain only (not applied to face) 2 points No response 1 point Verbal Response Oriented 5 points Confused conversation, but able to answer questions 4 points Inappropriate words 3 points Incomprehensible speech 2 points No response 1 point Motor Response Obeys commands for movement 6 points Purposeful movement to painful stimulus 5 points Withdraws in response to pain 4 points Flexion in response to pain (decorticate posturing) 3 points Extension response in response to pain (decerebrate posturing) 2 points No response 1 point David Wesley, M.D. 34

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36 Concussion Diagnosis Clinical Diagnosis Possible CT or MRI to rule out Skull fracture Bleeding Edema Repeat clinical assessments until symptoms fully resolve David Wesley, M.D. 36

37 Concussion Symptoms Disorientation Amnesia or other memory problems Unconsciousness or altered consciousness Headache Nausea and vomiting Ringing in the ears Difficulties with speech, balance, judgment, or coordination Difficulties with concentration and learning Difficulty sleeping David Wesley, M.D. 37

38 Biomarkers S100 Protein well-researched Others include: neuron-specific enolase (NSE) and cleaved tau protein (CTP) Primarily for research Tend to peak at hours Peak values more predictive than initial values Non-specific David Wesley, M.D. 38

39 Low Technology Functional Assessment Eyes closed, 20 seconds in each of 6 positions Guskiewicz KM. Balance assessment in the management of sport-related concussion. Clin Sports Med 30 (2011) David Wesley, M.D. 39

40 Low Technology Functional Assessment Eyes closed, 20 seconds in each of 6 positions Guskiewicz KM. Balance assessment in the management of sport-related concussion. Clin Sports Med 30 (2011) David Wesley, M.D. 40

41 Low Technology Functional Assessment Eyes closed, 20 seconds in each of 6 positions Guskiewicz KM. Balance assessment in the management of sport-related concussion. Clin Sports Med 30 (2011) David Wesley, M.D. 41

42 Low Technology Functional Assessment Guskiewicz KM, Ross SE, Marshall SW. Postural stability and neuropsychological deficits after concussion in collegiate athletes. J Athl Train 2001;36: David Wesley, M.D. 42

43 Outline Epidemiology Anatomy/Physiology Injury Mechanisms Diagnosis & Assessment Treatment David Wesley, M.D. 43

44 Concussion Treatment Supportive Early education Reduce anxiety Create realistic expectations Manage specific symptoms Acetaminophen for headaches and other pains Rest with gradual return to physical activity Monitor for post-concussion syndrome David Wesley, M.D. 44

45 Management of Persistent Symptoms Mott TF, McConnon ML, Rieger BP. Subacute to chronic mild traumatic brain injury. Am Fam Physician Dec 1;86(11): David Wesley, M.D. 45

46 Outline Epidemiology Anatomy/Physiology Injury Mechanisms Diagnosis & Assessment Treatment Outcomes David Wesley, M.D. 46

47 Concussion Outcomes Concussion is a self-limiting disease Symptoms usually resolve in 2 6 weeks Persistent, new, or worsening symptoms May indicate more serious brain damage Require additional work-up May have psycho-social overlay David Wesley, M.D. 47

48 Risk Factors for Poorer Outcomes (persistent symptoms) Mott TF, McConnon ML, Rieger BP. Subacute to chronic mild traumatic brain injury. Am Fam Physician Dec 1;86(11): David Wesley, M.D. 48

49 Chronic Traumatic Encephalopathy AKA punch-drunk or dementia pugilistica Also: football, wrestling, soccer; epileptics, head bangers, domestic abuse victims; etc. First concussion places individual at risk of repeat concussion => further concussions Possible mechanisms Axonal injury => neuronal death Abnormal protein deposits (Aβ plaques as in AD) Location, location, location David Wesley, M.D. 49

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