Past, Current and Future Concepts in Traumatic Brain Injury { G. Alexander Hishaw, MD Medical Director of Polytrauma Southern Arizona VA Assistant Professor of Neurology & Psychiatry University of Arizona Health Sciences Center Disclosures BioDirection Member of the Medical Advisory Board 1
The Symptoms The Recovery The Long Term Consequences Controversy A dispute, especially a public one, between sides holding opposing views. Sam Cooper coined the phrase in 1384 from the Latin controversia meaning to turn against. When multiple people of reasonable intelligence can analyze the same data and come away with different ideas Alex Hishaw, 2010 2
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Clinical description included Inappropriate affect Disinhibition and lack of restraint Impaired insight and self monitoring Social withdrawal Failure to perceive and respond to interpersonal cues Acute injury results from primary (mechanical) physical disruption of the brain traumatically induced structural injury and/or physiological disruption of brain function as a result of an external force that is indicated by new onset or worsening of at least one of the following clinical signs, immediately following the event: 1. Any period of loss, or a decreased level, of consciousness 2. Any loss of memory for events immediately before or after the injury 3. Any alteration in mental state at the time of the injury (confusion, disorientation, slowed thinking, etc) 4. Neurological deficits (weakness, loss of balance, change in vision, praxis, paresis/plegia, sensory loss, aphasia, etc) that may or may not be transient 5. Intracranial lesion 4
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There are two types of injury 1. Diffuse axonal injury from stretch injuries to the deep white matter 2. Direct trauma causing contusion, hemorrhages and lacerations (coup/contrecoup injuries) There are two types of injury 1. Diffuse axonal injury is commonly seen in mild TBI 2. Contusion is more common in moderate and severe TBI 7
10/5/2015 Ghahar et al. Secondary (delayed, nonmechanical) postinjury factors include excitotoxic amino acid release, including glutamate. Oxidant injury from free radical release may result in secondary injury. Secondary causes of injury following the immediate head injury include physiological and pathological responses, such as alterations in cerebral blood flow and cerebral perfusion pressure. Reperfusion injury may result. Seizures may occur, along with centrally mediated systemic effects, which may include shock, electrolyte imbalances, and hypothermia. Hypoxia, brain edema, increased intracranial pressure, hemorrhage, ischemia, and infection (with open head injuries) may occur. 8
The Symptoms The Symptoms Somatic Behavioral/Emotional Cognitive 9
The Symptoms Somatic Headache Fatigue or decreased energy Dizziness Sensitivity to noise or light Insomnia or sleep disturbances Seizures The Symptoms Behavioral/Emotional Anxiety Depression Affective lability Irritability or loss of temper (rage episodes) Disinhibition or aggression (socially inappropriate behavior) Loss of impulse control Apathy Posttraumatic stress disorder 10
The Symptoms Cognitive Impaired concentration (distractibility) Impaired memory (learning and retrieval) Impaired language (production or comprehension) Executive dysfunction (poor problem solving, organizational skills, task maintenance or shift, impaired executive control of language, insight, abstraction and judgment The Symptoms 11
The Symptoms The Recovery 12
The Recovery The Recovery >90% of individuals who suffer a mild traumatic brain injury recover completely in a month to three months 13
The Recovery Why do I still have symptoms? The Recovery Mood disturbance Sleep disturbance Chronic pain Substances or medications 14
The Recovery Mood disturbance Pre Associated Post The Recovery Sleep disturbance Difficulties initiating sleep Difficulties maintaining sleep Disrupted sleep wake cycle Sleep apnea 15
The Recovery Chronic pain Other associated injuries The Recovery Substances or medications Are we treating symptoms or simply masking them 16
The Long Term Consequences The Long Term Consequences Secondary Worsening 17
The Long Term Consequences Secondary Worsening CTE The Long Term Consequences Secondary Worsening CTE Alzheimer s 18
The Conclusion The most common symptoms after a mild traumatic brain injury are known as postconcussive symptoms. These symptoms improve with time in the normal recovery process and are not signs of permanent brain damage. These are not cause for concern or worry. The Conclusion We still have much to learn about every aspect of traumatic brain injury including: Injury recognition Symptom attribution Recovery best practice 19
The Conclusion Steve Rapcsak, MD Behavioral Neurology Geoffrey Ahern, MD Behavioral Neurology Michael Moore, PHD Psychologist Tobias Freebourn, MD Physiatrist Robin Mirante Speech Pathology Rebecca Brinkerhoff Speech Pathology Susan Lucht Clinical Director Dan Program Support Assistant Dianne Lethaby, RN RN and Case Manager Louisa Viles Social Work and Case Manager The Conclusion Margo Burrows Nurse Practitioner Lupe Surratt Pharmacist Gabriele Koschorke, MD Andrew Jones, PHD Gifford Hoyer Eve Broughton Pain Clinic Charles Cole Physical Therapist Carol Hawthorne Occupational Therapist Mandy Perigo Therapeutic Rec Specialist Florinda Romero-Vagedes Dietician Lorien Nelson OEF/OIF Program Manager Adrienne Weede OEF/OIF Case Manager Richard Primeau Audiologist Jo Ellen Jenott Blind Rehab Optometry David Davis Orthotist/Prosthetis Travis Walsh Nuclear Medicine Lawrence Buadu Neuroradiology 20
10/5/2015 THANK YOU 21