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Mild Traumatic Brain Injury

Concussions

David Wesley, M.D.

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Outline

Epidemiology

Anatomy/Physiology

Injury Mechanisms

Diagnosis & Assessment

Treatment

Outcomes

David Wesley, M.D. 2

Outline

Epidemiology

David Wesley, M.D. 3

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

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Epidemiology of Traumatic Brain Injuries

North Carolina (2010-2011) 140,234 ED visits for TBI

39.0% falls

17.6% struck by person or object

14.1% MVA’s

Sex

Men: 7.9 visits per 1,000 person-years

Women: 6.8% per 1,000 person-years

Age

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

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Kerr ZY, Harmon KJ, etal. The epidemiology of traumatic

brain injuries treated in emergency departments in North

Carolina, 2010-11. NCMJ. 2014;75(1):8-14.

TBI In North Carolina 2010-2011

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Kerr ZY, Harmon KJ, etal. The epidemiology of traumatic

brain injuries treated in emergency departments in North

Carolina, 2010-11. NCMJ. 2014;75(1):8-14.

TBI In North Carolina 2010-2011

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Kerr ZY, Harmon KJ, etal. The epidemiology

of traumatic brain injuries treated in

emergency departments in North Carolina,

2010-11. NCMJ. 2014;75(1):8-14.

Rate of concussion by sport among 19,903 high school athletes : North Carolina, 1996–1999

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Schulz MR, Marshall SW, etal. Incidence and risk factors

for concussion in high school athletes, North Carolina

1996-1999. Am J Epidemiol 2004;160:937–944

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

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Schulz MR, Marshall SW, etal. Incidence and risk factors

for concussion in high school athletes, North Carolina

1996-1999. Am J Epidemiol 2004;160:937–944

Outline

Epidemiology

Anatomy/Physiology

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Anatomy – bones of the skull

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Anatomy – bones of the skull

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Anatomy - lobes

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Atrain Education

https://www.atrainceu.com

Anatomy - neurons

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Anatomy - neurons

American Association for the Advancement of Science

Science 2014;343:600-610

Anatomy - matters

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Anatomy – inner brain

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Atrain Education

https://www.atrainceu.com

Cerebrospinal Fluid

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Sub Arachnoid Space

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Outline

Epidemiology

Anatomy/Physiology

Injury Mechanisms

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Coup Contracoup

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http://www.wellnessbite.com/brain-injury-increases-risk-of-dementia

Intracranial Pressure

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Vintracranial (constant) = Vbrain + VCSF + Vblood + Vmass lesion

Intra Cranial Hemorrhage

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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

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Herniation

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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

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Sub Arachnoid Space

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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

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AXONAL SHEARING

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Axonal Shearing

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Brainbow Hippocampus

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Outline

Epidemiology

Anatomy/Physiology

Injury Mechanisms

Diagnosis & Assessment

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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

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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

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Concussion Diagnosis

Clinical Diagnosis

Possible CT or MRI to rule out

Skull fracture

Bleeding

Edema

Repeat clinical assessments until symptoms fully

resolve

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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

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Biomarkers

S100 Protein well-researched

Others include: neuron-specific enolase (NSE) and

cleaved tau protein (CTP)

Primarily for research

Tend to peak at 48 – 72 hours

Peak values more predictive than initial values

Non-specific

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Low Technology Functional Assessment

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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) 89-102.

Low Technology Functional Assessment

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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) 89-102.

Low Technology Functional Assessment

David Wesley, M.D. 41

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) 89-102.

Low Technology Functional Assessment

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Guskiewicz KM, Ross SE, Marshall SW. Postural stability and

neuropsychological deficits after concussion in collegiate athletes.

J Athl Train 2001;36:263–73.

Outline

Epidemiology

Anatomy/Physiology

Injury Mechanisms

Diagnosis & Assessment

Treatment

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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

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Management of Persistent Symptoms

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Mott TF, McConnon ML, Rieger BP. Subacute to

chronic mild traumatic brain injury. Am Fam

Physician. 2012 Dec 1;86(11):1045-51.

Outline

Epidemiology

Anatomy/Physiology

Injury Mechanisms

Diagnosis & Assessment

Treatment

Outcomes

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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

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Risk Factors for Poorer Outcomes (persistent symptoms)

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Mott TF, McConnon ML, Rieger BP. Subacute to

chronic mild traumatic brain injury. Am Fam

Physician. 2012 Dec 1;86(11):1045-51.

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

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