Traumatic Brain Injury
TBI
Nabeel Kouka, MD, DO, MBA
www.brain101.info
Brain Injuries
Congenital brain injury Acquired Brain Injury
Pre-birth During birth After birth process
Traumatic Brain Injury
(external physical force)
Non-traumatic
Brain Injury
Closed Head Open Head
Injury Injury
What is a TBI?
Sudden damage to the brain due to an external
force.
2 Types
• Closed Head Injury- Occurs when the head
forcefully collides with another object (for
example the windshield of a car) but doesn't
fracture or penetrate the skull.
• Open Head Injury- Occurs when an object (for
example a bullet) fractures the skull and
debris enters the brain and rips the soft brain
tissue in its path.
Epidemiology
Percentage of Average Annual Traumatic Brain Injury-Related Emergency
Department Visits, Hospitalizations, and Deaths, by External Cause, United States,
1995-2001
Suicide, 1% Unknown,
9%
Other Transport, Other, 7%
2%
Falls, 28%
Pedal Cycle
(non MV), 3%
Assault, 11%
Motor Vehicle-
Traffic, 20%
Struck
By/Against, 19%
National Prevalence Rates of Various Disabilities
400,000 w/ Spinal Cord Injuries
500,000 with Cerebral Palsy
2 million Americans with Epilepsy
3 million with Stroke disabilities
4 million with Alzheimer’s Disease
5 million with persistent mental illness
5.3 million with TBI disability
7.3 million Americans with mental retardation
TBI in the United States (by Cause)
Motor Vehicle
9%
- Traffic
20%
Falls
32% Assault
28% Other
11%
Unknown
Two types of TBI
OPEN-HEAD CLOSED-HEAD
INJURY INJURY
(penetrating)
Example:
Example:
• Coup-Contra Coup
• Skull fracture that
• Diffuse axonal injury
penetrates the brain
• Gunshot wound
Two Classes of Brain Injury
• PRIMARY • SECONDARY
THE INJURY IS MORE THE INJURY EVOLVES OVER
OR LESS COMPLETE A PERIOD OF HOURS TO
AT THE TIME OF DAYS AFTER THE INITIAL
IMPACT
TRAUMA
1. SKULL FRACTURE
1. BRAIN SWELLING/EDEMA
2. CONTUSION/ BRUISING OF 2. INCREASED INTRACRANIAL PRESSURE
THE BRAIN 3. INTRACRANIAL INFECTION
4. EPILEPSY
3. HEMATOMA/BLOOD CLOT
ON THE BRAIN 5. HYPOXEMIA (LOW BLOOD OXYGEN)
6. HIGH OR LOW BLOOD PRESSURE
4. DIFFUSE AXONAL INJURY 7. ANOXIA/HYPOXIA (LACK OF OXYGEN TO
THE BRAIN)
TBI Severity Levels
• Mild- Only when there is a change in the mental status
at the time of the injury; concussion.
• Moderate- Loss of consciousness last for minutes to
hours; confused for days or weeks. Impairments can
be temporary or permanent.
• Severe- Unconscious state for days, weeks, or months.
Impairments are permanent.
TBI in children
can be especially devastating,
as a child’s brain is in an almost constant
state of development.
Brain Rates of Development
5 Distinct
Periods of
Maturation
P - O parietal/
occipital
P-O C central (limbic &
brainstem)
C
P-O T T temporal
T C F-T
C F - T frontal/
F-T P-O temporal
F-T
Cerebral Cortex
Numerical Data
Number of neuronal cells in cerebral cortex
neurons ----------- 10-15 billion
glial cells ---------- 50 billion
Estimation of number of cortical neurons
von Economo and Koskinas (1925) 14.0 billion
Shariff (1953) 6.9 billion
Sholl (1956) 5.0 billion
Pakkenberg (1966) 2.6 billion
Normal Brain CT Scan
Brain Concussion
• Impaired function (varying time frame)
• No structural damage to speak of directly
• Can lead to degradation over time
• Extreme variance in severity
– LOC
• Diffuse
Brain Concussion
Brain Contusion
Contusion w/Contra-Coup Injury
Diffuse Axonal Injury
Intraventricular Haemorrhage
Intraventricular Haemorrhage
Brainstem Haemorrhage
Subarachnoid Hemorrhage
a. Subarachnoid Hemorrhage b. Transtentorial herniation
c. Intraventricular hemorrhage e. Diffuse axonal (shearing) injury
Intracranial Haematomas
• Epidural
– arterial bleeding
– quick onset
– less common
• Subdural
– venous bleeding
– wide range of onset time
– can build on each other without symptoms
Acute Subdural Haematoma
Acute Subdural Haematoma w/Midline Shift
Chronic Subdural Haematoma
* Heterogeneous mass
a. Focal convexity of medial
margin
b. Dilated Ipsilateral Ventricle
c. Midline Shift
d. Diffuse Brain Edema
e. Scalp Hematoma
Acute Epidural Haematoma
Management
The specific goals in the acute management of
severe traumatic brain injury are:
1. Protect the airway & oxygenation
2. Ventilate to normocapnia
3. Correct hypovolaemia & hypotension
4. CT Scan when appropriate
5. Neurosurgery if indicated
6. Intensive Care for further monitoring and management
Significant Head Injuries
• Signs of increased intercranial pressure
– Visual difficulties
– Vomiting
– Dyspnea
– Decreased pulse
Glascow Coma Scale
Intracranial Pressure (ICP)
v.Intracranial (constant) = v.Brain + v.CSF + v.Blood + v.Mass Lesion
CPP = MAP - ICP
CPP: Cerebral Perfusion Pressure
MAP: Mean Arterial Pressure
ICP: Intracranial Presure
Indications for ICP Monitoring
Indications for ICP monitoring Risk of raised ICP
Severe Head Injury (GCS 3-8)
* Abnormal CT scan 50-60%
* Normal CT Scan
Age > 40 or BP < 90 mm Hg 50-60%
or abnormal motor posturing
* Normal CT scan 13%
No risk factors
Moderate Head Injury (GCS 9-12)
* If anaesthetised/sedated Approx. 10-20% will deteriorate
* Abnormal CT scan to severe head injury
Mild Head Injury (GCS 13-15)
* Few indications for ICP measurement Only around 3% will deteriorate
Key Recommendations
Maintenance of CPP reduces mortality in severe head injury.
• ICP monitoring is recommended in most comatose patients
with severe head injury.
• ICP should be treated when > 20 mm Hg,
Hg but maintenance
of CPP is probably more important.
How Brain Injuries treated?
How Brain Injuries treated?
