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Traumatic Brain Injury
Traumatic Brain Injury
- Alteration of brain function caused by an external force
- 15-25 years old
- M > F
- Etiology: Falls > MVA > Assaults > Sports
- Diagnostic Tool: CT Scan
I. MECHANISM OF INJURY
1. Acceleration Injury
- When a moving force hits the head
2. Deceleration Injury
- When a moving head meets a stationary object
3. Coup Injury
- Injury of the brain on the site of impact
4. Counter-Coup Injury
- Injury of the brain opposite to the site of impact
II. PATHOPHYSIOLOGY
1. Primary Brain Injury
- Damage that occurs immediately as a result of trauma to the brain
- TYPES:
A. Diffuse Axonal Injury
Shearing of subcortical axons within the myelin sheath (+) mechanical
strain that leads to Wallerian degeneration
Due to high velocity acceleration and deceleration forces
Responsible for initial loss of consciousness
Distinguishing feature of TBI
SITES:
o Corpus Callosum MC site
o Parasagittal White Matter
o Midbrain and Pons
B. Cerebral Contusion
AKA: Cortical Bruises
Commonly occur at the crests of gyri
Contusions may result from low-velocity impact (falls, blow)
Coup and counter-coup injury
SITES:
o Inferior Frontal Lobe
o Anterior Temporal Lobe
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2. Secondary Brain Injury
- Develops over hours and days after the initial impact
- TYPES:
A. Hypoxic-Ischemic Injury
Due to decreased of O2 and blood supply to the brain, the tissue undergoes
death and infarction
Causes:
o Systemic Hypotension
o Anoxia
o Damage to Vascular Territories
B. Increased Intracranial Pressure
Normal: 4-15 mmHg; 5-10 mmHg
With TBI: > 20 mmHg
It may result to:
o Normal Pressure Hydrocephalus
o Brain Herniation
o Papilledema Bulging of the optic disc; may damage CN 2
(+) Cushing Sign
o AKA: Hakim’s Triad
o S/Sx: bradycardia, bradypnea, hypertension
Pharmacological Tx: Mannitol
Tx: Elevate head at 30 degrees above horizontal
C. Brain Herniations
1. Uncal Herniation
Uncus of temporal lobe
Structures involved:
o Cerebral Peduncle C/L Hemiplegia
o RAS Coma
o Oculomotor Nerve I/L CN 3 Palsy
o PCA C/L Homonymous Hemianopsia
2. Central/ Transtentorial Herniation
Diencephalon and part of Temporal Lobe
Structures involved:
o Pons and Midbrain Decerebrate posture
o RAS Coma
3. Tonsilar Herniation
Structures involved:
o Cerebellar Tonsil neck pain and stiffness
o Vasomotor Center Alteration of BP, PR, RR
o RAS Coma
o Indirect Activation Pathway Flaccidity
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4. Normal Pressure Hydrocephalus
Adult form of hydrocephalus
Communicating type
Problems with reabsorption of CSF in the arachnoid villi
MGT: Ventriculoperitoneal Shunt (VP Shunt)
Increased ICP Mannitol
TRIAD:
o Dementia
o Incontinence
o Gait Ataxia
III. NEUROLOGICAL MANIFESTATIONS
1) Spasticity
- Velocity dependent resistance
2) Cognitive Impairments
- Alteration of consciousness, attention, concentration, executive function, memory and
learning
- Level of Arousal:
A. Comatose
(-) sleep-wake cycle
(+) ventilator dependent
B. Vegetative State
(+) sleep-wake cycle
(-) ventilator dependent
(-) environmental awareness
C. Minimally Conscious State
There is minimal evidence of environmental awareness
D. Stupor
Pt can be aroused only briefly with vigorous repeatedly sensory
stimulation
E. Obtunded
Sleeps often and when aroused, shows decreased alertness and interest
in the environment
3) Neurodevelopmental Impairments
- Agitation/ Aggression
- Irritability
- Mental inflexibility
- Apathy lack of interest/concern
- Disinhibition/ Impulsivity
- Emotional lability rapid exaggerated changes in the mood
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4) Dysautonomia
- AKA: Paroxysmal Sympathetic Hyperactivity; Paroxysmal Autonomic instability with
Dystonia
- S/Sx:
Increased BP, PR, RR
Hyperthermia
Diaphoresis
Hypertonia
Decorticate/ decerebrate posturing
Teeth grinding
5) Post-traumatic Seizure
- MGT: Anticonvulsant Drugs Phenytoin
6) Post-traumatic Amnesia
- The length of time between the injury and the time at which the patient is able to
consistently remember ongoing events
- Measured by:
A. Galveston Orientation and Amnesia Test (GOAT) 0-100; N: >75
B. Orientation Log Test
7) Others
- Pressure Ulcers bed turning position every 2 hours
- DVT MC complication: Pulmonary Embolism
- Heterotopic Ossification bone formation near the joint; MC site: SH (MES), Hip (PT
apps)
- Fractures
- Muscle Atrophy
- Contractures
- Pneumonia
IV. SCALES
1) Severity of TBI
2) Glasgow Coma Scale
EYES
MOTOR
VERBS
4 Spontaneous
6 Follows
5 Oriented
3 Upon Command
5 Localizes
4 Confused/ Disoriented
2 Pain
4 Withdraw
3 Inappropriate words
1 No Response
3 Decorticate
2 Incomprehensible
2 Decerebrate
1 No Response
1 No Response
MILD
MODERATE
LOC
0 30 minutes
30 minutes 1 day
>1 day
PTA
0 1 day
1 7 days
>7 days
GCS
13 - 15
9 - 12
3 - 8
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*Glasgow Liege Scale
- Used to assess the severity of TBI
- (+) Assessment of Brainstem Reflexes
a. Fronto-Orbicular Reflex
- Percussion of glabella elicits contraction of Orbicularis Oculi
b. Vertical and Horizontal Oculocephalic/Oculovestibular Reflex
- Doll’s eye maneuver ability to fix vision in one object/area when moving the head
c. Pupillary Light Reflex
- Constriction of pupils upon exposure to light
d. Oculocardiac Reflex
- Bradycardia induced by applying pressure to the eyeball
3) Glasgow Outcome Scale Extended
I
Dead
II
Vegetative state
(+) sleep-wake cycle
III
Lower
Severe
Disability
Pt needs full assistance throughout the day
IV
Upper
Pt needs some assistance/supervision; can be alone for 8 hours
V
Lower
Moderate
Disability
Independent in ADL, but has not return to previous position/lifestyle
VI
Upper
Able to resume previous position/lifestyle c modifications
VII
Lower
Good
Recovery
Able to resume previous position/lifestyle c some reporting problems
VIII
Upper
Complete return to previous lifestyle with no reported problems
4) Ranchos Los Amigos
I
No
Response
II
Generalized
III
Localized
IV
Confused
Agitated
V
Inappropriate
VI
Appropriate
VII
Automatic
VIII
Purposeful
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I. NO RESPONSE
- Pt appears to be in a deep sleep
- Unresponsive to any stimulus
II. GENERALIZED RESPONSE
- Responses maybe physiological changes, gross body movements and/or vocalization
- Responses are not related to the type of stimulus
III. LOCALIZED RESPONSE
- Responses are directly related to the type of stimulus presented
- May follow simple commands in an inconsistently and delayed manner
IV. CONFUSED AGITATED
- Pt is in heightened state of activity
- Behavior is bizarre and non-purposeful
- Pt lacks short and long-term recall
V. CONFUSED INAPPROPRIATE
- Pt is able to respond to simple commands fairly consistently
- Memory is severely impaired
- Unable to learn new information
VI. CONFUSED APPROPRIATE
- Pt shows goal-directed behavior
- May follow simple directions
- There is carry over for re-learned tasks such as self-care
VII. AUTOMATIC APPROPRIATE
- Learning at a decreased rate
- Judgement remains impaired
- Robot-like behavior
- Pt may initiate social or recreational activities
VIII. PURPOSEFUL APPROPRIATE
- (+) Environmental awareness
- Can learn without supervision
V. NEUROPLASTICITY
1) Use it or lose it Failure to drive specific brain functions can lead to functional degradation
2) Use it and improve it Training that drives specific brain function can lead to an enhancement
of the function
3) Specificity The nature of training experience dictates the nature of plasticity
4) Repetition matters Induction of plasticity requires sufficient repetition
5) Intensity matters Induction of plasticity requires sufficient training intensity
6) Time matters Different forms of plasticity occur at different times during training
7) Salience matters The training experience must be sufficiently salient to induce plasticity
8) Age matters Plasticity induced training occurs more readily in younger brain
9) Transference Plasticity in response to one training experience can enhance at acquisition of
similar behavior
10) Interference Plasticity in response to one training experience can interfere at acquisition of
other behavior

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