2.1 Traumatic Brain Injury Flashcards by Naomi Nakazato

Introduction

This is an inujry to the brain caused by an external force that may lead to alteration in brain function and other brain pathology.

Can be d/t a blow to the head or a penetrating injury

Traumatic Brain Injury

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Introduction

What is the difference between a Traumatic or Non-traumatic brain injury?

Non-traumatic: Internally Aquired
Traumatic: Externally Aquired

Ex of Non-traumatic: Stroke, Brain Tumor

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Introduction

What is the difference between TBI an a head injury?

Head Injury: A blow to the head/laceration and may occur w/o causing injury to the brain

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Introduction

What is the difference between an Open and Closed TBI?

Open TBI: Head is hit by an object and the skull breaks, thus penetrating the brain tissue and disrupting the dura mater.
Closed TBI: Occurs when the skull is intact but with injury to the brain tissue

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Introduction

Classification of TBI that occurs 80% of the time

Including Head Contusion

Mild TBI

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Introduction

Classification of TBI that occurs 10% of the time

Moderate and Severe TBI

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Introduction

3 Common Causes of Non-traumatic Brain Injury

Toxins, Metabolic Abnormalities, Anoxia

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Common Causes of Non-traumatic Brain Injury (Toxic)

This toxin is associated with development of Parkinson’s Disease

Manganese (Mn)

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Common Causes of Non-traumatic Brain Injury (Toxic)

This toxin can lead to Multiple Sclerosis

Zinc

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Common Causes of Non-traumatic Brain Injury (Toxic)

A disorder where the body cannot execrete copper and thus accumulated in the liver and the brain

Wilson’s Disease

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Common Causes of Non-traumatic Brain Injury (Toxic)

This toxin can lead to Wilson’s Diseases

Copper

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Common Causes of Non-traumatic Brain Injury (Metabolic Abnormalities)

This deficiency can affect the brain and cause neurologic/psychologic symptoms like: Confusion, memory loss, delirium, depression, and hallucinations

Calcium Metabolism

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Common Causes of Non-traumatic Brain Injury (Metabolic Abnormalities)

Metabolic abnoramlity where fatty cells deposit in different organs such as liver and spleen that can lead to progressive loss of function of nerves and brain

Gaucher’s/Niemann-Pick

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Common Causes of Non-traumatic Brain Injury (Anoxic)

Condition where there is a lack of oxygen to tissue which can result to Cardiac Arrest, CVD, and CO Poisoning

Anoxia

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Common Causes of Non-traumatic Brain Injury (Anoxic)

Areas prone to Anoxia

Hippocampus and Basal Ganglia

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TBI Epidemiology

T/F: TBI is the leading cause of injury related death and disability in the US

True

Considered as a major cause of death and disability

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TBI Epidemiology

Falls in the elderly with a rapid increase of __%

80%

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TBI Epidemiology

Struck by or against an object with a __%

58%

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TBI Epidemiology

In the leading cause realted to hospitalizations, why are MVA patients ranging from 14-44 yrs. old?

D/t likelihood of individuals to be more agressive and high risk takers or do not wear proper safety equipment

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TBI Epidemiology

What is the leading cause of TBI?

Falls

Usually experienced by the elderly

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TBI Epidemiology

Cause of TBI that has the highest fatality rates

MVA

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TBI Epidemiology

Leading cause of Sports TBI

Diving

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TBI Epidemiology

Single largest indirect cause of TBI

Alcohol

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Anatomy

The brain lies in the (1) continuous with the (2) via the (3)

Cranial Cavity
Spinal Cord
Foramen Magnum

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# Anatomy The percent of an adult brain to a person's body weight

# Anatomy Normal cerebral blood flow must be maintained at __ tissue of brain

50/mL/min/100g

# Anatomy What are the 3 meninges surrounding the brain? (Arrange from superficial to deep)

Dura → Arachnoid → Pia Mater

# Anatomy It is a clear, colorless liquid produced by the choroid plexus

Cerebrospinal Fluid

# Anatomy In which space is the cerebrospinal fluid floating?

Subarachnoid Space

# Anatomy What types of gliding is the brain capable of doing while it floats in the CSF in the subarachnoid space?

Anteroposterior and lateral movement

# Anatomy What limits the anteroposterior movement of the brain in the subarachnoid space?

Superior Cerebral Veins to the Superior Sagittal Sinus

# Anatomy What prevents the lateral movement of the brain in the subarachnoid space?

Falx Cerebri | This is an extension of tough dura matter

# Anatomy This lobe is considered the seat of intelligence and where most cognitive functions are housed.

Frontal Lobe ## Footnote It includes: Judgement, long-term memory, critical thinking skills, calculations, communication, and personality

# Anatomy This lobe is responsible for reception od auditory stimuli, sensory aspect of speech, and short-term memory

Temporal Lobe

# Anatomy This lobe is involved in processing, interpretting, and discriminating different sensory inputs

Parietal Lobe

# Anatomy This lobe is involved in the reception and interpretation of visual stimuli

Occipital Lobe

# Anatomy This is responsible for conscious regulation od motor coordination and control of voluntary movements. It is also involved in unconscious proprioception and balance control of the body | Known as "little brain"

Cerebellum

# Anatomy This is where most reflex and autonomic responsed of the body are regulated

Brainstem ## Footnote Includes: Breathing, digestive processes, vasomotor control, and wakefulness

# Anatomy Areas of the brain divided into different areas according to the tissue structure and cellular organization

Brodmann's Areas

# Brodmann's Area Associated with interpretation and localization of different sensations such as pain, temperature, touch and pressure

Primary Somatosensory Cortex (BA 3,1,2)

# Brodmann's Area Responsible for exercuting motor movements of contralateral body segments

Primary Motor Cortex (BA 4)

# Brodmann's Area Receives synthesized connections from the primary and secondary cortices and respond to several types of inputs involved in complex associations

Somatosensory Association Cortex (BA 5, 7)

# Brodmann's Area Critival for the guidance od movement and control of proximal and trunk muscles, and contributes to the planning of complex and coordinted motor movments

Premotor Cortex (BA 6)

# Brodmann's Area Conjugate horizontal movement of the eyes away from the stimulus

Frontal Eye Fielve (BA 8)

# Brodmann's Area Contains a well-defined map of the spatial information required for vision

Primary Visual Cortex (BA 17)

# Brodmann's Area Receives visual signals where they are interpreted and the form is recognized

Secondary Visual Cortex (BA 18, 19)

# Brodmann's Area Situated close to the extenral ear and involves complex languafe and auditory processing

Wernicke's Area (BA 22)

# Brodmann's Area Considred to be a part of the Wernicke's Area for receptive speech and affectation in this area can lead to Gerstmann Syndrome

Angular Gyrus (BA 39) and Supramarginal Gyrus (BA 40)

# Brodmann's Area S/x of Gerstmann Syndrome

L-R Indiscrimination, Finger Agnosia, Agraphia, Acalculia

# Subjective (Demographics) Why are males more prone to TBI?

More agressive, adventurous, and high-resk takers

# Subjective (Demographics) Peak Age that is prone to TBI

15-24 yrs olds (De Lisa)

# Subjective (Demographics) TBI at very young ages are usually associated with what?

Shaking Baby Syndrome or child abuse

# Subjective (Physical Impairment) Condition where objects appears to be moving even if it does not actually move

Oscillopsia

# Subjective (Neuromuscular Impairment) Neuromuscular Impairments will vary depending on what?

Location of the Lesion

# Subjective (Cognitive Impairment) The mental process of knowing and applying information

Cognition

# Subjective (Cognitive Impairment) T/F Pts with TBI are not prone to have cognitive impairments

False

# Subjective (Cognitive Impairment) T/F: Cognitive processes are intricate and localizing specific anatomic structures involved in the process is difficult

True

# Subjective (Cognitive Impairment) What are the diffecnt executive functions

Planning, Cognitive Flexibility, Initiation and Saelf-generation, Response Inhibition, Serial ordering, Sequencing

# Subjective (Cognitive Impairment: Execute Function) Strategic problem solving skill

Planning

# Subjective (Cognitive Impairment: Execute Function) Ability to adapt thinking and behavior

Cognitive Flexibility

# Subjective (Cognitive Impairment: Execute Function) Self-initiated encoding of information

Initiation and Self-generation

# Subjective (Cognitive Impairment: Execute Function) Ability to repress inapproriate responses

Response Inhibition

# Subjective (Cognitive Impairment) What will be done if the pt or relatives includes impairment of the complex neural processes in their subjective report?

Objective Examination of the Cerebrum will be conducted

# Subjective (Cognitive Impairment) Main complaint of relatives and commonly seen in patients

Altered Levels of consiousness | Esp. in RLA Levels 1-3

# Subjective (Level of Consciousness) Level that has no response to stimuli and not usually permanent

Comatose

# Subjective (Levels of Consciousness) Sx under Comatose

1. (-) Arousal System 2. Closed eyes 2. (-) Sleep Wake Cycle 3. (-) Auditory and Visucal Function 4. (-) Communicative Function 5. (+) Abnormal and postural reflexes

# Subjective (Levels of Consciousness) Level where it is dissociation between wakefulness and awareness

Vegetative State

# Subjective (Levels of Consciousness) Sx under Vegetative State

1. (+) Dissociation d/t unintegrated higher centers with the brainstem 2. (+) Sleep Wake Cycle 3. Awake b ut unaware of environment 4. May startle d/t visual/auditory stimuli 5. No meaningful communicative and cognitive functions 6. Movements are non-puposive and usually reflexive

# Subjective (Levels of Consciousness) Leve, of minimal evidence of self or environmental awareness

Minimally Conscious State

# Subjective (Levels of Consciousness) Sx of Minimally Conscious State

1. Cognitive behaviors are inconsistent, reproducible, or sustained 2. (+) Sleep wake Cycle 3. Localized painful stimuli and sound stimuli 4. Demonstrate visual pursuit of an object

# Subjective (Levels of Consciousness) Level of an unresponsive state and returns to unconsious state when strong noxious stimuli is withdrawn

Stupor

# Subjective (Levels of Consciousness) Sx of Stupor

1. Temporary arousal with strong noxious stimuli 2. Vigorous and repeated stimulation

# Subjective (Levels of Consciousness) Level where there is a constant need of stimulus to stay awake. | Confused when awake/conscious or unreproductive interaction

Obtunded

# Subjective (Levels of Consciousness) Sx of Obtuned

When aroused, exhibits decreased alertness and interest in the environment

# Subjective (Levels of Consciousness) Level where there is arousal with stimulus but falls asleep when stimulus is withdrawn

Lethargy

# Subjective (Levels of Consciousness) Sx of Lethargy

1. Arousable but disoriented 2. Loss of treain of thought 3. Morbid drowsiness

# Subjective (Levels of Consciousness) Level where pt is awake, attentive, and meaningfully interactive

Alert

# Subjective (Levels of Consciousness) Sequence of Recovery After Coma

1. Eye Opening (CN 3) 2. (+) Brainstem Function - Sleep Wake Cycle 3. (+) Hypothalamus Function - Ability to follow commands 4. Able to talk and communicate appropriately (Best Indicator of Recovery)

# Subjective (Levels of Consciousness) State of 1 month of unconsciousness

Persistent Vegetative State

# Subjective (Levels of Consciousness) Sx of Persistent Vegetative State

1. (+) Sleep Wake Cycle 2. Pupillary Constriction (Light Reflex) 3. (+) Oculocephalic - Good Prognosis 4. (+) Primitive Behavior (Chewing and Rolling Eye movement) 5. Spontaneous response

# Subjective (Levels of Consciousness) These impairments are more debilitating in the long run than physical disability

Neurobehavioral Impairments

# Subjective (Neurobehavioral Impairments) Inability to hold a response or suppress inappropriate or unwated behavior

Disinhibition

# Subjective (Neurobehavioral Impairments) Lack of interest or concern

Apathy

# Subjective (Neurobehavioral Impairments) Rapid, often exacerbated changes in mood (uncontrollable crying/laughing)

Emotional Lability

# Subjective (Neurobehavioral Impairments) Inability to swtch between thinking about 2 different concepts

Mental Inflexibility

# Subjective (Communication Impairments) Deficits Include:

1. Disorganized and tangential oral/written communication 2. Imprecise language 3. Word retrieval difficulties 4. Disinhibited and socially inappropriate language

# Subjective (Classification of TBI) May result either from brain tissue coming into contact with an object or an external object which can penetrate the bone

Primary Injury

# Subjective (Classification of TBI) T/F: Contact forces also occur when the head is prevented from moving after it is struck

True

# Subjective (Classification of TBI) Occurs when the head is set into motion and the brian tissue repidly accelerates/ decelerates

Inertial Forces

# Subjective (Classification of TBI) Any damage to brain tissue that takes palce after the initial injury

Secondary Injury

# Subjective (Classification of TBI) Occurs as a result of events that followa fter tissue damages

Cell Death

# Subjective (Classification of TBI) T/F: Both primary and secondary mechanisms of injury are mutually exclusive and often occur in isolation

False | It is not mutually exclusive and often to not occur in isolation

# Subjective (Primary Injury of TBI) It is a distinguishing factor of TBI where microscopic disruption and tearing of axons and small blood vessels from shear-strain of angular acceleration

Diffuse Axonal Injury

# Subjective (Primary Injury of TBI) What is the most common cause of DAI?

MVA

# Subjective (Primary Injury of TBI) T/F: Recovery from DAI is abrupt

False | It is usually gradual

# Subjective (Primary Injury of TBI) Common manifestation of Diffuse Axonal Injury

Coma

# Subjective (Primary Injury of TBI) LOC is d/t ___?

Direct axonal shearing and disruption of the intra-axonal cytoskeleton | Axons damaged d/t shearing force → swelling and disconnection of axons

# Subjective (Primary Injury of TBI) Common sites of disruption in DAI

1. Corpus callosum 2. Subcortical white matter 3. Brainstem

# Subjective (Primary Injury of TBI) Structures usually spared in DAI

1. Upper Medulla 2. CN 9 & 11

# Subjective (Primary Injury of TBI) Injury results from relatively low-velocity impact such as blows and falls

Cerebral/Cortical Contusion

# Subjective (Primary Injury of TBI) Another name for Cerebral Contusion

Parenchymal Contusion/Cortical Bruising

# Subjective (Primary Injury of TBI) Difference between Cerebral Contusion and DAI

DAI: High-velocity impacts Cerebral Contusions: Low-velocity impacts

# Subjective (Primary Injury of TBI) Common areas affected by Cerebral Contusions

Undersurface of the frontal and anterior temporal lobes

# Subjective (Primary Injury of TBI) What causes the undersurface of the frontal and anterior temporal lobes to have brain tissue and vascular disruptions

Presence of bony prominences on the base of the skull

# Subjective (Primary Injury of TBI) Manifestation on Contusion @ Frontal Lobe

Long-Term Memory

# Subjective (Primary Injury of TBI) Manifestation on COntusion @ Temporal Lobe

Short-term Amnesia

# Subjective (Primary Injury of TBI) T/F: Cerebral Contusions elevate the risk for seizures and are more likely to produce focal deficits

True | Ex. Aphasia, Motor weakness

# Subjective (Primary Injury of TBI) Injury that occurs under the impact site

Coup Injury ## Footnote Ex. Brain is still accelerating but the body has already stopped → brain tissue still moves forward hitting skull

# Subjective (Primary Injury of TBI) Injury where contusions remote or away from the injury site and opposite of the impact

Countercoup ## Footnote Ex. sudden recoil of body after the impact will lead to deceleration → brain a little delayed → brain is translated backward hitting the skull

# Subjective (Primary Injury of TBI) Combined where injury is both under the impact site then away from the injury site

Coup-countercoup

# Subjective (Primary Injury of TBI) Classified as a mild traumatic brain injury where duration to define persistent deficits can range from 3-12 months

Concussion

# Subjective (Primary Injury of TBI) Key Criteria of Concussion

1. Confusion 2. Disorientation 3. LOC for less than 30mins 4. PTA for less than 24 hrs

# Subjective (Primary Injury of TBI) Occurs 3 months after concussion

Post Concussional Syndrome

# Subjective (Primary Injury of TBI) Common manifestations of PCS

1. LOC 2. Memory Deficit 3. Irritability 4. Agitation 5. Headache 6. Fatigue

# Subjective (Primary Injury of TBI) Concussional Grade: 1. Transient Confusion s LOC 2. Concussion sx resolve in >5mins

Grade 1

# Subjective (Primary Injury of TBI) Concussional Grade: 1. Transient Confusion s LOC 2. Concussion sx resolve in >15mins

Grade 2

# Subjective (Primary Injury of TBI) Concussional Grade: Brief or prolonged LOC

Grade 3

# Subjective (Primary Injury of TBI) A less common cause of parenchymal injury caused by metallic or bony fragments

Direct Laceration

# Subjective (Primary Injury of TBI) Neurons remote from a site of injury, but anatomically connected to the damaged area, becoming functionally depressed

Diaschisis

# Subjective (Primary Injury of TBI) T/F: Every structure in the brain is directly/indirectly connected to all other strucures

True

# Subjective (Primary Injury of TBI) What affectation occurs d/t a focal cortical lesion?

Affect contralateral cortical functioning by way of interconnections in the corpus callosum

# Subjective (Primary Injury of TBI) T/F: Fucntionally connection regions in the neocortex will not undergo diaschisis after a focal stroke

False. ## Footnote It will d/t the loss of afferent connections

# Subjective (Primary Injury of TBI) Local impact and subsequent laceration of underlying dural veins and arteries

Epidural Hematoma

# Subjective (Primary Injury of TBI) Interior forces and the tearing of bridging veins when angulat acceleration shears vessels located in the subarachnoid space

Subdural Hematoma

# Subjective (Secondary Injury of TBI) Normal ICP

5-20cm of H2O

# Subjective (Secondary Injury of TBI) Ominous manifestation of an increased ICP and must be monitored in comatose pts

Cushing's Triad

# Subjective (Secondary Injury of TBI) Cushing's Triad

1. Hypertension 2. Irregular Breathing 3. Bradychardia

# Subjective (Secondary Injury of TBI) Lack of oxygenated blood flow to the brain tissue | May cause severe damage to parenchymal tissues

Ischemia

# Subjective (Secondary Injury of TBI) Caused by systemic hypotension, anoxia, or damage to specific vascular territories of the brain

Hypoxic-Ischemic Injury

# Subjective (Secondary Injury of TBI) Signature injury of military conflicts d/t frequent use of explosives in the battle front

Blast Injury

# Subjective (Secondary Injury of TBI) Direct effect of blast overpressure which can trigger oscillations going to the brain thus increasing CSF/venous pressure

Primary Blast Injury

# Subjective (Secondary Injury of TBI) Injuries due to fragments propulsed by blast wave

Secondary Blast Injury

# Subjective (Secondary Injury of TBI) Injuries d/t impact w/ other objects

Tertiary Blast Injury

# Subjective (Secondary Injury of TBI) Occurs as a concomitant close injury brought about by asphyxia and exposure to toxic inhalants

Quarternary Blast Injury

# Subjective (Ancillary Procedure) Primary method in examining tumors and vascular abnormalities

MRI

# Subjective (Medications) Antoconvulsant drug given to pts with TBI

Phenytoin

# Subjective (Medications) Lowers inflammatory process of the body but increases CSF cortisol

Corticosteroids

# Subjective (Medications) Has a neuroprotective property

Progesterone

# Subjective (Duration of PTA) Length of time between the injury and the time at which the patient is able to consistently remember ongoing events

Post traumatic Amnesia

# Subjective (Duration of PTA) Duration of PTA: 0-1 Days

Mild TBI

# Subjective (Duration of PTA) Duration of PTA: >1 day to <7 days

Moderate TBI

# Subjective (Duration of PTA) Duration of PTA: > 7 Days

Severe TBI

# Subjective (Memory Loss) Loss of previous emories after the incident

Retrograde Amnesia/Evocation

# Subjective (Memory Loss) Inablity to learn new things

Anterograde Amnesia/Fixation Amnesia

# Objective (Vital Signs) Elevated SNS activity occurs as a normal reponse to trauma

Dysautonomia