Brain Injuries

Question 1

Traumatic Brain Injury ( TBI) Description and Definitions

Answer 1

-loss of consciousness, posttraumatic amnesia, disorientation and confusion, or, in more severe cases, neurological signs
* Complex changes in physical, cognitive, neurobehavioral due to
brain damage
* Damage occurs post birth
* Not associated to congenital or degenerative disease

Question 2

Mild TBI:

Answer 2

• Loss of consciousness of <30 minutes
• Posttraumatic amnesia of <24 hours and disorientation and confusion
• Glasgow Coma Scale (GCS) score of 13 to 15.

Question 3

Moderate TBI

Answer 3

• Loss of consciousness of 30 minutes to 24 hours
• Posttraumatic amnesia of 24 hours to 7 days
• GCS score of 9 to 12

Question 4

Severe TBI:

Answer 4

Loss of consciousness of more than 24 hours
* Posttraumatic amnesia of more than 7 days
* GCS score of 3 to 8 (American Psychiatric Association, 2013)

Question 5

Primary brain damage

Answer 5

Focal lesions
Diffuse lesions

Question 6

Diffuse lesions

Answer 6

• Occur throughout multiple brain areas and may result from an explosion, motor
  vehicle accidents, or sport collisions. Often at speeds of 15mph or more.
• Motor vehicle accidents typically result in both coup and contrecoup injuries

Question 7

Focal lesions

Answer 7

• Limited in scope and are associated with direct impact of short duration such as occurs with gunshot
• Occurs throughout multiple brain areas and may result from an explosion, motor vehicle accidents, or sport collisions

Question 8

Secondary damage

Answer 8

Occurs within hours and days of impact. Factors leading to secondary damage may include inflammatory responses, raised intracranial pressure, and decreased cerebral blood flow or
ischemia

Question 9

General Medical Complications

Answer 9

1st wk symptoms following mild TBI: dizziness, fatigue, memory difficulties, headaches
* Coma
* Hydrocephalus -Buildup of fluid in the cavities ands pressure
-Seizures
-Deep vein thrombosis following TBI is up to 54%
-Dysautonomia - severe TBI

Question 10

TBI Etiology

Answer 10

 Falls (most common)
 Motor vehicle accidents (most common severe TBI)
 Violence
* TBI ER visits most common below the age 5 and > age 85
* 61% of vehicle accidents involved males
* 1/3 to 1/2 intoxicated time of injury

Question 11

Diagnostic Testing

Answer 11

• Glasgow Coma Scale (GCS)
• Disability Rating Scale (DRS) – expanded on GCS info; good validity &
  reliability
• Rancho Los Amigos Scale, aka Levels of Cognitive Functioning
• CT scan & MRI

Question 12

TBI

Answer 12

• Physical
• Cognitive
• Communicative
• Neurobehavioral changes.
  -all different
  -Impact all Occupational performance

Question 13

Diagnostic Testing: Glasgow Coma Scale

Answer 13

Rating of:
* Eye opening,
* Motor responses, &
* Verbal responses
*To assess level of consciousness
*Used to quantify severity of brain injury & predict outcome
*Beset known & widely accepted scale of coma

Question 14

Cerebellar or intention tremors

Answer 14

-slow tremors that occur at the end of purposeful movement associated with ataxia,hypotonia, and balance disorders
-occur in trunk-
-4-6 sec

Question 15

-Resting tremors

Answer 15

Correlated with striatal damage and involve a pill-rolling movement at rest, occurring at a
similar rate

Question 16

Essential tremors

Answer 16

Slow constant tremors that typically affect more distal musculature, occur at a frequency of 8 to 12 per second, and increase with anxiety and maintained positions.

Question 17

Physiologic tremor

Answer 17

Present in every person and occurs at the same rate as essential tremor. It can be exacerbated by fatigue, stress, strong emotions, caffeine, and fever

Question 18

Cognitive Deficits

Answer 18

Among the most common, difficult, and long-lasting consequences, both adults and children.
* Retrograde and anterograde amnesia affect learning and cognitive rehabilitation.
* Retrograde amnesia, or memory loss prior to the accident,
* Anterograde amnesia, defined as the inability to learn new long-term
declarative information, is typically the last to improve.
* Motor learning is often functional during rehab process, despite memory loss
 Sustained attention and concentration
 Initiation & termination of activities
 Reasoning skills
 Executive functions & abstract thought
 Generalization
 Processing of information or comprehension
 Memory
 Visual (more common than visual perceptual deficits)
 Visual perceptual
 Self-monitoring and impulse control
-Safety awareness & judgment

Question 19

Psychosocial Deficits

Answer 19

 Perseveration
 Poor control of temper
 Aggression / irritability
 Apathy
 Depression
 Suicide
 PTSD

Question 20

Neurobehavioral Status

Answer 20

 Natural part of the recovery process
 Occur as a result of cognitive deficits interacting with brain dysfunction
 Typically seen whether it’s a mild, mod, or severe injury
 Includes:
-Impulsivity, irritability, poor control of temper, aggression, disinhibition, &
apathy
 Comprehensive behavior management program

Question 21

Cranial Nerve Dysfunction

Answer 21

 Absent pupillary reflex to light (CN III)
 Damage to midbrain
 Fixed or dilated pupil
 Pressure on the oculomotor nerve,
 Homonymous hemianopsia (CN II)
 Loss of sense of smell (Anosmia) (CN I)
 High-frequency hearing loss (CN VIII)
 Glossopharyngeal (IX) / vagus nerves (X)
 Dysfunction results in an absent or depressed gag reflex
 Dysphagia

Question 22

Visual Deficits from Optic Nerve II

Answer 22

 Visual rather than perceptual deficits
 Diplopia
 Problems with accommodation and convergence
 Visual field deficits
 Saccadic dysfunction
 Strabismus
 Condition in which the eyes do not properly align with each other when looking at an object
 Binocular or oculomotor deficits
 Refractive deficits
 Eyelid movement dysfunction
 Nystagmus
 Involuntary, rapid, rhythmic movement (horizontal, vertical, rotatory, or mixed, i.e., two
types) of the eyeball.
 Ptosis
 Drooping of the upper eyelid due to paralysis or disease

Question 23

Precautions

Answer 23

 Acute stages: intracranial pressure (ICP) must be monitored
 In the later stages, fall precautions to avoid further injury and supervision to assist in daily tasks.
 Note that there are likely other injuries present

Question 24

TBI Course and Prognosis

Answer 24

• Highly individual; factors include: age, gender, preinjury hx
• May reduce life span by 9 yrs
• Prognosis factors: trauma score, GCS score, biomarkers, presence / absence of hypoxia, length of coma, duration of amnesia
• Abuse associated with mortality of children < 1yr old

Question 25

Acute Phase medical management

Answer 25

Focus: preservation of life, prevention  Endotracheal tube  CAT scan  Possible surgical decompression  Indwelling urinary catheter  Close attention to skin integrity is essential,  Nasogastric tube  About one-third of those hospitalized with TBI aspirate food  Respiratory therapy  Prophylactic medication

Question 26

Rehabilitation:

Answer 26

-in the acute phase may begin as soon as neurological stability is achieved  Prevent joint deformity  Provide graded sensory stimulation  Maximize the person’s function  Minimize additional physical or psychosocial impairments  Prevent complications  Accommodation, compensatory techniques when max potential achieved  Caregiver Education

Question 27

Tumors of CNS Primary site vs Secondary site

Answer 27

Site of origin, even when the tumor has spread to other parts of the body or brain (secondary site)

Question 28

Malignant tumors

Answer 28

 Abnormal cells that multiply rapidly  Metastasize  Brain tumors rarely metastasize beyond the brain

Question 29

Benign tumors

Answer 29

 Not cancerous, does not spread  May become life threatening, continue cell growth = increased pressure on structures

Question 30

Tumors of the CNS Etiology

Answer 30

* Brain tumors = chemical changes in brain cells * Most brain tumors develop for no apparent reason * High levels of ionizing radiation * Exposure to neurogenic / carcinogenic substances

Question 31

Tumors of the CNS Signs and Symptoms

Answer 31

* Up to 50% experience sleep disturbance * Fatigue (most significant problem) * Headaches * Depression / anxiety / mood changes * Pain * Cognitive Dysfunction

Question 32

Tumors of the CNS Medical / Surgical Management

Answer 32

* Surgery * Chemotherapy * Radiation therapy * Stereotactic radiosurgery (precision) * Steroids / anti-epileptic drugs * Reduce brain edema and ameliorate the person’s symptoms * Complementary / alternative therapies * Meant to treat symptoms

Question 33

Anterograde amnesia

Answer 33

memory loss that occurs when you can’t form new memories.

Question 34

Contrecoup injury

Answer 34

occurs at sites remote to the actual impact site on the head.

Question 35

Decerebrate rigidity Decorticate rigidity

Answer 35

-involuntary extensor positioning of the arms, flexion of the hands, with knee extension and plantar flexion when stimulated as a result of a midbrain lesion. - abnormal posturing characterized by -Stiffness with bent arms/straight/clenched -Sign of severe brain damage.

Question 36

Dysautonomia

Question 37

Heterotopic ossification

Answer 37

disrupts ANS

Question 38

Metastasis

Answer 38

development of secondary malignant growths at a distance from a primary site of cancer

Question 39

Hydrocephalus

Answer 39

accumulation of cerebrospinal fluid occurs within the brain. This typically causes increased pressure inside the skull

Question 40

Nystagmus

Answer 40

condition where your eyes make rapid, repetitive, uncontrolled movements.

Question 41

Retrograde amnesia

Answer 41

form of memory loss that affects the ability to access memories formed before the onset of amnesia.