Brain injury management Flashcards
What are the risk factors for TBI?
Male (1.5-2.5x)
Age 15-24 or 75+
Alcohol
Risk taking behaviour
Lower socioeconomic status
Psychiatric history
What are the types of TBI?
Direct impact - damage to tissue underlying the impact area
Coup-contre coup - usually after hitting stationary object (generally contre coup is worse)
Acceleration-deceleration - shearing forces cause diffuse axonal injury (road accidents)
Blast injury - damage from shockwave
What are the two types of cerebral hypoxia?
Hypoxic brain injury - due to loss of oxygen supply
Hypoxic-ischaemic injury - due to compromise of blood supply (cardiac arrest/respiratory depression)
Brain scans may look normal in the first few days, over time damage will arise
What areas of the brain are affected most by hypoxia?
Basal ganglia
Thalami
Highly metabolic areas
Worsened by antipsychotics or alcohol withdrawal
What factors affect the recovery in hypoxia?
Duration of hypoxia
Speed of emergency care delivery
Pre existing health status
What is a contusion?
Mix of cortical necrosis and haemorrhage
Where are contusions most common?
Orbital PFC
Medial PFC
temporal pole
Occipital contre coup
What are the pathological outcomes of DAI?
Axonal tear
Myelin resorption
Retraction ball formation
What GCS score indicates severe TBI?
8 or less (comatose)
What is the application of GCS?
Useful in acute scenario
Not a reliable indicator of prognosis
What are symptoms of mild TBI?
Confusion, disorientation
Altered mental state
Headache
Transient loss of function
What is the definition of mild TBI/concussion?
Immediate transient alteration or loss of consciousness after force to the head
How might mild TBI be treated acutely?
Anxiolytics or analgesics
May not need hospital admission
How might severe TBI be treated acutely?
Ventilation and life support
Neurosurgical intervention (eg evacuation of haematoma)
What are the psychiatric consequences of moderate to severe TBI?
25-50% of survivors
Confusion and disorientation
Memory impairment
Dysexecutive syndrome
Affective outbursts: emotional lability
Chronic irritability
Epileptic episodes
Hallucinatory episodes
Paranoia
Intellectual impairment
How long might post traumatic amnesia last?
Minutes to weeks
(Onset might be delayed, such as in extradural haemorrhage)
What is the watershed for PTA and memory improvement?
6 weeks
How does PTA link to long term outcome?
1hr - return to work within a month
More than 2 weeks - residual cognitive impairments
PTA explains 25-50% of outcome
What is the last function to return usually in patients that fully recover?
Anterograde amnesia
What are indicators of severity of head injury?
GVS
Duration of loss of consciousness
Duration of PTA
Delirium
Neurological signs and symptoms
Skull fracture or imaging abnormalities
Blood in CSF
What percentage of people suffer mood and anxiety disorders after brain injury?
20-30% in the first year (particularly in left frontal lobe damage)
Anxiety - 10-15%
PTSD - 10-30% (less common if PTA was 1hr+)
How does psychosis typically present post-TBI?
Much less common
Occurs in predisposed individuals
May interact with cognitive deficits (losing things may fuel persecutory delusions)
Confusional states and confabulation are not strictly psychosis
What are the risk factors for suicide?
3-4x more common than general population
Risk factors for TBI
Alcohol
Substance use
Male
Risk taking behaviour
Lower socioeconomic status
What is the prognosis for postconcussional syndrome?
50% better at 2 months
90% better at 12 months
What is the possible aetiology for postconcussional syndrome?
Pre morbid personality
Emotional factors
Possible damage to white matter tracts (diffusion tensor imaging)
Compensation/litigation?
How common is personality change/behavioural disturbance post brain injury?
~50% (10-70%)
Associated with long term changes, particularly with frontal lobe damage
What factors affect personality change?
Pre morbid
Cognitive status
Psychiatric illness
Personality disorder
Substance use
Post injury
Care/support
Neuro rehabilitation
Complicating effects of legal proceedings
How does personality change progress?
Seen in 30-60% of moderate- severe brain injury survivors
Fluctuates but persists over time
May need to be moved to specialist care
What are the pharmacological considerations in brain injury?
Start low go slow
Titrate cautiously and monitor for adverse effects
Sedating drugs may compromise cognitive/physical gains over time
Wean down meds over time and liaise with other services
What are early pharmacological interventions?
Reduction of agitation
Propranolol, amantadine, valproate, carbamazepine, antipsychotics
Don’t use: benzodiazepines, opiates, phenytoin, psychostimulants
What are longer term pharmacological interventions for brain injury?
Valproate and carbamazepine
Propranolol
Antidepressants may have use even outside of mood disorder
(Antipsychotics only for those with psychosis)
What non-pharmacological treatment is used post BI?
Physiotherapy
Psychology
Occupational therapy
Speech and language therapy
Social care and placement
What would be the work of a psychologist post brain injury?
Neuropsychological assessment
CBT
Cognitive training
Relaxation
Mindfulness
Anger management
Social skills training
What would be the work of OT post brain injury?
Real world skills
Task oriented
Shopping, cooking, household
Managing demands of life
What would be the work of a SaLT post brain injury?
Dysphasia
Dysphagia
Dysarthria
Communication problems, including style
What is the most extreme form of apathy?
Rare
Akinetic mutism
Associated with damage to ACC
How common is apathy in BI survivors?
10%
What treatments are used for apathy post BI?
Dopamine agonists (amantadine)
Psychostimulants (methylphenidate)
Some use of antidepressants but for depressed patients
What is cognition?
Mental process of knowing, including perception awareness reasoning and judgement
How do frontal lobe syndromes present?
Personality change
Orbitofrontal:
Disinhibition
Euphoria
Emotional lability
Poor judgement
Dorsolateral:
Loss of initiative, apathy
Slowing of thought and action
Inattention
Distractibility
Poor planning and judgement
Reduced verbal fluency
Brocas
How might parietal lobe syndromes present?
Cortical sensory loss
Astereognosis (recognition by touch)
Disorders of body schema
Anosognosia
Gerstmann syndrome
What are the features of Gerstmann syndrome?
Dyscalculia
Dysgraphia
Finger agnosia
R-L disorientation
How might temporal lobe syndromes present?
Auditory deficits
Sensory dysphasia (Wernicke’s)
Visual impairments (prosopagnosia)
Memory impairments
Personality change/psychosis (superstition/schizotypal)
How might occipital lobe syndromes present?
Cortical blindness
Homonymous hemianopia
Scotomata
Visual agnosia
Alexia without agraphia
What is the underlying mechanism of cerebellar cognitive affective syndrome?
Reciprocal connections between the cerebellum and cortical regions are disturbed by cerebellar damage
