Lecture 6: Traumatic Brain Injury: Chapter 15 + part of chapter 16 epilepsy Flashcards
1
Q
What is a traumatic brain injury? Give 3 aspects
A
- The most common type of acquired brain injury (ABI) among people under age 50
- The injury is caused by violence or a mechanical force that affects the skull from the outside
- Clinically very diverse outcomes
2
Q
What is almost always a temporary disorder for those who suffer TBI? What does it indicate about the severity of the injury?
A
A temporary disorder of consciousness. The severity and duration provide an indication of the severity of the brain injury
3
Q
Give 2 types of acquired brain injuries (ABI)
A
- TBI
- Stroke
4
Q
What can you say about the epidemiology of TBI in age group 25 and younger?
A
TBI is the most common cause of brain damage in children and young adults
5
Q
How can you explain the increase in TBI in elderly?
A
Due to ageing population and higher survival rates
6
Q
Why do men sustain TBIs twice as frequently as women?
A
More risk behavior
7
Q
What are the 2 main causes of TBI?
A
- Falls
- Transportation-related injuries
8
Q
What are risk factors for TBI? (4)
A
- Age <24 and elderly
- Men
- Low SES, low education, unemployment
- Alcohol/substance use
9
Q
What are 3 things associated with long-term mortality of TBI?
A
- Age
- Lack of independence
- Tube feeding
10
Q
How does TBI influence the development of children under 7? And after 9?
A
7: development of TBI kid is similar to peers, but eventually flattens
9: development is closer to the level of functioning in peers without TBI
11
Q
What is the link between TBI and later illnesses?
A
Increased risk of getting dementia or a psychiatric disorder
12
Q
What are the 3 types of amnesia surrounding a TBI event?
A
- Retrograde: time prior to event
- Anterograde: no storage new info
- Post-traumatic: disturbed encoding and loss of memory at the time of the TBI event
13
Q
Why are epidemiological numbers of TBI incidences probably much lower than the actual number?
A
Many patients with a mild TBI aren’t hospitalized and therefore not registered
14
Q
What is the Boxer’s syndrome?
A
Syndrome in adults. The adults show a delayed effect of the injury, just like kids that get TBI before age 7
15
Q
What are the 2 mechanisms that result in the pathophysiology of TBI?
A
- Immediate damage from biomechanical forces
- Secondary damage caused by complications
16
Q
What is the Glasgow Coma Scale (GCS)? What is the EMV score?
A
Used to test spontaneous reaction of a patient to being addressed and can be used to map severity of impairments of consciousness
- Active opening eyes (E)
- Motor reaction (M)
- Verbal reaction (V)
17
Q
What is the relation between post traumatic amnesia (PTA) and the Glasgow Coma Scale (GCS)?
A
Duration of PTA correlates with GCS
18
Q
What are 3 aspects of post traumatic amnesia (PTA)?
A
- Predictive of long-term cognitive status and neuroimaging findings
- Determines presence and severity of TBI
- Long PTA –> severe injury
19
Q
What is another word for a mild TBI? How is it classified?
A
Concussion
No agreed classification. Controversy over definition and symptom duration
20
Q
Which tool is most predictive of long-term cognitive status following a TBI?
A
Duration of post traumatic amnesia
21
Q
When would you use CT or MRI for TBI?
A
CT: used in acute stages for their cost-effectiveness and availability
MRI: preferable in subacute/chronic stages for its predictive power
22
Q
How is EEG used in TBI?
A
Used for damage assessment
23
Q
How do the effects of TBI develop?
A
Over various timeframes from minutes to years. Recovery is often months
24
Q
What are the 2 types of head injuries?
A
- Penetrating injuries (PHI)
- Closed injuries (CHI)
25
What is the most common cause of penetrating injuries?
Gunshot wounds
26
What is the difference in mortality between penetrating and closed head injuries?
PHI: 6,6 times more mortality than CHI
27
What are the 3 types of penetrating head injuries?
1. Objects embedded in the head
2. Entry and exit wounds
3. Tagential injury: bone fragments often driven into the brain
28
What are 4 important aspects of neuropathology of penetrating head injuries?
1. Penetration location
2. Trajectory
3. Fragment scattering
4. Relation to behavioral outcome
29
What are 3 factors affecting the outcome of penetrating head injuries?
1. Speed: fast --> more damage
2. Wobble/straight
3. Malleability/plasticity
30
What are 4 consequences of extensive blood loss?
1. Hypotension: low blood pressure
2. Hypovolemia: less blood circulating in the body
3. Local/general cerebral oedema
4. Intracranial haematomas
31
What is especially likely to be impaired regardless of injury location?
Short-term memory
32
What is the progression of recovery of TBI?
First year: rapid gains
After that slow gains, mainly due to learned accommodations
33
Give an example of cognitive impairments that can improve and one that persists
Improve: language disorders
Persist: visual blind spots
34
What are closed head injuries and what are common causes?
Non-penetrating injuries, such as falls, blunt head trauma etc.
35
How does the damage in closed brain injuries occur?
It occurs in stages: initial impact followed by secondary physiological process
36
Closed head injuries typically result in....
Generalized brain injuries
37
Why are biomechanics important for closed head injuries?
Crucial in determining primary and secondary effects
38
What 2 things result in diffuse axonal injury and what is that?
Frontal or lateral impact (not with twisting the head)
It causes cell bodies of neurons to be torn away from their axons
39
What are 3 consequences of shearing of the corpus callosum?
1. Atrophy and corresponding neuropsychological dysfunction
2. Diminished speed of processing due to hemisphere integration issues
3. Damage extends far from focal site due to the disruption and inflammation
40
What is hemosiderin?
An iron-laden residue that shows in MRI for subacute and chronic injuries
41
What is a coup and contrecoup lesion?
When a blow to the front of the head results in contrecoup lesions at the back, because of mechanical forces that squish the back of the brain against the skull
Other way around also possible
42
What is the primary damage of TBI?
Direct damage in head caused by violence
--> Open
---> Closed
43
What is dai (diffuse axonal injury)?
Damage that occurs after a rotating force. It's usually combined with microhemorrhage and ultimately axonal degeneration
44
What are contusions and how are they created?
Bruises of gray matter because of linear movements
Can lead to coup-contrecoup lesions
45
What is secondary brain injury? What are 3 types?
Disorders caused by the damage elsewhere in the body
1. Hypoxia: oxygen deprivation
2. Ischemia
3. Necrosis of tissue
4. Oedema (brain swelling)
46
What is traumatic sub-arachnoid hemorrhage (TSAH)? Name 3 aspects
1. Bleeding in subarachnoid space as a secondary complication after TBI.
2. Often in moderate and severe brain injury combined with local bruises
3. Associated with poorer and slower cognitive recovery
47
What is pyrexia?
Fever
48
What are the 3 phases of TBI?
1. Acute
2. Subacute
3. Chronic
49
What often happens after a coma?
Post traumatic amnesia: disorientation and unable to encode info in the brain
50
What is the percentage of severity of brain injury for mild-moderate-severe injuries?
Mild: 80%
moderate: 10%
Severe: 5-10%
51
What is meant with islands of memory?
Short periods of clarity when a person is experiencing PTA (post traumatic amnesia)
52
What is mental fatigue?
The patient is required to make an extra mental effort in situations that used to require less mental energy
53
What is considered to be at the core of many cognitive problems that TBI patients experience?
Mental slowness, because many situations in everyday life require rapid information processing
54
What are 5 domains where patients frequently have cognitive disorders after TBI?
1. Speed of processing
2. Attention
3. Memory
4. Executive function
5. Social cognition
55
What are 3 typical attentional disorders?
1. Focusing attention when distracted
2. Dividing attention under time pressure
3. Sustaining attention over time
56
Which type of amnesia fits with problems with consolidation? Which type of amnesia fits with affected learning?
Consolidation: retrograde and PTA
Learning: anterograde
57
What is dysarthria?
Difficutly controlling speech muscles
58
What is a common language disorder after TBI and where would that damage be located?
Dysarthria: damage right hemisphere
Also subtle language disorders such as naming, word finding, fluency
59
How do TBI patients often change in character?
More self-centred, emotionally flat, less empathy
60
Give some examples of disinhibited behavior
Vulgar comments, making jokes, fits of anger or sexual disinhibition
61
What are 5 sensory alterations in secondary damage?
1. Anosmia: impaired smell
2. Visual impairments
3. Dizziness/balance problems
4. Hearing defects
5. Hypersensitivity
62
What are 4 criteria of mild TBI of the American Congress of Rehabilitation Medicine (ACRM)?
1. Loss of consciousness (LOC) for 30min or less
2. PTA not longer than 24 h
3. Alteration in mental state at time of accident (dazed, disoriented, confused)
4. Focal/central neurological deficits that may pass or not (transient)
63
What are 2 causes of neuropathology in mild TBI's?
1. Mechanical forces and cellular changes (especially affect axons)
2. Physiological disruptions (inflammatory reactions in white matter)
64
What is post-concussion syndrome/disorder? Which model explains these complaints?
When complaints of a mild TBI last longer than 3 months
Biopsychosocial model
65
What is the biopsychosocial model?
Neuropsychological injury interacts with vulnerable personality traits (coping), environmental demands (stress) and emotional reactions (fear)
This can explain the post-concussion syndrome
66
Why can cognitive issues manifest days or weeks after an accident?
Due to other injuries or medication
67
How fast do people with mild TBI recover? Which symptoms may persist (3)?
Hours to weeks
1. Headaches
2. Fatigue
3. Dizziness
68
What reveals subtle long term mild TBI affects?
Reaction time and neurophysiological measures
69
What are 3 risk factors for worse outcomes of TBI?
1. Age >40
2. Pre-existing conditions
3. History of brain illness
70
Why are predictions of outcomes of mild TBI hard?
The interactions between cognitive, emotional and behavioral factors
71
What is cogniform disorder?
When there are excessive cognitive complaints or unexpectedly poor performance in relation to the injury (often mild TBI)
72
How are symptoms maintained or worsened after TBI? (2)
1. Stress / depressive reactions at the time of the accident
2. Premorbid personality or psychiatric disorders
73
What does enlargement of ventricles indicate?
Cell loss in the brain
74
How do whiplashes occur and what most often causes them?
Sudden swing of the head backward and then forward
In traffic accidents
75
What are 4 typical physical symptoms of a whiplash?
1. Neck pain
2. Occipital headache
3. Back pain
4. Upper limb pain
76
Why do whiplash patients often don't meet criteria for concussion or mild TBI?
In a whiplash there is often no actual brain injury
77
What are 4 psychological symptoms of whiplash?
1. Impact on sleep
2. Attention issues
3. Memory issues
4. Fatigue, dysphoria
78
What are 3 early symptoms of post mild TBI? How do they evolve over time?
Communication, perceptual or conceptual disturbances
Symptoms clear up for most, but subtle defects may remain
79
Whiplash associated disorders can be hard to distinguish from TBI based complaints. How can a hospital make the distinguishment?
Using imaging techniques: that reveals there is no clear damage to the brain in the case of whiplash
80
What is the difference between whiplash and post-concussion syndrome?
Whiplash: no altered consciousness and pain has a central role
81
What is dysphoria?
A state of unease and dissatisfaction
82
What percentage of people with whiplash also get depression?
35%
83
What are 4 types of memory impairments in TBI patients?
1. Remote memory
2. Retrograde amnesia
3. Post traumatic amnesia (PTA)
4. Anterograde amnesia
84
What is remote memory?
Long-term memory of events happening earlier in your life is partially impaired after TBI
85
What are 2 groups of patients with persistent complaints after mild TBI?
1. Initially smooth recovery with limited attention to the consequences of their injury. After resuming former activities, some symptoms remain problematic, but the connection to the brain injury isn't made
2. Patients are preoccupied with consequences of brain injury and have an excessive number of cognitive and physical complaints that are disproportional to the severity of the injury
86
What is malingering?
Diagnosis when there is a suspicion of conscious and intentional exaggeration or simulation of symptoms with the purpose of external gain
87
How fast do people recover from whiplash? Which percentage has the chronic post-whiplash trauma after that?
Recovery within 6 weeks
20% have chronic post whiplash trauma
