TBI and Concussion

Question 1

Traumatic Brain Injury (TBI)

Answer 1

TBI is an insult to the brain from an external mechanical force, possibly
leading to permanent or temporary impairment of cognitive, physical, and
psychosocial functions, with an associated altered state of consciousness.

Question 2

The Head Injury Interdisciplinary Special Interest Group of the American
Congress of Rehabilitation Medicine defines mild head injury as “a
traumatically induced physiologic disruption of brain function, as manifested
by one of the following:

Answer 2

○ Any period of loss of consciousness (LOC),
○ Any loss of memory for events immediately before or after the accident,
○ Any alteration in mental state at the time of the accident,
○ Focal neurologic deficits, which may or may not be transient.”

Question 3

Initial assessment of a patient who has suffered a traumatic brain
injury involves rapid determination of the ____

Answer 3

Glasgow Coma Score.

Question 4

Within the first 48 hours, usually at the 30-minute mark, the GCS
defines the severity of TBI with the following parameters:

Answer 4

○ Severe TBI: 3-8
○ Moderate TBI: 9-12
○ Mild TBI: 13-15

Question 5

Other criteria for defining Mild TBI include:

Answer 5

○ GCS score greater than 12
○ No abnormalities on CT scan
○ No operative lesions
○ Length of hospital stay less than 48 hrs

Question 6

The following criteria define Moderate TBI:

Answer 6

○ Length of stay at least 48 hours
○ GCS score of 9-12 (could be higher)
○ Operative intracranial lesion
○ Abnormal CT scan findings

Question 7

Traumatic Brain Injury (TBI) Epidemiology

Answer 7

○ Males are twice as likely to sustain a TBI than females.
○ The peak age of TBI is between 15 and 30 years of age
○ Motor Vehicle Accidents (MVAs) account for 50% of all TBIs

Question 8

Primary vs secondary injury

Answer 8

○ Primary injury- Occurs at the moment of the trauma
○ Secondary injury- Occurs shortly after the trauma and produces effects
that may continue for a long time

Question 9

Examples of Primary Injuries:

Answer 9

○ Skull fractures
○ Auditory/vestibular dysfunction
○ Intracranial hemorrhages
○ Coup/contrecoup contusions
○ Concussion
○ Diffuse axonal injury

Question 9

Examples of secondary injuries include:

Answer 9

■ Increased excitatory amino acids
■ Increased intracranial pressure (ICP)
■ Cerebral edema
■ Hydrocephalus
■ Brain herniation
■ Chronic Traumatic Encephalopathy (CTE)

Question 9

Traumatic Brain Injury (TBI) acute management

Answer 9

○ Normal Saline for IVFs, just enough to keep the patient euvolemic.
○ Allow the BP to be high. Don’t aggressively treat hypertension.
○ Consider hyperventilating the patient (if they are intubated).
○ Consider Anticonvulsants, as seizures can occur in 5-15% of TBI Pts.
○ Consider small or brief doses of Hypertonic Saline (NaCl 3%) or Mannitol to help reduce ICP by “dehydrating” the brain by osmosis.
○ Raise the head of bed to 30 degrees
○ Many TBI patients will eventually require some form of surgical intervention, whether it relates to monitoring ICP, evacuating
hematomas, providing room to swell, or placing CSF drains.

Question 10

Concussion

Answer 10

● A mild traumatic brain injury (MTBI) is also known as a Concussion.
● A broader definition is a traumatically induced
physiologic disruption in brain function that is manifested by LOC, memory loss, alteration
of mental status or personality, or focal neurologic deficits.

Question 11

Concussion pathophysiology

Answer 11

○ Concussion is caused by injury to
the deep structures of the brain,
leading to widespread neurologic
dysfunction that can result in a
wide array of signs or symptoms,
including impaired consciousness,
nausea, headaches, etc.

Question 12

Considered a mild form of diffuse
axonal injury

Answer 12

Concussion

Question 13

Concussion presentation

Answer 13

○ Confusion, blank expression, or blunted affect
○ Delayed responses and emotional changes
○ Headaches
○ Dizziness
○ Visual disturbances
○ Amnesia
○ Signs of increased ICP
■ Persistent vomiting
■ Worsening headache

Question 14

Concussion diagnosis

Answer 14

■ Non-contrast CT Head-
● Imaging study of choice, although it will be negative for a
patient with a true concussion (MTBI)
■ MRI Brain-
● Can/should be ordered for those with prolonged symptoms
(more than 7 days) or when late symptoms arise
■ Neuropsychological testing-
● Recommended for most with significant injury

Question 15

Get a Head CT in patients with concussion and any of the following:

Answer 15

■ GCS score less than 15
■ Focal neurologic deficit
■ Seizure
■ Coagulopathy/anticoagulated
■ Aged 65 or older
■ Skull fracture
■ Persistent headache or vomiting
■ Retrograde amnesia exceeding 30 minutes
■ Intoxication
■ Soft tissue injury of the head or neck

Question 16

Screening tool for pediatric patients with head injury

Answer 16

(PECARN) Head CT Rule

Question 17

Concussion management

Answer 17

○ Most patients who suffer a concussion recover in 48-72 hours.
○ Headaches may continue on and off, usually fading within 2-4 weeks.
○ The most important part of treatment is cognitive and physical rest from any significant activity for at least a couple of days
○ Athletes should be kept from participating in contact sports, and may return to play when they meet the following criteria:
■ Complete clearing of all symptoms
■ Complete return of all memory and concentration
■ No symptoms with provocation tests (jogging, sprinting, sit-ups, or push-ups- elevation in BP and HR)
○ There is no scientific evidence that any medications improve
recovery after suffering a concussion.

Question 18

Post-Concussion Syndrome

Answer 18

● A sequela of a minor head injury (MTBI).
○ An area of debate among researchers and
neurologists regarding the definition
○ Poorly understood etiology
● Postconcussive syndrome consists of prolonged symptoms that are related to the initial head injury.
● The severity of the concussion does not necessarily predict who will experience prolonged symptoms.
● The literature suggests that 29-90% of patients experience postconcussive symptoms after MTBI.

Question 19

Risk factors for prolonged symptoms after a concussion:

Answer 19

○ Multiple concussions
○ Increasing age
○ Lower education level
○ Female > Male
○ Poor coping skills, mental illness (more on this
later)

Question 20

Post-Concussion Syndrome pathophysiology

Answer 20

○ Two main theories: Neurogenic and Psychological.
Post-Concussion Syndrome
○ Neurogenic Factors
■ Shearing forces to neurons
■ Proliferation of phosphorylated tau
proteins (pTau) as a result of damage
■ Slower neurological recovery
following successive mTBIs
■ Chronic traumatic encephalopathy,
such as with football players

○ Psychological Factors
■ Inability to cope
● “All or nothing” delusions
■ Poor perceptions of TBI
■ Comorbid psychiatric
disorders (particularly PTSD)
■ High stress
■ Malingering

Question 21

Clinical Presentation of Post-Concussion Syndrome

Answer 21

○ Headache is the most common prolonged symptom.
○ Brainstem or cranial nerve signs or symptoms.
■ Dizziness (the second most common symptom), vertigo, nausea, tinnitus, blurry vision, hearing loss, diplopia, diminished sense of taste and smell, sensitivity to noise/light
○ Psychological and neurovegetative problems.
■ Anxiety, irritability, depression, sleep disturbance, change in appetite, decreased libido, fatigue, personality changes
○ Cognitive impairment, such as memory or attention deficits

Question 22

Post-Concussion Syndrome diagnosis

Answer 22

■ Generally when symptoms persist for 4 weeks
○ While there are DSM-5 criteria, this leaves out many individuals who have prolonged symptoms of concussion
○ Biomarkers such as pTau or S-100B are generally poor for diagnosing PCS
○ Vestibular oculomotor screening (VOMS) can play a role in both diagnosis and follow-up

Question 23

Post-Concussion Syndrome Imaging

Answer 23

○ CT scan can be used to determine the presence of intracranial abnormalities and skull fractures if history and physical exam suggest new focal deficit or worsening symptoms of increased ICP

Question 24

Post-Concussion Syndrome management

Answer 24

○ Patients with a presentation consistent with post-concussive syndrome require thorough physical examination.
○ There is no medication that has been shown to prevent or hasten the resolution of postconcussion syndrome.
○ Providing extensive patient education and reassurance has been shown to hasten subjective recovery
○ Supportive therapy is the mainstay of management.
■ Non-narcotic analgesics (e.g. NSAIDs)
■ Antiemetics (e.g. Ondansetron [Zofran])
■ Sleep, healthy diet, hydration