TBI/Concussion

Question 1

The 2017 consensus statement lists the following signs and symptoms of concussion:

Answer 1

Symptoms—somatic (eg, headache), cognitive (eg, feeling like in a fog) and/or emotional symptoms (eg, lability)

Physical signs (eg, loss of consciousness (LOC) Although published findings in concussion describe LOC associated with specific, early cognitive deficits, it has not been noted as a measure of injury severity.77 78, amnesia); A variety of immediate motor phenomena (eg, tonic posturing) or convulsive movements may accompany a concussion. Although dramatic, these clinical features are generally benign and require no specific management beyond the standard treatment of the underlying concussive injury.

Balance impairment (eg, gait unsteadiness)

Behavioral changes (eg, irritability)

Cognitive impairment (eg, slowed reaction times)

Sleep/wake disturbance (eg, somnolence, drowsiness).

Question 2

However, this list is not exhaustive and the following additional signs and symptoms have been cited elsewhere in the literature

Answer 2

Chronic headaches,
Dizziness and vertigo
Difficulty concentrating
Word-finding problems
Depression
Impulsiveness

Question 3

Diagnoses of concussion

Answer 3

Head trauma recipients are initially assessed to exclude a more severe emergency such as an intracranial hemorrhage. This includes the “ABCs” (airway, breathing, circulation) and stabilization of the cervical spine which is assumed to be injured in any athlete who is found to be unconscious after head or neck injury. Indications that screening for more serious injury is needed include worsening of symptoms such as headaches, persistent vomiting,[51] increasing disorientation or a deteriorating level of consciousness,[52] seizures, and unequal pupil size.

Question 4

What is primary and secondary brain injury?

Answer 4

Primary brain injury refers to the sudden and profound injury to the brain that is considered to be more or less complete at the time of impact. This happens at the time of the car accident, gunshot wound, or fall.

Secondary brain injury refers to the changes that evolve over a period of hours to days after the primary brain injury. It includes an entire series of steps or stages of cellular, chemical, tissue, or blood vessel changes in the brain that contribute to further destruction of brain tissue.

Question 5

Signs and symptoms (TBI)

Answer 5

symptoms of mild TBI include headache, vomiting, nausea, lack of motor coordination, dizziness, difficulty balancing,[36] lightheadedness, blurred vision or tired eyes, ringing in the ears, bad taste in the mouth, fatigue or lethargy, and changes in sleep patterns.[35] Cognitive and emotional symptoms include behavioral or mood changes, confusion, and trouble with memory, concentration, attention, or thinking.[35] Mild TBI symptoms may also be present in moderate and severe injuries.[35]

A person with a moderate or severe TBI may have a headache that does not go away, repeated vomiting or nausea, convulsions, an inability to awaken, dilation of one or both pupils, slurred speech, aphasia (word-finding difficulties), dysarthria (muscle weakness that causes disordered speech), weakness or numbness in the limbs, loss of coordination, confusion, restlessness, or agitation.[35] Common long-term symptoms of moderate to severe TBI are changes in appropriate social behavior, deficits in social judgment, and cognitive changes, especially problems with sustained attention, processing speed, and executive functioning.[28][37][38][39][40] Alexithymia, a deficiency in identifying, understanding, processing, and describing emotions occurs in 60.9% of individuals with TBI.[41] Cognitive and social deficits have long-term consequences for the daily lives of people with moderate to severe TBI, but can be improved with appropriate rehabilitation.[40][42][43][44]

Question 6

What happens when ICP rises

Answer 6

When the pressure within the skull (intracranial pressure, abbreviated ICP) rises too high, it can be deadly.[45] Signs of increased ICP include decreasing level of consciousness, paralysis or weakness on one side of the body, and a blown pupil, one that fails to constrict in response to light or is slow to do so.[45] Cushing’s triad, a slow heart rate with high blood pressure and respiratory depression is a classic manifestation of significantly raised ICP.[4] Anisocoria, unequal pupil size, is another sign of serious TBI.[33] Abnormal posturing, a characteristic positioning of the limbs caused by severe diffuse injury or high ICP, is an ominous sign.[4]

Question 7

The 2 most common causes of TBI are:

Answer 7

Falls

Road Traffic Accident [RTA] This includes vehicle collisions, pedestrians being hit by a vehicle, vehicle-cyclist and car-motorcyclist collisions as well as bicycle and motorbike crashes which do not involve another vehicle.

Generally there is both focal and diffuse axonal damage.

Mechanical brain injury occurs due to axonal shearing, contusion and brain oedema.

Question 8

Delayed non-mechanical Damage

Answer 8

AKA Secondary Damage. Non-mechanical brain injury is caused by ischaemic[4], cytotoxic and inflammatory processes.

One of the most significant factors is the excessive release of glutamate and aspartate, which alter cell wall permeability which ultimately leads to destruction of axons[5].

Question 9

Clinical Presentation (TBI)

Answer 9

The presentation depends on the areas of the brain which have been damaged.

Spasticity if one of the early signs of TBI. This often develops a week after the injury. Symptoms include hypertonicity and spasm of the affected muscles and an increase in deep tendon reflexes; it’s severity can range from mild stiffness of the muscles to severe (and painful) muscle spasms.