Traumatic Brain Injury

Question 1

Moderate to severe traumatic brain injury (TBI)

Answer 1

results from damage to brain tissue caused by an external mechanical force, can include:
loss of consciousness
post-traumatic amnesia (PTA)
positive neuroimaging, or
objective neurological findings attributed to TBI on physical or mental status examination

Question 2

Uncomplicated mild traumatic brain injury (mTBI)

Answer 2

“concussion:

Involves a traumatically induced physiological disruption of brain function that results in a graded set of clinical symptoms that most often resolve spontaneously.

Alteration or loss of consciousness and other transient neurologic signs are typically used to define mTBI.

Question 3

Primary Injury examples of TBI

Answer 3

skull fracture
contusion
subarachnoid hemorrhage
mechanical injury to axons and blood vessels.

Because of the anatomical arrangement of the brain and skull, focal injury is most common in the frontal and temporal lobes.

Diffuse axonal injury tends to be most prominent at the gray–white matter junctions.

Question 4

Secondary Injury examples of TBI

Answer 4

Hypoxia
ischemia
swelling/edema
hypotension
mass lesions
increased intracranial pressure (ICP)
poor cerebral perfusion pressure.

Question 5

Risk factors for TBI based on age

Answer 5

0-7 years: falls or child abuse
15-24: motor vehicle related injuries
65+ falls

Question 6

Risk factors that increase the likelihood of persistent problems (>3 months post injury) after mTBI include:

Answer 6

• medical factors (prior neurological injury, recent/multiple mTBIs, chronic pain or medical conditions)
• demographic (female, less education)
• mental health (depression, substance use, misattribution bias)
• secondary gain (litigation, disability incentives)

Question 7

Rates of TBIs

Answer 7

mild: 70-80%
moderate: 20%
severe: 15-20%

Question 8

mTBI but with positive neuroimaging is called

Answer 8

complicated mTBI

Functional outcome after such injury tends to be similar to moderate TBI.

Question 9

Classification of TBI severity can be accomplished using a combination of various indicators:

Answer 9

Glasgow Coma Scale (GCS) score

Time to follow commands (TFC)

Length of PTA

*however, no universally accepted TBI classification system exists

Question 10

Recovery after moderate to severe TBI often takes more than

Answer 10

1 year

Question 11

Two general approaches to cognitive rehabilitation

Answer 11

restorative skills training - focus on treatments intended to reinforce or directly improve specific cognitive domains

compensatory skills training - teach patients strategies to compensate and adapt to cognitive impairments

computer- based cognitive rehabilitation has very limited utility in improving function. Instead, broad-based, real-world training in problem solving and compensatory techniques tends to be the most effective treatment.

Question 12

TBI neuropsychological expectations

Answer 12

“Hold tests” (vocabulary, information) are generally unaffected

Processing speed (most commonly impacted d/t impact on white matter integrity)

Complex attention problems (divided) - children who sustain moderate to severe TBI may develop secondary ADHD.

Possible visual spatial difficulties secondary to EF

Memory, again possible d/t EF - reduced processing speed, learning capacity, and organizational skills, thus leading to faulty encoding, storage, and retrieval.

Depression and anxiety are common following TBI

Question 13

Chronic Traumatic Encephalopathy (CTE)

Answer 13

a unique distribution of p-tau accumulates in the depths of the cortical sulci, which in turn is associated with severe behavioral, cognitive and mood changes in older adulthood.

BUT Recent comprehensive literature reviews suggest that the neuropathological changes described in CTE are not unique to that condition, and that a sizable percentage of persons who have such changes will not develop dementia or commit suicide.

Question 14

Glasgow Coma Scale (GCS)

Answer 14

A scale that assesses responsiveness in patients who have sustained brain injury.

There are three parameters: eye opening, motor response, and verbal response.

The scale ranges from 3 to 15, with scores of 8 or less indicating severe injury and scores over 13 associated with mild injuries.

It is common to use the term “complicated mild” with GCS over 13 in the context of positive acute neuroimaging findings.

In severe TBI, lower GCS (3 to 5) is clearly associated with increased mortality rates.

Question 15

What is the best predictor of TBI prognosis?

Answer 15

PTA

Question 16

Subdural hematoma (SDH)

Answer 16

Caused by rupture of bridging veins between sulci on the upper surface of the brain. In high-speed injuries, hematomas are commonly found in the frontal and anterior temporal lobes due to the skull and brain’s anatomical arrangement.

Question 17

The primary role for neuroimaging in the acute phase following moderate to severe TBI?

Answer 17

neurosurgical planning (e.g., epidural or subdural hematoma causing significant midline shift)

as opposed to determining severity, which is done with GCS, TFC, and PTA.

Question 18

Low stimulation protocols are commonly implemented during the acute phases of recovery following moderate to severe TBI primarily to

Answer 18

reduce the cerebral metabolic rate

Even when severely injured the brain will expend energy when exposed to external stimulation (e.g., noise, bright light, tactile stimuli).

Low stimulation protocols also result in less sensory processing demands on the individual and thus are primarily employed to reduce the cerebral metabolic rate.

Question 19

Following mild TBI in children and adults, postconcussive symptoms persisting beyond a month have been found to benefit most from interventions aimed at…?

Answer 19

physical exercise - that does not worsen symptoms reduced postconcussive symptoms in “active rehabilitation” models.

Question 20

Which combination of factors would generally have the most impact on long-term outcome following traumatic brain injury in a pediatric patient?

Answer 20

injury severity and psychosocial support

Question 21

Compared to acceleration-deceleration brain injury, penetrating brain injury carries a higher risk for…?

Answer 21

seizure and infection

Penetrating head trauma typically results in blood-brain barrier compromise and the introduction of foreign matter into brain parenchyma (e.g., bullet fragments, bone shards, hair). These factors significantly increase the risk for infection and seizure relative to nonpenetrating injuries.

Question 22

What are the most common physical complaints following moderate to severe traumatic brain injury in adults?

Answer 22

fatigue and sleep disturbances

Question 23

What symptoms tend to contribute to poorer community re-entry in adults with severe TBI?

Answer 23

personality changes and behavioral problem

Question 24

What cognitive domains will most likely generalize to real-world tasks using direct retraining techniques?

Answer 24

Attention, visual scanning, and spatial organization

Question 25

Brain injury during which school years confers the most risk for a poor outcome?

Answer 25

Preschool. Children who sustain traumatic brain injury during infancy and early childhood have worse neuropsychological and functional outcomes than those injured in later childhood or the teenage years.

Question 26

The most common sites of brain contusion in TBI due to jagged bony prominence abutting brain tissue in the cranial vaults are:

Answer 26

anterior temporal lobes and orbitofrontal regions abut jagged bony prominence

Question 27

Brain regions most impacted by coup-countercoup injury?

Answer 27

Frontal and temporal lobes