Traumatic Brain Injury and Concussion

Question 1

What are the typical clinical signs and symptoms of a traumatic brain injury?

Answer 1

Hx of impact to head
Headache
Vomiting
Double/blurred vision

Signs: confusion, drowsiness, unconsciousness, pupillary abnormalities, cutaneous injury to head or face, Battle’s sign (bruising over mastoid process), panda eyes (blood within soft tissue around eye)

Question 2

What is the difference between primary and secondary brain injury?

Answer 2

Primary - damage at time of impact, shearing of neurons + blood vessels, cerebral contusions, irreversible

Secondary - inflammatory cascade as result of injury

Question 3

What occurs as part of secondary brain injury?

Answer 3

• loss of cerebral autoregulation (opening/closing arterioles) - areas of ischaemia
• breakdown of BBB
• neuronal swelling
• brain oedema
• cell death

Question 4

What score can be used to determine a pts level of consciousness?

Answer 4

Glasgow Coma Scale (GCS)
15 - max
3 - min

Question 5

What GCS reflects a mild, moderate and severe brain injury?

Answer 5

Mild (14/15)
Moderate (9-13)
Severe (3-8)

Question 6

How is a mild TBI defined?

Answer 6

1 or more of:

• loss of consciousness <30 mins
• loss of memory about accident/before accident for as much as 24h
• alteration of mental state at time of accident
• focal neurological deficit

Question 7

Describe an extradural haematoma.

Answer 7

Primary TBI

• laceration of middle meningeal artery/other arteries/venous sinuses due to trauma
• most commonly in temporal region where skull is thinner
• does not necessarily result in significant brain injury
• can lead to secondary injury if untreated

Question 8

Describe subdural haematomas.

Answer 8

Acute/chronic
acute - white blood on CT, shape mirrors skull, midline shift of brain
chronic - develops over weeks, patchy/grey blood on CT, over 65yo, bridging veins bleed, mild headache, brain swells

Question 9

Describe subarachnoid haemorrhage.

Answer 9

Hx of cutaenous injury duet to trauma (e.g. fighting)

CT - is there an aneurysm as well as head injury?

Question 10

Describe cerebral contusions

Answer 10

Bruising of brain
can be mild or more severe
- swelling can occur within 48-72 hours
- most pts have had a serious head injury with LOC

Question 11

Describe diffuse axonal injury

Answer 11

Due to rapid deceleration, shearing of neurons, causes conduction block

• don’t see anything on scan
• Hx of fall w LOC + neuro symptoms

Question 12

What surgical procedure can be done after a TBI and there is swelling or lots of bleeding?

Answer 12

Craniectomy

• prevent ischaemia due to swelling
• stops pt from dying before brain gets better

Question 13

Which factors influence outcome after TBI?

Answer 13

Age, post-resus GCS, pupillary response (poor if they are not working), hypotension, hypoxia, CT findings, other injuries

Question 14

What is the initial treatment after a TBI?

Answer 14

• Treat hypotension + hypoxia to return blood supply
• intubate if GCS <8
• treat other injuries
• shave hair + suture lacerations to prevent bleeding + infection
• scan
• evacuate intracranial haematomas if surgically safe
• intensive care, monitor ICP
• maintain adequate fluid intake
• monitor + treat hypernatremia
• rehab

Question 15

What is the role of surgery in TBI?

Answer 15

Limited role - it can improve survival at the cost of increasing levels of severe disability

Question 16

What is the link between TBI and epilepsy?

Answer 16

Those with TBI 5x more likely to develop epilepsy

Question 17

What is concussion?

Answer 17

Term interchangeable with mild, diffuse TBI

• direct/indirect blow to head
• rapid onset of short-lived impairment of neurological function
• functional disturbance rather than structural injury, LOC or no LOC
• normal CT/MRI scan (means pt can go home safely)
• diagnosed with Hx of head impact + appropriate symptoms

Question 18

Treatment of concussion?

Answer 18

Rest and return when symptom-free
(return to play gradually)

If it lasts longer than a week, refer to relevant specialist