TRAUMATIC & ACQUIRED BRAIN

INJURY

James F. Malec, PhD, ABPP-Cn, RpProfessor & Research Director

PM&R, Indiana University School of Medicine& Rehabilitation Hospital of Indiana

Emeritus Professor of Psychology, Mayo Clinic

Overview1. What is traumatic brain injury?

2. What sorts of injuries or events can cause TBI?

3. What behaviors should lawyers be looking for that might be red flags for TBI?

4. What questions should we be asking our clients to verify TBI (other than seeking medical records)?

5. How is TBI diagnosed? Is imaging necessary or helpful? Are there other ways to diagnose?

6. What are the symptoms of TBI?7. How can TBI impact cognition?8. Can TBI be cured or ameliorated and if so, how? What is the long term

prognosis for persons with TBI?

What is traumatic brain injury?

Definitions TBI Model System (moderate-severe): TBI is defined as

damage to brain tissue caused by an external mechanical force as evidenced by medically documented loss of consciousness or post traumatic amnesia (PTA) due to brain trauma or by objective neurological findings that can be reasonably attributed to TBI on physical examination or mental status examination.

CDC: A TBI is caused by a bump, blow, or jolt to the head or a penetrating head injury that disrupts the normal function of the brain. Not all blows or jolts to the head result in a TBI.

TBI Severity Ranges from “mild” (i.e., a brief change

in mental status or consciousness) to “severe” (i.e., an extended period of unconsciousness or memory loss after the injury)

Concussion = mild TBI Severity based on initial injury

NOT severity of sequelaeThese are associated but not perfectly

TBI Severity Severity based on initial injury

Glasgow Coma Scale (GCS)Duration of loss of consciousness (LOC)Duration of post-traumatic amnesia (PTA)Time to follow commands

Severity NOT based on severity of sequelae or symptoms

Severity of injury and sequelae are associated but not perfectly

Glasgow Coma Scale

Eye Opening Response Spontaneous; eyes open with blinking

at baseline: 4 points To verbal stimuli, command, speech: 3

points To pain only (not applied to face): 2

points No response: 1 point

Glasgow Coma Scale Motor Response

Obeys commands for movement: 6 points Purposeful movement to painful stimulus: 5

points Withdraws in response to pain: 4 points Flexion in response to pain (decorticate

posturing): 3 points Extension response in response to pain

(decerebrate posturing): 2 points No response: 1 point

Glasgow Coma Scale

Verbal ResponseOriented: 5 points Confused conversation, but able to

answer questions: 4 points Inappropriate words: 3 points Incomprehensible speech: 2

points No response: 1 point

Glasgow Coma Scale GCS = sum of three components Usually worst within first 24 hours Motor score alone is good proxy for

entire scale In current practice, often invalidated by

emergency intubation/sedation

Post-traumatic Amnesia (PTA) Time between injury and recovery of

continuous anterograde memoryUsually signified by orientation to person,

time, placeScales used in research, eg, O-LOG,

Galveston Orientation and Amnesia Test (GOAT)

Memory loss may also be retrogradeRetrograde < anterograde

Post-traumatic Confusional State (Delirium) PTA or memory loss is one component Disturbance of awareness/attention Behavior disturbance

Agitation vs. abulia Sleep cycle disturbance

TBI severity Mild (Concussion)

GCS >13LOC < 30 minPTA <24 hrsmay include no LOC or PTA and normal GCS

(15) with disruption of consciousness, ie, dazed or confused

Complicated mildAbove criteria + positive neuroimagingSequelae similar to moderate

TBI severity Moderate

GCS = 9-12LOC = 30 min-24 hrsPTA = 24 hrs-1 wk

SevereGCS < 9LOC > 24 hrsPTA > 1 wk

Systems with finer grades exist Others differentiate only mild vs.

moderate/severe

ABI: Acquired brain injury Brain damage from other causes, eg,

anoxia, cerebrovascular event, electrocution, poisoning or metabolic imbalance

Not congenital or developmental Not progressive (eg, dementia, MS,

Huntingtons, Parkinsons) Stroke

With vs. without hemiplegia

What sorts of injuries or events can cause TBI?

Causes of TBI Any injury to the brain resulting from an

external forceMost common: car accidents, falls, fights,

blast injuries Penetrating or nonpenetating Usually results from a blow to the head May result from acceleration-

deceleration or blast injury without direct head trauma

What behaviors should lawyers be looking for that might be red flags for TBI?

Most Common TBI/ABI Sequelae Impaired attention or memory Limited behavioral or emotional control

Impulsivity vs. lack of initiation Above may also result from many other

causes including personality, psychiatric disorder, sleep disorder, other medical illness

TBI/ABI requires documentation of an event that abruptly disrupted consciousness and resulted in identifiable brain damage or sequelae attributable to brain damage

What questions should we be asking our clients to verify TBI (other than seeking medical records)?

OSU-TBI-ID Systematic method for discovering a

history of significant TBI as suggested by:Hospitalization, ER visits, car accident, falls,

fights, blast injuriesLoss or alteration of consciousnessMultiple injuries

Only for TBI Form, information and training at:

http://www.ohiovalley.org/tbi-id-method/

How is TBI diagnosed? Is imaging necessary or helpful? Are there other ways to diagnose?

Mayo Criteria: Moderate-Severe (DEFINITE)One or more of the following criteria apply:1. Death due to this TBI2. Loss of consciousness of 30 minutes or more3. Post-traumatic anterograde amnesia of 24 hours or more4. Worst Glasgow Coma Scale full score in first 24 hours

(unless invalidataed upon review, e.g., attributable to intoxication, sedation, systemic shock)

5. One or more of the following present: intracerebral, subdural, or epidural hematoma, cerebral contusion, hemorrhagic contusion, penetrating TBI (dura penetrated), subarachnoid hemorrhage, brain stem injury

Mayo Criteria: Mild (PROBABLE)Not moderate-severe and one or more of the following criteria apply:1. Loss of consciousness of momentary to

less than 30minutes2. Post-traumatic anterograde amnesia of

momentary to less than 24 hours3. Depressed, basilar or linear skull

fracture (dura intact)

Mayo Criteria: Symptomatic (POSSIBLE)Not moderate-severe or mild and one or more of the following symptoms are present: Blurred vision Confusion (mental state changes) Dazed Dizziness Focal neurologic symptoms Headache Nausea

Imaging Intracranial damage attributable to

trauma is clear evidence of TBIAlthough subdural hematoma will be

challenged MRI more sensitive than CT TBI can also be present with normal

neuroimaging

Diagnosis with normal imaging History of injury and sequelae are critical Medical diagnosis by brain injury

specialist, ie, neurosurgeon, neurologist, neuropsychiatrist, physiatrist (PM&R)Not all in these specialties are brain injury

experts Neuropsychology evaluation and testing

“consistent with” TBI/ABINeuropsychologists = clinical psychologists

○ May diagnose within DSM

What are the symptoms of TBI?

Symptoms of Mild TBI[from Rivermead Postconcussion Symptoms Questionnaire]

Headaches Dizziness Nausea and/or Vomiting Noise Sensitivity, easily

upset by loud noise Sleep Disturbance Fatigue, tiring more

easily Being Irritable, easily

angered Feeling Depressed or

Tearful

Feeling Frustrated or Impatient

Forgetfulness, poor memory

Poor Concentration Taking Longer to Think Blurred Vision Light Sensitivity, Easily

upset by bright light Double Vision Restlessness

Symptoms of Moderate-Severe TBI Similar to mild but more severe More often include impairments of

higher order abilitiesReasoning and judgmentPlanningSelf-awareness

No symptoms are specific to TBI or ABI

How can TBI impact cognition?

Effects on Cognition Neurotransmitter disruption

Often transient in mild TBI Structural damage

Neural damage to brain areas that are critical for specific types of cognition○ Frontal lobes: reasoning, judgment, self-regulation○ Left hemisphere: language○ Right hemisphere: spatial abilities○ Temporal lobe, hippocampus: memory

Diffuse axonal injury: disconnection syndromes, impaired attention

Can TBI be cured or ameliorated and if so, how? What is the long term prognosis for persons with TBI?

Only Cure is PreventionAnd prevention of secondary complications/ injuries

Rehab Works• Inpatient• Outpatient/

Community-based• Medical and

behavioral interventions

• Ideally: early, focused, lifelong follow-along

Long term PrognosisMuch better than it is…

jmalec@rhin.com