Traumatic Brain InjuryTraumatic Brain Injury

Galen V. Henderson, M.D.Brigham and Women’s Hospital

Harvard Medical School

Outline

• Epidemiology• Concussion• Types of hemorrhages with TBI• Treatment of intracranial HTN• Penetrating injuries• Surgical decompression• Intracranial monitoring vs. neuro

exam and cerebraling

TBI in the United States

52,000 Deaths

275,000Hospitalizations

1,365,000Emergency Department Visits

??? Receiving Other Medical Care or No Care

At least 1.7 million

TBIs occur in the United States

each year.*

* Average annual numbers, 1995-2001

Causes of Death in US, Causes of Death in US, 20122012

(37/100,000)

Causes of Death in US, Causes of Death in US, 20122012

Age > 65: Accidents are #9 cause of death; rate 94.5/100,000

Classification of Head Classification of Head (Brain) Injury(Brain) Injury MinimalMinimal

GCS 15GCS 15

MildMild GCS 14-15GCS 14-15

ModerateModerate GCS 9-13GCS 9-13

SevereSevere GCS GCS << 8 8

Glasgow Coma ScaleGlasgow Coma ScaleBest Motor Response:Best Motor Response:

ObeysObeys 66Localizes painLocalizes pain 55Flexion withdrawalFlexion withdrawal 44Flexion abnormal (decorticate rigidity)Flexion abnormal (decorticate rigidity) 33Extension (decerebrate rigidity)Extension (decerebrate rigidity) 22No responseNo response 11

Best Verbal Response:Best Verbal Response:Oriented and conversesOriented and converses 55Disoriented and conversesDisoriented and converses 44Inappropriate wordsInappropriate words 33Incomprehensible soundsIncomprehensible sounds 22No responseNo response 11

Eye Opening:Eye Opening:SpontaneouslySpontaneously 44To verbal stimuliTo verbal stimuli 33To painTo pain 22Never Never 11

3-3-1515

ConcussionConcussion Immediate and transient loss of consciousnessImmediate and transient loss of consciousness accompanied by a brief accompanied by a brief

period of amnesia after a blow to theperiod of amnesia after a blow to the head. head.

128/100,000 population in the US128/100,000 population in the US

The clinicalThe clinical status of the momentary sensation of being "starstruck," orstatus of the momentary sensation of being "starstruck," or

dazed, after head injury without a brief period of loss of consciousnessdazed, after head injury without a brief period of loss of consciousness is is uncertain, but it is generally considered the mildest formuncertain, but it is generally considered the mildest form of concussion.of concussion.

Young children have the highest rates.Young children have the highest rates. Sports and bicycle accidents account for the majority of casesSports and bicycle accidents account for the majority of cases

among 5- to 14-year-oldsamong 5- to 14-year-olds

Falls and vehicular accidentsFalls and vehicular accidents are the most common causes of are the most common causes of concussion in adults.concussion in adults.

Mechanism of Concussion

Ropper A, Gorson K. N Engl J Med 2007;356:166-172

Somatic Symptoms

Persistent low grade headache

Dizziness

Vertigo

Fatigability

Insomnia

Nausea/vomiting

Symptoms of post-concussive syndrome

Mood

Anxiety

Depression

Irritability

Cognitive Deficits

Slow thinking

Poor attention and concentration

Impaired memory

fMRI and symptom severityfMRI and symptom severity

Control group

Low PCS group

Moderate PCS group

High PCS group0

0.1

0.2

0.3

0.4

0.5

∆ B

OL

D

(%)

2

0

0.1

0.2

0.3

0.4

**

∆ B

OL

D

(%)

1

Chen JK, Johnston KM, Collie A, McCrory P, Ptito A. J Neurol Neurosurg Psychiatry  2007; 78(11): 1231-1238.

12

Control Low PCS Moderate PCS High PCS

Spectrum of

Pathologic Features

and Outcomes

of Traumatic

Brain Injury

DeKosky ST et al. N Engl J Med 2010;363:1293-1296.

Epidural HemorrhageEpidural Hemorrhage Occurs in about 3% of head injuriesOccurs in about 3% of head injuries

Acute presentation; 40% have lucid interval with Acute presentation; 40% have lucid interval with delayed (hrs) LOCdelayed (hrs) LOC

90% have skull fx; 85% of these are temporal90% have skull fx; 85% of these are temporal

Children get EDHs without fxChildren get EDHs without fx

Elderly rarely get EDHs – dura firmly adherentElderly rarely get EDHs – dura firmly adherent

Amount of blood seen in fatal EDHs is 100-150mlAmount of blood seen in fatal EDHs is 100-150ml

Source of bloodSource of blood Torn meningeal vesselsTorn meningeal vessels Torn dural sinusTorn dural sinus Diploic veinsDiploic veins Marrow sinusoidsMarrow sinusoids

Epidural HemorrhageEpidural Hemorrhage

Hyperdense Bi-ConcaveHyperdense Bi-Concave

Limited by sutures (unless Limited by sutures (unless fracture crossed suture fracture crossed suture line)line)

Subdural HemorrhageSubdural Hemorrhage Acute to subacute presentationAcute to subacute presentation

Associated with severe trauma (except in elderly and Associated with severe trauma (except in elderly and especially those with coagulopathy)especially those with coagulopathy)

Associated with non-traumatic events (hypertensive Associated with non-traumatic events (hypertensive hemorrhage or ruptured AVM with SAH/SDHhemorrhage or ruptured AVM with SAH/SDH

Source of bloodSource of blood Torn bridging veinsTorn bridging veins Laceration of cortical vesselsLaceration of cortical vessels Expanding contusion hematomaExpanding contusion hematoma

Acute SDHAcute SDH

50% associated with a skull fx (not always 50% associated with a skull fx (not always at site of SDH)at site of SDH)

Most lethal form of SDH; 40-60% mortality Most lethal form of SDH; 40-60% mortality raterate

Frequently associated with other forms of Frequently associated with other forms of injury (DAI, contusions etc.)injury (DAI, contusions etc.)

Acute SDHAcute SDH

Amount of blood which is Amount of blood which is ““significantsignificant”” depends on pt age and rate of accumulationdepends on pt age and rate of accumulation

Infants: few mlsInfants: few mls

Toddlers: 30-50 mlToddlers: 30-50 ml

Children and adults: 150-200 mlChildren and adults: 150-200 ml

Subarachnoid HemorrhageSubarachnoid Hemorrhage

TraumaticTraumatic Most common causeMost common cause Seen in almost any significant injury (+/- impact)Seen in almost any significant injury (+/- impact)

In areas of contusions, lacerations, penetrating injuriesIn areas of contusions, lacerations, penetrating injuries Under SDHs where traction on bridging veins tears Under SDHs where traction on bridging veins tears

arachnoid vesselsarachnoid vessels

Non-traumaticNon-traumatic Ruptured aneurysm/vascular malformationRuptured aneurysm/vascular malformation Torn/dissection of vertebral arteryTorn/dissection of vertebral artery

Acceleration/DecelerationAcceleration/Deceleration Brain:Brain:

SDHSDH Diffuse vascular injuryDiffuse vascular injury Traumatic axonal injuryTraumatic axonal injury Contusional TearsContusional Tears

Eye:Eye: Retinal hemorrhages, Optic nerve Retinal hemorrhages, Optic nerve

sheath hemorrhagesheath hemorrhage Spine:Spine:

StretchingStretching

Gunshot WoundsGunshot Wounds

Damage is dependent on energy of Damage is dependent on energy of missile which is dependent on the missile which is dependent on the velocityvelocity

Tissue damageTissue damage Permanent track of bulletPermanent track of bullet Temporary cavity which follows bulletTemporary cavity which follows bullet

Low-velocity bullet: 4-5 x bullet sizeLow-velocity bullet: 4-5 x bullet size Hi-velocity bullet: up to 15 times bullet sizeHi-velocity bullet: up to 15 times bullet size

Secondary missiles (bone fragments)Secondary missiles (bone fragments)

Gunshot WoundsGunshot Wounds

Low Velocity Bullets (most civilian handguns)Low Velocity Bullets (most civilian handguns) Most often do not exit skullMost often do not exit skull Ricochet off inner table to form secondary trackRicochet off inner table to form secondary track Exhaust energy and come to rest in brainExhaust energy and come to rest in brain

High Velocity Bullets or Shotgun at close/contact High Velocity Bullets or Shotgun at close/contact rangerange Most often exit skull producing massive fracturesMost often exit skull producing massive fractures Large temporary cavityLarge temporary cavity Often thrusts much of brain out of headOften thrusts much of brain out of head

DON’T FORGET TO PROTECT THE C-SPINE !!

Hemopericardium

Liver lacerations

FACTORS CAUSING SECONDARY BRAIN INJURY

THE 4 H’s• HYPERCAPNEA

• HYPOXIA ( PaO2 < 60 mmHg; SpO2 < 90%)

• • SYSTEMIC HYPOTENSION ( < 90 mmHg )

• INTRACRANIAL HYPERTENSION

OTHER FACTORS CAUSING SECONDARY BRAIN INJURY

ISCHEMIA

VASOSPASM

SEIZURES

LOSS OF AUTOREGULATION

Intracranial HTN Treatment ModalitiesIntracranial HTN Treatment Modalities

Insert ICP monitorInsert ICP monitor General goals: Maintain ICP < 20 mm Hg and CPP > General goals: Maintain ICP < 20 mm Hg and CPP >

70 mm Hg70 mm Hg For ICP > 20-25 mm Hg for > 5 minutesFor ICP > 20-25 mm Hg for > 5 minutes

Drain CSF via ventriculostomyDrain CSF via ventriculostomy Elevate head of bedElevate head of bed OsmotherapyOsmotherapy Sedation, agitation and fever controlSedation, agitation and fever control HyperventilationHyperventilation Pressor therapy to maintain MAP and ensure CPPPressor therapy to maintain MAP and ensure CPP

For refractory intracranial HTNFor refractory intracranial HTN Phenobarbital/Hypothermia/Decompressive Phenobarbital/Hypothermia/Decompressive

craniotomycraniotomy

Osmolality of IV fluidsOsmolality of IV fluids

Fluid Osmolality (mOsm/kg)

5% Dextrose 252

Lactated ringers 250-260

Plasma 285

5% Albumin 290

Normal Saline 0.9% 308

25% Albumin 310

6% Hetastarch 310

2% Normal Saline 682

3% Normal Saline 1025

25% Mannitol 1375

7.5% Normal Saline

23.4% Normal Saline

2400

8008

Surgical Treatment of Surgical Treatment of Intracranial HTNIntracranial HTN

Original Article Decompressive Craniectomy in Diffuse Traumatic

Brain Injury

D. James Cooper, M.D., Jeffrey V. Rosenfeld, M.D., Lynnette Murray, B.App.Sci., Yaseen M. Arabi, M.D., Andrew R. Davies, M.B., B.S., Paul D'Urso, Ph.D., Thomas

Kossmann, M.D., Jennie Ponsford, Ph.D., Ian Seppelt, M.B., B.S., Peter Reilly, M.D., Rory Wolfe, Ph.D., for the DECRA Trial Investigators and the Australian and New

Zealand Intensive Care Society Clinical Trials Group

N Engl J MedVolume 364(16):1493-1502

April 21, 2011

Study Overview

• Patients with severe traumatic brain Patients with severe traumatic brain injury and refractory intracranial injury and refractory intracranial hypertension were randomly assigned hypertension were randomly assigned to either decompressive craniectomy or to either decompressive craniectomy or standard care.standard care.

• Craniectomy was associated with a Craniectomy was associated with a significant reduction in intracranial significant reduction in intracranial pressure but worse outcomes.pressure but worse outcomes.

.

Cooper DJ et al. N Engl J Med 2011;364:1493-1502

.

Cooper DJ et al. N Engl J Med 2011;364:1493-1502

Original Article A Trial of Intracranial-Pressure Monitoring in

Traumatic Brain Injury

Randall M. Chesnut, M.D., Nancy Temkin, Ph.D., Nancy Carney, Ph.D., Sureyya Dikmen, Ph.D., Carlos Rondina, M.D., Walter Videtta, M.D., Gustavo Petroni, M.D.,

Silvia Lujan, M.D., Jim Pridgeon, M.H.A., Jason Barber, M.S., Joan Machamer, M.A., Kelley Chaddock, B.A., Juanita M. Celix, M.D., Marianna Cherner, Ph.D., and Terence

Hendrix, B.A.

N Engl J MedVolume 367(26):2471-2481

December 27, 2012

Study Overview

• In this randomized trial involving 324 In this randomized trial involving 324 patients with severe traumatic brain patients with severe traumatic brain injury in Bolivia and Ecuador, guideline-injury in Bolivia and Ecuador, guideline-based management with intracranial based management with intracranial pressure monitoring was not superior to pressure monitoring was not superior to management based on imaging and management based on imaging and clinical assessments.clinical assessments.

Cumulative Survival Rate According to Study Group.

Chesnut RM et al. N Engl J Med 2012;367:2471-2481

Cellular Cellular MetabolismMetabolism

ICPICP

ExamExam

EEGEEG

CPPCPP

TCDTCDMAPMAP

Summary

• Epidemiology• Concussion• Types of hemorrhages with TBI• Treatment of intracranial HTN• Penetrating injuries• Surgical decompression• Intracranial monitoring vs. neuro

exam and cerebral imaging

Thank You For Your AttentionThank You For Your Attention