traumatic brain injury - i scott s. rubin, ph.d. department of communication disorders

Traumatic Brain Injury - IScott S. Rubin, Ph.D.

Department of Communication Disorders

States with Highest Rates of Traumatic Brain Injury-related Fatalities

State/District Annual TBI Fatality Rate per 100,000 population1

Rank by population size2

Wyoming 34.2 51

Montana 30.4 44

Louisiana 28.9 22

Nevada 28.7 35

Mississippi 28.4 31

District of Columbia

28.1 50

Arkansas 28.0 33

Idaho 27.9 39

Alabama 27.0 23

Oklahoma 26.3 28

TBI Data –At Risk Groups

Males - 15 and 24 years of age • 2:1 Males:Females

Young children and individuals over 75 years of age Falls around the home are the leading

cause of injury for infants, toddlers, and elderly people. Violent shaking of an infant or toddler is another significant cause.

TBI Risk Factors More Risk Factors -

SES• Lower SES = higher incidence of TBI

Previous TBI

TBI Data The leading

causes for adolescents and adults – 50% Automobile &

motorcycle accidents, or pedestrians

20% violent crimes – assaults

20% falls Sports? Other

causes?

0

TBI Data 200,000 Americans die

each year from injuries. half million more

hospitalized. 10 percent of the

surviving individuals = mild to moderate, threatening their ability to live independently.

200,000 have serious problems that may require institutionalization or some other form of close supervision.

A 44 year old man was

referred to the accident and emergency department by the psychiatric services, having claimed to have hammered several nails through his skull over a three month period. The patient had a long history of depression, personality disorder, and previous deliberate self-harm. He had remained well throughout this period and had been cleaning the wounds with weak antiseptic on a regular basis. He had concealed the injuries by wearing a hat. Two days prior to admission he had inserted a much larger 12.7 cm (5 inch) masonry nail and had developed left sided weakness and unsteadiness of gait.

James, G., et al. (2006). A case of self-inflicted craniocerebral penetrating injury. Emerg. Med. J. 23: e32. [Summary] 

Type of Injury TBI – Open vs Closed

Open• Dural covering is penetrated• Localized/Focal damage

Open head woundaka, “penetratinghead injury”

Open head woundaka, “penetratinghead injury”

Bullet 1/3

Open head woundaka, “penetratinghead injury”

Bullet 2/3

Open head woundaka, “penetratinghead injury”

Bullet 3/3

A 32-year-old Caucasian male with a history of repeated self-injury drilled a hole in his skull using a power tool and subsequently introduced intracerebrally a binding wire from a sketchpad. An emergency craniotomy was performed around the site of cranial injury, and the foreign body was carefully extracted. The wire was located partially in the subdural space and partially in the right hemisphere of the brain. The patient made an excellent recovery and was referred to a psychiatrist for further treatment. This is a rare case of unusual and complex repetitive self-destructive behavior without apparent suicidal intent.

Karabatsou, K., et al. (2005). Self-Inflicted Penetrating Head Injury in a Patient With Manic-Depressive Disorder. Am. J.  Forensic Med. Pathol. 26: 174-7. [Summary]

Open head woundaka, “penetratinghead injury”

Knife 1/5

Open head woundaka, “penetratinghead injury”

Knife 2/5

Open head woundaka, “penetratinghead injury”

Knife 3/5

Open head woundaka, “penetratinghead injury”

Knife 4/5

Open head woundaka, “penetratinghead injury”

Knife 5/5

Type of Injury Closed (CHI) – Meninges not torn!

• blow to head

Acceleration/Deceleration Linear Velocity

• Coup contusion & Contrecoup contusion

Coup - Contracoup

Angular Acceleration (movement of brain)

• Abrasions/Lacerations• Twisting/Shearing

• DAI (diffuse axonal injury)• Hemorrhages & Cranial Nerve trauma

Diffuse Axonal Injury Other than shearing – different types of

axonal injury

Hemorrhage (from any cause)• Extracerebral • Intracerebral

Hemorrhage versus Hematoma

TBI Hemorrhagic Contusion frontal & Temporal

Subarachnoid hemorrhage

Edema & Midline Shift (CT)

Depressed Skull Fracture & Hematoma

Extradural Hematoma (CT)

Extradural Hematoma

Cerebral Edema Intercranial Pressure Hypoxic-Ischemic

Damage Seizures

• Early onset• Late onset

Issues to consider Consciousness

Diminished Coma

• Reactivity – “reflexive”• Perceptivity –

• Learned – language, gesture…• Acquired – flinching from fear…

Damage Areas and Associated Deficits

Recovery – With Hyperbaric Treatments

Deficits Frontal Lobe

Class? What deficits could you expect?

Deficits Frontal Lobe

Problems:• Paralysis• Sequencing• Attending• Problem solving• Loss of spontaneous interaction with others• Loss of flexible thinking• Perseveration• Expressive language problems• Mood changes• Social behavior changes• Personality

Deficits Parietal Lobe

Functions? What deficits could you expect?

Deficits Parietal Lobe

Problems:• Inability to attend to more than one object at a time• Anomia• Agraphia• Reading problems• Drawing• Distinguishing left from right• Math• Lack of awareness of self and/or surrounding space• Lack of visual attention• Hand to eye coordination

Deficits Occipital Lobe

Functions? What deficits could you expect?

Deficits Occipital Lobe

Problems:• Vision

• Colors• Inaccurately seeing objects

• Difficulty locating objects• Hallucinations• Inability to recognize movement• Reading and writing problems

Deficits Temporal Lobe

Functions? What deficits could you expect?

Deficits Temporal Lobe

Problems:• Difficulty recognizing faces• Difficulty understanding spoken words• Disturbance of selective attention• Identification and verbalization about objects• Short-term memory loss• Changes in sexual behavior• Problems with long-term memory• Right lobe causes persistent talking

Deficits Brain Stem

Problems:• Decreased vital capacity for breathing• Dysphagia• Organization and perception of environment• Balance and movement problems• Dizziness and nausea• Sleeping difficulties

Deficits

Cerebellum Functions?

Deficits Cerebellum

Problems:• Coordination of fine movements• Ability to walk• Inability to reach out and grab objects• Tremors• Dizziness• Slurred Speech• Inability to make rapid movements

Frontolimbic Structures Begins next presentation

Frontolimbic Injury Executive System Impairment

Reduced awareness of personal strengths and weaknesses Difficulty setting realistic goals Difficulty planning and organizing behavior to achieve the

goals Impaired ability to initiate action needed to achieve the

goals Difficulty inhibiting behavior incompatible with achieving the

goals Difficulty self-monitoring and self-evaluating Difficulty thinking and acting strategically, and solving real-

world problems in a flexible and efficient manner General inflexibility and concreteness in thinking, talking

and acting

Frontolimbic Injury Cognitive Impairment

Reduced internal control over all cognitive functions

Impaired working memory Disorganized behavior related to

impaired organizing schemes Impaired reasoning Concrete thinking Difficulty generalizing

Frontolimbic Injury Psychosocial/Behavioral Impairment

Disinhibited, socially inappropriate, and possibly aggressive behavior

Impaired initiation or paucity of behavior Inefficient learning from consequences Perseverative behavior; rigid, inflexible

behavior Impaired social perception and interpretation

TBI - Change of Topic CAUTION - This is a transition! To understand the course of TBI

patient recovery – one must understand Coma.

So – On to Coma!

TBI - Coma Coma Defined:

a deep state of unconsciousness. A person in a coma is alive but not able to move or respond to the environment. Coma may result from an illness, or from a traumatic head injury.

TBI - Coma Glascow Coma Scale:

Based on level in 3 areas• Eye Opening • Motor Response• Verbal Response

Scores are determined as response is tested. Total score is determined by adding the three categories.

Highest possible score is 15. This score would indicate a person who is awake, oriented, and following commands.

Lowest score is 3. This score would indicate a person deeply unconscious.

A score of 8 or lower generally indicates a person with a severe Brain Injury.

TBI - Coma Glascow Coma Scale:

Eye Opening Patient Response Score Opens eyes on own 4 Opens eyes when asked to in a loud voice 3 Opens eyes when pinched 2 Does not open eyes 1

First 2 are to speech – the last 2 are to pain.

TBI - Coma Glascow Coma Scale:

Best Motor Response Patient Response Score Follows simple commands 6 Pulls examiner's hand away when pinched 5 Pulls part of body away when examiner

pinches patient 4 Flexes body inappropriately to pain –

decorticate posturing 3 Body becomes rigid in an extended position

when examiner pinches victim, decerebrate posturing 2

Has no motor response to pinch 1

1st is to verbal command – the rest are to pain.

TBI - Coma Glascow Coma Scale:

Verbal Response Patient Response Score Carries on a conversation correctly

& tells examiner where he is, who he is, and the month and year 5

Seems confused or disoriented 4 Talks so examiner can understand victim

but makes not sense 3 Makes sounds that examiner can't understand 2 Makes no noise 1

TBI - Coma Glascow Coma Scale: If you can not add 3

numbers – avalable as Pocket PC program!

TBI - Coma The Rancho Los Amigos Levels of

Cognitive Functioning (RLA) Designed to measure and track an individual's

progress early in the recovery period. They have been used as a means to develop "level-specific" treatment interventions and strategies designed to facilitate movement from one level to another. A RLA level is determined based on behavioral observations.

The RLA scale designates eight (8) levels of function: - see the following…

TBI - Coma The Rancho Los Amigos

Level I – No Response• The individual appears to be in deep sleep

and is completely unresponsive to any stimuli.

TBI - Coma The Rancho Los Amigos

Level II – Generalized Response• The individual reacts inconsistently and

non-purposefully to stimuli. Responses are limited in nature and often the same regardless of the stimuli presented. Responses may include gross motor movements, vocalization, and physiologic changes. Response time is likely to be delayed. Deep pain evokes the earliest response.

TBI - Coma The Rancho Los Amigos

Level III – Localized Response• The individual responds specifically but

inconsistently to stimulus. Responses are directly related to the type of stimuli presented. For example, an individual's head will turn toward a sound or his/her eyes will focus on an object when presented. The individual may follow simple commands and may respond better to some people (i.e. family and friends) than others.

TBI - Coma The Rancho Los Amigos

Level IV – Confused – Agitated• The individual is in a heightened state of activity

with severely decreased ability to process information. Behavior is non-purposeful relative to the immediate environment. Attempts to climb out of bed, remove restraints, and hostility are common. The individual requires maximum assistance to perform self-care activities. An individual may sit, reach, or walk, but will not necessarily perform these activities upon request.

TBI - Coma The Rancho Los Amigos

Level V – Confused – Inappropriate• Patient appears alert and responds to simple

commands. More complex commands, however, produce responses that are non-purposeful and random. The patient may show some agitated behavior it is in response to external stimuli rather than internal confusion. The patient is highly distractible and generally has difficulty in learning new information. He can manage self-care activities with assistance. His memory is impaired and verbalization is often inappropriate.

TBI - Coma The Rancho Los Amigos

Level VI – Confused – Appropriate• The individual shows goal-oriented behavior, but is

dependent upon external input for direction. Response to discomfort is appropriate. Responses are incorrect due to memory problems, but are appropriate to the situation. Simple commands are followed consistently and carry-over for relearned activities is evident. Orientation is inconsistent but awareness of self, family, and basic needs is increased.

TBI - Coma The Rancho Los Amigos

Level VII – Automatic – Appropriate• The individual appears appropriate within hospital

and home settings, goes through daily routine automatically but is robot-like, with shallow recall of activities performed. Has absent-to-minimal confusion and lacks insight. The individual frequently demonstrates poor judgment and problem solving and expresses unrealistic future plans. With structure the individual is able to initiate tasks or social and recreational activities.

TBI - Coma The Rancho Los Amigos

Level VIII – Purposeful – Appropriate• The individual is alert and oriented, able to recall

and integrate past and recent events and is aware of and responsive to the environment. Independence in the home and community has returned. Carry-over for new learning is present, and the need for supervision is absent once activities have been learned. Social, emotional and cognitive abilities may still be decreased.

Transition Also in Presentation 2

Mild Head Injury Issues follows…

TBI – Mild head Injury Loss of consciousness (or alteration

in consciousness) under an hour – probably more like 10 minutes.

Referred to as “Concussion” Most likely return to “normal” May be associated with Post-

concussion Syndrome. (see next slide)

TBI – Post-Concussion Syndrome Symptoms: headache, dizziness,

concentration problems, memory problems, irritability, and decreased energy.

Should clear in 5 to 10 weeks.

TBI – Accident Neurosis May accompany Post-Concussion

Syndrome. Psychological disorder – exaggerates

symptoms. Increases depression and anxiety. Higher incidence – in Men or Women? Higher incidence if litigation is involved.

TBI - Continued Next presentation begins with

Prognosis in TBI.