MILD TRAUMATIC BRAIN INJURY MILD TRAUMATIC BRAIN INJURY IN PATIENTS WITH VASCULAR IN PATIENTS WITH VASCULAR DEMENTIADEMENTIA

Yuri AlekseenkoYuri Alekseenko

Department of Neurology and NeurosurgeryDepartment of Neurology and NeurosurgeryVitebsk Medical UniversityVitebsk Medical UniversityVitebsk, BelarusVitebsk, Belarus

Istanbul, Turkey, 2005 Istanbul, Turkey, 2005

Traumatic Brain InjuryTraumatic Brain Injury

the incidence of TBI is high - between 229 and 1967 the incidence of TBI is high - between 229 and 1967 per 100,000per 100,000

the highest incidence occurring in men, aged 15 to 24 the highest incidence occurring in men, aged 15 to 24 yearsyears

90-95% of all traumatic brain injuries are considered 90-95% of all traumatic brain injuries are considered

mild (MTBI)mild (MTBI)

Mild Traumatic Brain Injury. Revised Guidelines on Early Mild Traumatic Brain Injury. Revised Guidelines on Early Management. Management. EFNS Task force on MTBI, Scientific Panel of EFNS Task force on MTBI, Scientific Panel of Neurotraumatology, 2005Neurotraumatology, 2005

MTBI in patients with VDMTBI in patients with VD

The diagnosis of mild traumatic brain injury (MTBI) The diagnosis of mild traumatic brain injury (MTBI) and general assessment of neurological functions in and general assessment of neurological functions in patients with patients with vascular dementia (VD)vascular dementia (VD) is usually is usually complicatedcomplicated

The assessment and interpretation of main MTBI or VD The assessment and interpretation of main MTBI or VD symptoms and history in such circumstances remains symptoms and history in such circumstances remains a challengea challenge

The The distinction between traumatic and primary or distinction between traumatic and primary or secondary cerebral vascular effects is rather difficultsecondary cerebral vascular effects is rather difficult

MTBI + VDMTBI + VD

HI + VDHI + VD

MTBI + VDMTBI + VD MTBI MTBI VD decompensation VD decompensation

Cerebrovascular disorders Cerebrovascular disorders secondary MTBI secondary MTBI (syncope, epileptic seizure, vertigo and imbalance (syncope, epileptic seizure, vertigo and imbalance disorders …)disorders …)

VD and/or TBIVD and/or TBI

MTBI and/or MTBI and/or VD decompensation and/orVD decompensation and/or Traumatic intracranial complications (extracerebral Traumatic intracranial complications (extracerebral

haematoma, malignant brain oedema with diffuse haematoma, malignant brain oedema with diffuse brain swelling …)brain swelling …)

MTBI diagnostic criteriaMTBI diagnostic criteria

trauma history trauma history hospital admission Glasgow Coma Score (GCS) of 13–hospital admission Glasgow Coma Score (GCS) of 13–

15 15

brief (min/sec) loss or/and any alteration of brief (min/sec) loss or/and any alteration of consciousness (disorientation, confusion) at the time consciousness (disorientation, confusion) at the time of the accidentof the accident

posttraumatic amnesia – several minutes/hours posttraumatic amnesia – several minutes/hours physical symptoms (nausea, vomiting, dizziness, physical symptoms (nausea, vomiting, dizziness,

headache, autonomic disorders, etc)headache, autonomic disorders, etc)

MTBI+VDMTBI+VD

To clarify the reciprocal influence of such conditions To clarify the reciprocal influence of such conditions and improve the standard diagnostic protocols we and improve the standard diagnostic protocols we compared the structure of clinical signs and the compared the structure of clinical signs and the natural course of recovery in MTBI young patients with natural course of recovery in MTBI young patients with those of MTBI+VD patientsthose of MTBI+VD patients

Materials and methodsMaterials and methods

61 young males with MTBI (aged 16-39) and 61 young males with MTBI (aged 16-39) and

56 patients with MTBI (aged 56-78) on the background 56 patients with MTBI (aged 56-78) on the background of mild and moderate VDof mild and moderate VD

The quantitative analysis (duration/intensity) of main The quantitative analysis (duration/intensity) of main MTBI symptoms was carried outMTBI symptoms was carried out

VD patientsVD patients

Underlying chronic cerebrovascular pathology: Underlying chronic cerebrovascular pathology:

hypertensive encephalopathy (43%)hypertensive encephalopathy (43%) arteriosclerotic encephalopathy (31%)arteriosclerotic encephalopathy (31%) combined (H+A+ toxic and metabolic) (26%) combined (H+A+ toxic and metabolic) (26%)

MTBI diagnosisMTBI diagnosis

The criteria for selecting MTBI patients were as follows: The criteria for selecting MTBI patients were as follows:

brief (min/sec) loss or/and any alteration of brief (min/sec) loss or/and any alteration of consciousness (disorientation, confusion) at the time consciousness (disorientation, confusion) at the time of the accidentof the accident

posttraumatic amnesia – several minutes/hoursposttraumatic amnesia – several minutes/hours physical symptoms (nausea, vomiting, dizziness, physical symptoms (nausea, vomiting, dizziness,

headache, vegetative disorders, etc)headache, vegetative disorders, etc) absence of focal neurological deficitabsence of focal neurological deficit absence of scull fractureabsence of scull fracture normal CT or MRI scan of the brain normal CT or MRI scan of the brain recovery preferably in 1-2 weeks (young patients)recovery preferably in 1-2 weeks (young patients)

patients with significant concomitant neurological and patients with significant concomitant neurological and internal diseases were excluded from this study internal diseases were excluded from this study (young patients)(young patients)

MTBI+VDMTBI+VD

MTBI+VD patients demonstrated more extensive and MTBI+VD patients demonstrated more extensive and frequent disorders of consciousness and amnesia and frequent disorders of consciousness and amnesia and their different structure in comparison with young their different structure in comparison with young MTBI patients at the time of accidentMTBI patients at the time of accident

Disorders of consciousness Disorders of consciousness and amnesia in patients and amnesia in patients with MTBIwith MTBI

0

20

40

60

80

100

120

LOC amnesia anterogradeamnesia

MTBI MTBI+VD

MTBI symptomsMTBI symptoms

LOC and amnesia at the LOC and amnesia at the time of accident:time of accident:

Only 45% of MTBI+VD Only 45% of MTBI+VD patients were able to patients were able to confirm such confirm such disturbances by disturbances by themselves in themselves in comparison with young comparison with young MTBI patients (68%)MTBI patients (68%)

MTBI 68%

MTBI+VD

45%

TBI signsTBI signs

TThe signs of head trauma he signs of head trauma (abrasions, bruises) as an(abrasions, bruises) as an indirect evidence of a indirect evidence of a probable brain injury probable brain injury were were objectively observed in objectively observed in 84% of MTBI+VD patients84% of MTBI+VD patients compared with 72% of compared with 72% of young MTBI patientsyoung MTBI patients

MTBI 72%

MTBI+VD

84%

MTBI symptomsMTBI symptoms

Such symptoms as headache, dizziness, nausea, Such symptoms as headache, dizziness, nausea, vomiting, fatigue and some other autonomic disorders vomiting, fatigue and some other autonomic disorders (orthostatic dysregulation and thermodysregulation) (orthostatic dysregulation and thermodysregulation) were the most common manifestations of MTBIwere the most common manifestations of MTBI

Besides, MTBI and MTBI+VD patients demonstrate a Besides, MTBI and MTBI+VD patients demonstrate a wide variety of duration and intensity of such wide variety of duration and intensity of such symptomssymptoms

MTBI symptomsMTBI symptoms

MTBI+VD patients MTBI+VD patients had more frequent had more frequent nausea (92% and nausea (92% and 79%) but at the 79%) but at the same time they had same time they had less frequent less frequent vomiting in vomiting in comparison with comparison with young MTBI patients young MTBI patients (43% and 58% (43% and 58% accordingly)accordingly)

0

20

40

60

80

100

nausea vomiting

MTBI MTBI+VD

MTBI symptomsMTBI symptoms

Different types of headache were observed in all Different types of headache were observed in all young patients and only in 82% of MTBI+VD patients. young patients and only in 82% of MTBI+VD patients. At the same time headache and some other subjective At the same time headache and some other subjective disorders in patients with VD were less intensive, but disorders in patients with VD were less intensive, but went on a longer timewent on a longer time

0 2 4 6 8 10 12

MTBI

MTBI+VD

days

Headache Severe headache

MTBI symptoms - headacheMTBI symptoms - headache

MTBI symptoms - headacheMTBI symptoms - headache

In all MTBI and only in 79% of MTBI+VD cases the In all MTBI and only in 79% of MTBI+VD cases the headache appeared just after the trauma and headache appeared just after the trauma and gradually decreased during the first or the second gradually decreased during the first or the second week after the accidentweek after the accident

In 30% of all MTBI patients the most intensive In 30% of all MTBI patients the most intensive headache, dizziness and nausea were observed on the headache, dizziness and nausea were observed on the next day after the traumanext day after the trauma

MTBI symptoms - headacheMTBI symptoms - headache

In case of headache appearing some time after the In case of headache appearing some time after the trauma its interpretation as a MTBI symptom still trauma its interpretation as a MTBI symptom still remains controversialremains controversial

Remote headache in patients with MTBI might to a Remote headache in patients with MTBI might to a greater extent be associated with the influence of greater extent be associated with the influence of additional factors and other mechanisms additional factors and other mechanisms (psychological reactions to physical or emotional (psychological reactions to physical or emotional stress and other causes)stress and other causes)

MTBI+VDMTBI+VD

In 74% of In 74% of MBI+VD patients it could be considered as a MBI+VD patients it could be considered as a decompensation of an underlying cerebrovascular decompensation of an underlying cerebrovascular pathology (chronic hypertensive or arteriosclerotic pathology (chronic hypertensive or arteriosclerotic encephalopathy) on the background of MTBIencephalopathy) on the background of MTBI

ConclusionConclusion

TThe he distinction between primary and secondary distinction between primary and secondary traumatic brain injury (due to syncope, seizure or traumatic brain injury (due to syncope, seizure or vertigo, etc) in patients with VD as well as between vertigo, etc) in patients with VD as well as between neurological disorders of traumatic and secondary neurological disorders of traumatic and secondary vascular origin remains rather difficultvascular origin remains rather difficult

Persistent neurological dysfunctions including Persistent neurological dysfunctions including cognitive deficit cognitive deficit after the MTBI in patients with VD after the MTBI in patients with VD could be interpreted in most cases as a complex could be interpreted in most cases as a complex clinical condition with predominance of the existing clinical condition with predominance of the existing cerebrovascular pathologycerebrovascular pathology

ConclusionConclusion

Chronic cerebrovascular pathology seem to decrease Chronic cerebrovascular pathology seem to decrease the "concussion threshold", simultaneously producing the "concussion threshold", simultaneously producing some disorganisation influence on brain mechanisms some disorganisation influence on brain mechanisms and contributing to patients’ decompensation after and contributing to patients’ decompensation after the MTBIthe MTBI , the spectrum of symptoms after the trauma , the spectrum of symptoms after the trauma may be widermay be wider

CT or MRI should be considered in MTBI diagnostic CT or MRI should be considered in MTBI diagnostic protocol for patients with VDprotocol for patients with VD