TBI

Question 1

What is TBI?

Answer 1

Result of an external physical force to the brain causing transient or permanent neurological deficit

Question 2

M:F TBI?

Answer 2

3-4:1

Question 3

Age group most affected by TBI?

Answer 3

15-35

Question 4

What are the main mechanisms of TBI?

Answer 4

1. Focal pathology 2” contact (e.g. falls, assault)
2. Diffuse pathology a/w acceleration / deceleration (e.g. traffic accident)
   Brain also injured as a result of primary injury and secondary effects from the injury

Question 5

What may focal brain injury cause?

Answer 5

1. Lesion of scalp, skull and dura
2. Surface contusions and lacerations to the brain
3. Intracranial haematoma

Question 6

What are skull fractures strongly associated with?

Answer 6

Development of intracranial haematoma

Question 7

Where may contusions be located and what are they termed?

Answer 7

1. Site of injury = coup

2. Opposite point of contact = contrecoup

Question 8

Where are contusions more likely to be located?

Answer 8

Frontal and temporal lobes

Question 9

Where may intracranial haematomas be located?

Answer 9

• Extradural: ovoid mass of blood between bone and dura

- Intradural: SAH, SDH, ICH

Question 10

What are diffuse brain injuries?

Answer 10

Pathologies associated with acceleration / deceleration injuries.

Question 11

What are diffuse brain injuries called?

Answer 11

Diffuse axonal injury (DAI)

Question 12

What are the features of DAI?

Answer 12

• 1. lesions of corpus callosum and other midline structures, parasagittal white matter, inter ventricular septum and walls of third ventricle
• 2. Focal lesions in one or both dorsolateral sectors of the rostral brain stem
• 3. Microscopic evidence of widespread damage to axons

Question 13

What are the secondary mechanisms which may cause brain injury?

Answer 13

• Raised ICP
• Localised oedema around contusions
• Hypoxic damage
• Neurochemical / cellular changes

Question 14

What are the types of consequences of head injury?

Answer 14

• Neurological impairment
• Medical complications
• Cognitive / behavioural complications
• Longer term lifestyle difficulties

Question 15

What are the common neurological complications of TBI?

Answer 15

• Visual changes, esp diplopia CNVI palsy), altered accommodation and hemianopia
• Anosmia (40%)
• high level balance / coordination difficulties / vertigo / dizziness
• focal neuro deficits less common, related to focal trauma (e.g. assault with blunt instrument)

Question 16

What are the likely medical complications of TBI?

Answer 16

• Spasticity
• Post traumatic epilepsy
• Heterotopic ossification
• Hydrocephalus (less common)
• Endo: SIADH and DI
• Psych e.g. depression

Question 17

Type and management of spasticity post TBI?

Answer 17

May be generalised but usually causes focal problem.

• Rx: baclofen, botox if focal
• PT e.g. positioning, stretching

Question 18

What is baclofen?

Answer 18

• CNS depressant and muscle relaxant
• GABA receptor agonist
• Beneficial effects in spasticity result from action at spinal and supra spinal sites

Question 19

Prevalence post traumatic epilepsy?

Answer 19

8%

Question 20

High risk injuries for development post traumatic epilepsy?

Answer 20

• Open head injuries
• Penetrating injuries
• Large intracerebral bleeds
• Pts who have early seizure (24h>7d)

Question 21

Impact of seizures in first 24h on development of post traumatic epilepsy?

Answer 21

DO NOT IMPACT

Question 22

What is heterotopic ossification?

Answer 22

Laying down of abnormal bone around joints

Question 23

How does heterotopic ossification present?

Answer 23

Increased pain, heat, redness, swelling, decreased movement and often increased spasticity

Question 24

How is heterotopic ossification confirmed?

Answer 24

Triple phase bone scan

Question 25

How is heterotopic ossification managed?

Answer 25

- Indocid | - Surgery if functional impact once bone activity has ceased

Question 26

Where does heterotopic ossification most commonly affect?

Answer 26

In order: - hip - elbow - shoulder - knee

Question 27

When is hydrocephalus usually detected?

Answer 27

Rare complication; usually identified when pt function deteriorates or plateaus early in rehab

Question 28

What is PTA associated with (in addition to impaired memory)?

Answer 28

- Poor orientation - Poor attention - Disrupted sleep wake cycle - Fatigue - Capacity for easy overstimulation - Potential for significant agitation

Question 29

How is PTA measured?

Answer 29

- Period during which there is no reliable day to day memory. -Measured from time of injury EVEN IF PT IN COMA - measured using Westmead Scale (12pt) > orientation and memory

Question 30

When is a pt considered out of PTA?

Answer 30

Must score 12/12 for 3 consecutive days to be considered out of PTA

Question 31

Ideal management of PTA?

Answer 31

- Head injury service - Single room - Min stimulation - Restricted visitors - Reduce noise etc - Usu no therapy except to avoid complications (e.g. PT to min spasticity)

Question 32

What is indicated by PTA

Answer 32

Minor head injury (concussive type): quick and full recovery with appropriate management (except post concussion syndrome)

Question 33

What is indicated by PTA 24h-1w?

Answer 33

Moderate injury: recovery over months; may have residual problems but good functional recovery

Question 34

What is indicated by PTA 1-2weeks?

Answer 34

Moderate injury: good functional recovery over months

Question 35

What is indicated by PTA 2-4w?

Answer 35

Moderate-severe injury: prolonged recovery process over 1-2y. Permanent deficits likely.

Question 36

What is indicated by PTA >4w?

Answer 36

Severe injury - permanent deficits certain. Likely significant disability.

Question 37

What is PTA a marker of?

Answer 37

Cognitive deficits; NOT physical or language based disorders

Question 38

what are the most likely cognitive / behavioural problems post TBI?

Answer 38

- Memory impairment esp new learning - Frontal executive problems (problem solving, planning and organisation, idea generation, rigidity of thinking, judgement, impulsivity). Increased frustration, lack of insight, disinhibition. - Reduced attention (time, detail) - Fatigue - Reduced speed of information processing

Question 39

What are the main aims of TBI rehab?

Answer 39

- Monitor duration and reduce behavioural effects of PTA - Prevent complications / medical conditions - Assess cognitive and functional status on emergence from PTA - Remediate disability / activity limitation - Provide education for patients and carers - Follow up

Question 40

What are the longer term participation restrictions of TBI?

Answer 40

- Inability to return to work, $ stress - Difficulties maintaining and forming personal relationships - Minimal participation in recreation activities - Increased strain on family supports - Difficulties with independent living

Question 41

What is post concussion syndrome?

Answer 41

Subgroup of patients who develop persistent symptoms following minor head injury. Sx= - HA - Dizziness - Complaints of memory disorder esp STM - Fatigue - >3m post event

Question 42

Initial PTA Mx issues?

Answer 42

- appropriate PTA Mx (environment) - Assess basic physical functioning - Monitor behaviour, educate carers - Manage SIADH / other medical

Question 43

Mx issues on emerging from PTA?

Answer 43

- Formally assess cognitive state (1-3w post PTA) - Assess competency - Educate client and carers re potential outcome given duration - Education re drugs and alcohol - Education re driving (not for 3months, may need OT assessment) - Assess functional implications of injury - Assess ability to live independently - Refer to appropriate services

Question 44

Issues to review in OP follow up TBI? ~6w post discharge

Answer 44

- When to act on vocational rehab referral - Medically clear for driving assessment - Continue to encourage EtOH abstinence - Regular review on scheduled program (1,2,3,5,7,10y)