Traumatic Brain Injury - Dougherty

Question 1

Who must clear a young athlete to return to play?

Answer 1

A licensed health care professional.

Question 2

Self-reporting of TBI in females.

Answer 2

• Drowsiness and noise sensitivity.

- Longer post-concussion symptoms - higher score 3 months post-injury

Question 3

Self-reporting of TBI in males.

Answer 3

*Cognitive deficits and amnesia

Question 4

What is morbidity v. mortality?

Answer 4

Morbidity are long term effects post-injury.

Mortality is death.

Question 5

What 3 ages are most likely to sustain TBI?

Answer 5

1. Children (MALES) AGED 0-4
2. Older adolescents aged 15-19yo
3. Adults aged 65yo and older (falls)

Question 6

What age group has highest rates of TBI-related hospitalization and death?

Answer 6

Adults, 75+yo

Question 7

What are the respective results of diffuse neurodegeneration in the 1) cortex and 2) hippocampus?

Answer 7

• ESP. MALES+dopamine involvement
  1. Cortex=cognitive impairment
  2. Hippocampus = memory impairment

Question 8

• *Define the frontal and temporal poles: coup and contrecoup.
• Where does the major injury occur?

Answer 8

Coup - site of injury

Contrecoup - site diametrically opposite (site of major bleeding/injury)

Question 9

What is the difference between hemorrhage of brain tissue in a wedge-shaped area: subacute v. remote contusion?

Answer 9

Subacute - contusion and necrosis

Remote contusion - can cause depressed area of cortex and plaque formation.

Question 10

What is one of the initial pathophysiological changes in TBI? Ultimately leads to what?

Answer 10

Axolemmal permeability/mechanoporation, leading to Ca influx and subsequent calpain activation.
Ultimately: swelling in contiguous axons and finally, secondary AXOTOMY
TWISTING OF AXONS&raquo_space; TANGLES = inability to resolve

Question 11

What is significant about c-Jun N-terminal Kinases?

Answer 11

**THE REPAIR SQUAD - negatively affected by TBI = no recovery.
- Neurite outgrowth and elongation, brain development, apoptosis, axonal injury.
(Plays a role in normal growth and apoptosis necessary for recovery.)

Question 12

Memory deficits in 1) mild TBI and 2) Severe TBI.

Answer 12

Mild - transient deficits

Severe - permanent morbidity

Question 13

Neurons in what cortex have “memory fields”?

Answer 13

Prefrontal cortex (PFC) + dopamine

Question 14

What happens to dopaminergic afferents to the PFC pyramidal neurons after contusive brain trauma?
What can this subsequently lead to?

Answer 14

• Expression increased in PFC anywhere from 3hrs to 3days after injury.
• Can lead to depression-type sequella (dop and effects on 5Ht)

Question 15

What are the major things a licensed health care professional must evaluate to clear in a young athlete in order for them to return to play?

Answer 15

1. Comprehensive hx and PE&raquo_space; Neuro/mental status exam, Gait/Balance, Cognitive function
2. Clinical status determination (improvement v. deterioration)

Question 16

How long can neuropsychiatric sequelae last after TBI?

What are 2 manifestations/sequelae?

Answer 16

• For up to 3 months, some event for years.

- 1) Cognitive Deficits and 2) Behavioral manifestations

Question 17

What are 3 cognitive deficits?

Answer 17

Cognitive Deficits: Imparied attention, memory, decreased executive function

Question 18

What is one of the most frequently reported behavioral sequelae in TBI?

Answer 18

Major depression

Question 19

**What are 5 tests in the Gait and Balance Assessment?

Answer 19

1. **Romberg
2. **Romberg S (F shoulder/arm to 90, pronate/supinate, then touch nose with shoulder still F+ABD)
3. Single leg standing
4. Heal-toe walking
5. Normal gait

Question 20

What does SCAT2, ImPACT, etc. test?

Answer 20

Neurpsych evaluation - Used to develop a baseline and future assessment.

Question 21

What is the timeline for neurocognitive/psych testing?

Answer 21

• BASELINE taken before concussion occurs.
• Post concussion: testing at 24-72 hours, then again at Day 5-10.
• Must be BACK TO BASELINE before return to play.

Question 22

What are 8 domains measured with neurocognitive testing?

Answer 22

Combine: Baseline score
Memory,
Working Memory
Attention
Reaction time
Mental speed
Verbal memory
Visual memory
Processing speed

Question 23

Under what 4 conditions should an IMMEDIATE CTscan be considered?

Answer 23

1. Prolonged LOC (>1min)
2. Post concussive prolonged seizures
3. Major neuro deficits (esp motor)
4. Significant lethargy or rapid/progressive worsening of symptoms.

Question 24

What do CT or PET scans show in majority of cases?

What can functional MRI reveal?

Answer 24

• CT/PET unremarkable.

- fMRI can reveal tangles/decreased cortical blood flow to PFC during acute post-concussion.

Question 25

What is the only known effective treatment for a concussion?

Answer 25

REST

Question 26

What meds can be given?

Answer 26

- **Tylenol** for HA - drug of choice - NSAIDs (not in lg amounts bc TBI is a bruise) - No sedating meds

Question 27

Under what three condictions must athletes be asymptomatic in order to return to play?

Answer 27

At rest + With cognition + With exertion = ASYMPTOMATIC ALL THE TIME

Question 28

After what time frame marks probable longer recovery times?

Answer 28

More 5-15 minutes of mental status changes/"being out of it" after the concussion occurs. (v. 5 min)

Question 29

***3 components that need to be NORMAL before athlete can return to play?***

Answer 29

1. Neurocognitive 2. Symptoms 3. Physical Exam

Question 30

***Protocol for return to play? | What are the stages?

Answer 30

1. Cognitive and physical rest until asymptomatic 2. Light aerobic exercise 3. Sport-specific aerobic exercise 4. Non-contact drills; light resistance training 5. Full-contact training if medically cleared. 6. Game play

Question 31

Is the time frame for returning to play?

Answer 31

- At least 24 hours for each stage (1 week total), but CONSIDER MAKING EACH STAGE 2-3 DAYS for severe or multiple concussions.

Question 32

What three things should happen if sxs recur with exertion?

Answer 32

1) return to previous stage OR 2) rest for additional 1-3 days OR 3) Return to stage 1

Question 33

***What are 2 complications of concussions?

Answer 33

1. Postconcussion Syndrome -persistence of concussion sxs for >3mo post injury (neurophys/neuropath changes dt tangles/twisting) 2. 2nd Impact Syndrome - vulnerable period, especially in athletes

Question 34

**Describe 2nd Impact Syndrome

Answer 34

Before brain has fully healed, get another concussion, resulting in... - profound engorgement, massive edema, increased ICP - BRAIN HERNIATION, COMA, DEATH - MORBIDITY = 100% - MORTALITY = 50%

Question 35

At what point do you consider a neurology referral for an athlete?

Answer 35

- Increasingly getting injured more easily - SX GREATER THAN 2-3 WEEKS of complicated or severe symptom course. - Change in baseline cognitive function - Convulsions - Repeated concussions (proximity or requiring less force)

Question 36

7 things that MAY predict a prolonged recovery.

Answer 36

- Severe sx/duration more than 10 days - LOC more than 1 min - Less than 18yo - Co-morbidities (migraine, depression, ADHD, LD, sleep disorders) - Psychoactive drugs, anticoagulants - Dangerous style of play - Contact/collision sport, high sporting level