Traumatic Brain

Injury
TBI

Nabeel Kouka, MD, DO, MBA

www.brain101.info
 Brain Injuries

Congenital brain injury Acquired Brain Injury

Pre-birth During birth After birth process

Traumatic Brain Injury

(external physical force)
Non-traumatic
Brain Injury
Closed Head Open Head
Injury Injury
 What is a TBI?
Sudden damage to the brain due to an external
force.

2 Types
• Closed Head Injury- Occurs when the head
forcefully collides with another object (for
example the windshield of a car) but doesn't
fracture or penetrate the skull.

• Open Head Injury- Occurs when an object (for

example a bullet) fractures the skull and
debris enters the brain and rips the soft brain
tissue in its path.
 Epidemiology
Percentage of Average Annual Traumatic Brain Injury-Related Emergency
Department Visits, Hospitalizations, and Deaths, by External Cause, United States,
1995-2001

Suicide, 1% Unknown,
9%
Other Transport, Other, 7%
2%
Falls, 28%
Pedal Cycle
(non MV), 3%

Assault, 11%

Motor Vehicle-
Traffic, 20%
Struck
By/Against, 19%
National Prevalence Rates of Various
Disabilities
400,000 w/ Spinal Cord Injuries

500,000 with Cerebral Palsy

2 million Americans with Epilepsy

3 million with Stroke disabilities

4 million with Alzheimer’s Disease

5 million with persistent mental illness

5.3 million with TBI disability

7.3 million Americans with mental retardation

TBI in the United States (by Cause)

Motor Vehicle
- Traffic
9% 20%
Falls

Ass ault
32%

28% Other

11%
Unknown
 Two types of TBI

OPEN-HEAD CLOSED-HEAD
INJURY INJURY
(penetrating)
Example:
Example:
• Coup-Contra Coup
• Skull fracture that
• Diffuse axonal injury
penetrates the brain
• Gunshot wound
 Two Classes of Brain Injury
• PRIMARY • SECONDARY
THE INJURY IS MORE THE INJURY EVOLVES OVER
OR LESS COMPLETE A PERIOD OF HOURS TO
AT THE TIME OF DAYS AFTER THE INITIAL
IMPACT
TRAUMA
1. SKULL FRACTURE
1. BRAIN SWELLING/EDEMA
2. CONTUSION/ BRUISING OF 2. INCREASED INTRACRANIAL PRESSURE
THE BRAIN 3. INTRACRANIAL INFECTION
4. EPILEPSY
3. HEMATOMA/BLOOD CLOT 5. HYPOXEMIA (LOW BLOOD OXYGEN)
ON THE BRAIN
6. HIGH OR LOW BLOOD PRESSURE
4. DIFFUSE AXONAL INJURY 7. ANOXIA/HYPOXIA (LACK OF OXYGEN TO
THE BRAIN)
 TBI Severity Levels
• Mild- Only when there is a change in the mental status
at the time of the injury; concussion.

• Moderate- Loss of consciousness last for minutes to

hours; confused for days or weeks. Impairments can
be temporary or permanent.

• Severe- Unconscious state for days, weeks, or months.

Impairments are permanent.
 TBI in children
can be especially devastating,
as a child’s brain is in an almost constant
state of development.
Brain Rates of Development
5 Distinct
Periods of
Maturation
P - O parietal/
occipital

P-O C central (limbic &

brainstem)
C
P-O T T temporal
T C F-T
C P-O
F - T frontal/
F-T temporal
F-T
 Cerebral Cortex

Numerical Data

 Number of neuronal cells in cerebral cortex

neurons ----------- 10-15 billion
glial cells ---------- 50 billion

 Estimation of number of cortical neurons

von Economo and Koskinas (1925) 14.0 billion
Shariff (1953) 6.9 billion
Sholl (1956) 5.0 billion
Pakkenberg (1966) 2.6 billion
Normal Brain CT Scan

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 Brain Concussion

• Impaired function (varying time frame)

• No structural damage to speak of directly
• Can lead to degradation over time
• Extreme variance in severity
– LOC

• Diffuse
Brain Concussion

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Brain Contusion

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Contusion w/Contra-Coup Injury

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Diffuse Axonal Injury

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Intraventricular Haemorrhage

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Intraventricular Haemorrhage

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 Brainstem Haemorrhage

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 Subarachnoid Hemorrhage

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a. Subarachnoid Hemorrhage b. Transtentorial herniation

c. Intraventricular hemorrhage e. Diffuse axonal (shearing) injury
 Intracranial Haematomas
• Epidural
– arterial bleeding
– quick onset
– less common

• Subdural
– venous bleeding
– wide range of onset time
– can build on each other without symptoms
Acute Subdural Haematoma

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Acute Subdural Haematoma w/Midline
Shift

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 Chronic Subdural Haematoma
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* Heterogeneous mass
a. Focal convexity of medial
margin
b. Dilated Ipsilateral Ventricle
c. Midline Shift
d. Diffuse Brain Edema
e. Scalp Hematoma
Acute Epidural Haematoma

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 Management
The specific goals in the acute management of
severe traumatic brain injury are:
1. Protect the airway & oxygenation
2. Ventilate to normocapnia
3. Correct hypovolaemia & hypotension
4. CT Scan when appropriate
5. Neurosurgery if indicated
6. Intensive Care for further monitoring and management
 Significant Head Injuries

• Signs of increased intercranial pressure

– Visual difficulties
– Vomiting
– Dyspnea
– Decreased pulse
Glascow Coma Scale
 Intracranial Pressure (ICP)
v.Intracranial (constant) = v.Brain + v.CSF + v.Blood + v.Mass Lesion

CPP = MAP - ICP

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CPP: Cerebral Perfusion Pressure
MAP: Mean Arterial Pressure
ICP: Intracranial Presure
 Indications for ICP Monitoring
Indications for ICP monitoring Risk of raised ICP
Severe Head Injury (GCS 3-8)
* Abnormal CT scan 50-60%
* Normal CT Scan
Age > 40 or BP < 90 mm Hg 50-60%
or abnormal motor posturing
* Normal CT scan 13%
No risk factors
Moderate Head Injury (GCS 9-12)
* If anaesthetised/sedated Approx. 10-20% will deteriorate
* Abnormal CT scan to severe head injury
Mild Head Injury (GCS 13-15)
* Few indications for ICP measurement Only around 3% will deteriorate
 Key Recommendations
Maintenance of CPP reduces mortality in severe head injury.

• ICP monitoring is recommended in most comatose patients

with severe head injury.

• ICP should be treated when > 20 mm Hg,

Hg but maintenance

of CPP is probably more important.

How Brain Injuries treated?
How Brain Injuries treated?