8/23/2015

CVA & TBI

Cerebrovascular Disease
Kenneth Mutia, PTRP

Cerebrovascular Disease Cerebrovascular Disease

•AKA Cerebrovascular Accident, Stroke, • “Non-traumatic brain injury caused by occlusion or

rupture of cerebral blood vessels that results in sudden
or Brain attack neurologic deficits” (Braddom, 2011)
•Ancient Name? • Sudden occurrence of permanent damage to an
area of the brain caused by a blocked blood vessel
or bleeding within the brain
• Characterized by:
• Loss of motor control
• Altered sensation
• Language and/or cognitive impairment
• Disequilibrium
• coma

CVD: Epidemiology CVD: Risk Factors

• Non-modifiable • Modifiable
•3rd leading cause of death • Age • Hypertension
•Leading cause of disability • Gender • Heart disease
• Race • DM
•Incidence 2x every decade after 55y/o • Family history • Smoking
•Incidence of DEATH: • History of previous • Metabolic syndrome
stroke or event • Sedentary lifestyle
ICH>SAH>Thromboembolic
• Obesity
•30% of survivors → significant disability • Behavior or personality

1
 8/23/2015

CVD: Early Warning Signs CVD: Temporal Classification

• Sudden numbness or weakness of the face, •Transient Ischemic Attack

arm or leg; esp. on one side of the body
• Sudden confusion, trouble speaking, or
understanding
• Sudden trouble seeing
• Sudden trouble walking, dizziness, loss of
balance or coordination
• Sudden or severe headache
• Temporary blood flow interruption to the
brain
• Lasts to few minutes to hours, but >24 hrs
•Reversible Ischemic Neurologic Deficits
• Focal neurologic deficits recover within a
week
• >24hrs but <1week

CVD: Temporal Classification CVD: Pathophysiology

•Stroke in Evolution
• Stepwise incrementation ↑s in
CVD
neurologic deficits Ischemic 85% Hemorrhagic 15%
•Completed Stroke
• When no further deterioration in ICH 10% SAH 5%
neurologic status is seen
• Neurologic deficits stabilize
Thrombosis Embolic 20% Lacunar 5%
60%

CVD: Pathophysiology CVD: Ischemic Stroke

Interruption of blood flow •↓ blood distribution to the area

secondary to occlusion
Complete cerebral circulatory arrest
•Turbulence in bloodflow d/t HTN →
Core area of focal infarction & Ischemic
penumbra
damage in the intima → blood clot →
atherosclerosis
Ischemic Cascade
•↓ in blood vessel diameter → ↑
Further damage to brain cells
resistance → ↑ HTN
•6-8 min

2

CVD: Ischemic Stroke
•Produces cerebral edema
•Reaches a maximum by 3-4 days
•Generally subsides & disappears by 2-3
weeks
•Significant edema can ↑ICP
Ischemic Stroke: Embolic
•Emboli
•Smaller arteries
•Origin of embolus? Heart or peripheral
Vessels?
•Occurs in the morning or with activity
Ischemic Stroke: Lacunar
• Most common sites
• Internal Capsule
• Basal ganglia
• Thalamus
• Corona radiata
• Paramedian region of the brainstem
• Long standing HTN or DM
•Noteworthy: Earlier, more rapid, and
greater degree of neurologic recovery
8/23/2015
Ischemic Stroke: Thrombotic
• Thrombus formation → blockage of blood
flow
• Atherosclerosis
• Preceded by TIA 50% of the time
• Larger arteries
• Common sites
• Bifurcations of common carotid artery
• Origin of MCA & ACA
• Origin of Vertebral arteris & Subclavian Arteries
• Usually occurs at night or with inactivity
Ischemic Stroke: Lacunar
• Mini-thrombotic stroke
• Focal in nature (<1.5 cm diameter)
• Purely Sensory or Purely Motor
• What kind of arteries?
Hemorrhagic Stroke
•Rupture in cerebral arteries
•Sudden ↑ in HTN or Aneurysm
•Rarest type of stroke but most
catastrophic
•Loss of Consciousness
•Initial prognosis: 50-70% mortality rate
•If survived: best prognosis
•Hallmark?
3
 8/23/2015

Hemorrhagic Stroke: Intracerebral Hemorrhagic Stroke: Subarachnoid

• Blood vessel rupture •Bleeding into the subarachnoid space and

• Charcot-Bouchard aneurysm, AVM filling the basal cisterns
• Most common site •2nd-3rd decade of life – AVM
• Putamen
• Caudate •5th-6th decade of life – Succular Aneurysm/
• Pons Berry aneurysm – large vessels
• Cerebellum • Anterior part of CoW
• Thalamus
• Deep white matter •Worst Headache of my life 
• Younger patients •F>M

Hemorrhagic Stroke

•Hydrocephalus – complicates the stroke

•Obstruction of CSF flow
•Normal Pressure Hydrocephalus
• Complication of SAH Clinical Syndromes
• Communicating type
• TRIAD?

Circle of Willis

•Components?

4
 8/23/2015

Middle Cerebral Artery Syndrome

•MCA is the most common occluded

artery; the largest branch of ICA
•Lenticulostriate arteries – terminal
branches of the MCA

MCA Stroke: Main Stem MCA Stroke: Main Stem

•Contralateral hemiplegia • Dominant • Non-dominant

• Global Aphasia • Approsody
•Contralateral hemianesthesia • Apraxia • Anosognosia
• UE & Face > LE • Gertsmann Syndrome • Asomatognosia
•Homonymous hemianopsia • Affective Agnosia
• Visiospatial Deficit
•Frontal Gaze Pattern • Neglect Syndrome
•Dysphagia • Dysphagia
•Uninhibited neurogenic bladder • Upside-down reading

5
 8/23/2015

MCA Stroke: Upper Division MCA Stroke: Lower Division

• Dominant • Nondominant • Homonymous • Nondominant
• Broca aphasia • Aprosody hemianopsia • Affective agnosia
• Apraxia • Visuospatial deficit • Dominant
• Neglect syndrome • Wernicke aphasia

ACA Stroke PCA Stroke

• Contralateral hemiplegia •Hemisensory deficit
• Contralateral hemianesthesia •Dejerine-Roussy Syndrome
• LE > UE
• Frontal Gaze Pattern •Visual impairment
• Grasp reflex—groping •Visual agnosia
• Paratonia (or Gegenhalten) •Prosopagnosia
• Disconnection apraxia •Dyschromatopsia
• Akinetic mutism (abulia) •Alexia without agraphia
• Perseveration
• Sucking Reflex •Memory deficits

VBA Stroke Lacunar Strokes

• Loss of consciousness Syndrome Site
• Cranial Nerve Dysfunction Pure Motor
Internal Capsule – posterior limb
Basis Pontis
• Dizziness Pyramids
• Diplopia Thalamus
• Dysphagia Pure Sensory
Thalamocortical projections
• Dysphonia/ Dysarthria Sensory-Motor Junction of internal capsule & Thalamus
• Pontine Gaze Pattern
• Bulbar Symptoms
• Crossed motor/sensory syndrome
• Cerebellar Symptoms

6
 8/23/2015

Lacunar Strokes Brainstem

Syndrome Strokes
Site Symptoms
Weber Medial Basal of Midbrain C/L hemiplegia; I/L CN3
C/L loss of pain & To
Syndrome Site C/L of Joint posn
Benedikt Tegmentum of Midbrain C/L Ataxia & Chorea
Dysathria-Clumsy Internal Capsule – Anterior Limb I/L CN3
Hand Pons (B) Hemiplegia
Ataxic Corona Radiata; Internal Capsule; Pons Locked In Bilateral Pons (B)CN palsy
Hemiparesis Cerebellum Spared?
I/L CN6
Hemiballismus Head of caudate, thalamus, subthalamic nuclei Millard-
Lateral Pons I/L Facial Paralysis
Gubler C/L Hemiplegia
I/L Hemiataxia
I/L CN5
C/L loss of Pain & To
Wallenberg Lateral Medulla Nystagmus
I/L Horner’s syndrome
I/L Dyshpagia & Dysphonia

Madami ang Brainstem Strokes  Brainstem Strokes

• MIDBRAIN •PONS
Syndrome Site
Syndrome Site
Weber CN3 + Hemiplegia
Claude CN3 + Ataxia & Tremor Millard-Gubler/ AICA/ LIPS CN 6, 7, 8
CN3 + CHAT MIPS CN 2, 3, 6
Benedikt Raymond-Cestan/ UDPS CN 5, 6
(Chorea, Hemiplegia, Ataxia, Tremors)
Nothnagel* CN3 + Gaze paralysis + Ataxia Foville/ LDPS CN 6
Parinaud* Dorsal midbrain; loss of upward gaze

Brainstem Strokes

•MEDULLA
Syndrome Site
Avellis CN 9, 10
Wallenberg/ PICA/ LMS CN 5, 9, 10 CVD Impairments
Jackson CN 9-12
Pseudobulbar Palsy CN 7, 9-12
Dejerine/ MMS 12

7
 8/23/2015

Stages of Motor Recovery Stages of Motor Recovery

•Bobath •Brunnstrom
Stage Stage

Flaccidity Flaccidity

Spasticity Spasticity starts to appear

Relative Recovery Peak of spasticity

Spasticity starts to decline
Spasticity further declines
Spasticity disappears
Normal

Synergy Patterns Associated Reactions

Associated Reaction Description
Upper Extremity Lower Extremity Sterling’s Phenomenon Resisted Abd/Add of (N) side →
FLEXOR EXTENSOR FLEXOR EXTENSOR Abd/Add of Weak side (UE)
Scap Retract + Scap Protract + Raimiste’s Phenomenon Resisted Abd/Add of (N) side →
Elevate Depress Abd/Add of Weak side (LE)
Sh ABER Sh ADIR Hip FABER Hip EADIR Soque’s Phenomenon Arm elevation → hand will open
Elbow F Elbow E Knee F Knee E Homolateral limb Movement of the UE/LE → mimic
FA Sup FA Pron Ankle DF Ankle PF synkinesis by the LE/UE of the same side
Wrist F Wrist Ext Foot Inv Foot Ev
Finger F Finger F Toe PF Big toe E Toe PF Big toe E

What muscles are not involved in the synergy/ unaffected

by spasticity?

Associated Reactions Tone

Associated Reaction
Marie Foix
Huntington’s
Phenomenon
Listing Phenomenon
Instinctive grasp reflex
Instinctive avoiding
reflex
Pusher’s Syndrome
Description
Leg Ext + Toe Flex → Knee & Hip
Flex •Modified ashworth scale
Sneeze or Cough → ↑ Spasticity 0
1
Leaning on affected side
+1
Contact on palm → grasp
Contact on palm → avoid 2
3
Strong side will push the weak 4
side; weight bearing occurs on
weak side when sitting

8
 8/23/2015

Tone Apraxia
HYPOTONIA Cerebellar lesion
LMNL •Inability to perform skilled movement
HYPERTONIA UMNL despite having no loss of motor power,
Spasticity (velocity-dependent) - Pyramidal
* Opistotonus (extensor: head + neck) sensation, & coordination
Rigidity (velocity-indep)
* Cogwheel (leadpipe + tremor) - Extrapyramidal •Loss of ability to carry out correctly
* Leadpipe/ Plastic
CLONUS efferent discharge
certain movements in response to
(Extrapyramidal) stimuli that normally elicit them

Apraxias Apraxias
Apraxia Description Apraxia Description
Ideomotor Inability to carry out motor commands but can do Dressing Inability to dress one self
sponatneously Gait Inability to initiate walking
Ideational Inability to carry out motor commands, also cant do Sympathetic Apraxia of the unaffected hand
sponatneously
Kinetic-Limb Clumsiness or maladroitness of the limb
Oral Unable to carry out facial commands; most common
Alien hand Hand has a mind of its own
Constructional Difficulty producing 2D or 3D designs

Aphasias Aphasias

•Acquired language disorder in which NAMING (–)

there is an impairment in any of the FLUENCY (+) (–)
language modalities
•Disorder of language caused by a defect COMPREHENSION (+) (–) (+) (–)

in either production or comprehension

REPETITION (+) (–) (+) (–) (+) (–) (+) (–)
of vocabulary syntax
CONDUCTION

T. SENSORY

WERNICKE
ANOMIC

T. MOTOR

GLOBAL
BROCA

MIXED

9
 8/23/2015

Aphasia Map Aphasia Map

Aphasia Artery Areas Aphasia Artery Areas

Global MCA, superior B+W Transcortical ACA Anterior or superior to B
(early) Motor
Transcortical Sensory PCA Postero-inferior to W
Broca’s MCA, superior Broca’s area
(late) (postero-inferior frontal) Mixed Border of frontal, parietal,
temporal
Wernicke’s MCA, inferior Wernicke’s area
(postero-superior temporal)

Aphasia Map Language/Speech Impairments

Aphasia Artery Areas Impairment Description

Conduction MCA Parietal Anomia Inability to name
(insula, arcuate fasciculus) Agraphia Inability to write
Anomic MCA Temporo-parietal Aprosody Absence in deflection and difference in tone
Angular gyrus
Echolalia Repeats words that are heard

Language/Speech Impairments Language/Speech Impairments

Impairment Description Impairment Description
Palilalia Repeats syllables that are heard Neologism Coining of new words
Syntactic Telegraphic speech Jargon Incomprehensible speech
Aphemia Slow halting articulation but normal comprehension & Logorrhea Press of speech/ nonsense
writing Aphrasia Inability to speak in phrases; person may able to speak or
Aggramatism Sparse, hesitant, groping speech limited to most understand single words but not be able to communicate
essential content words with words that are arranged in meaningful sentences

10
 8/23/2015

Language/Speech Impairments Language/Speech Impairments

Impairment Description Impairment Description
Semantic Interchange 2 items normally found together (i.e spoon Perseveration lacking ability to transition or switch ideas
paraphrasia and fork) appropriately with the social context, as evidenced by
Phonemic Interchange 2 words that sound like them (i.e sheep & the repetition of words or gestures after they have
paraphrasia sheet) ceased to be socially relevant or appropriate
Confabulation production of fabricated, distorted or misinterpreted
memories about oneself or the world, without the
conscious intention to deceive

Visual Deficits Visual Deficits

Impairment Description Impairment Description
Somatognosia/ Lack of awareness of body structure and Visual agnosia Failure to recognize visually presented objects
autopagnosia relationship of body part to one self but can recognize with auditory or tactile cues
Unilateral neglect Inability to register or integrate stimuli and Prosopagnosia Inability to recognize familiar faces
perceptions from one side of the body and the Color agnosia Inability to recognize colors
environment
Simultagnosia Inability to perceive more that one thing at a
Anosognosia Failure to recognize severity of condition time
Finger agnosia Confusion in naming and localizing stimuli on Balint’s Syndrome Simultagnosia, ocular apraxia, optic ataxia
fingers

Perceptual Deficits Visual/ Perceptual Deficits

Impairment Description
Impairment Description Astereognosis Inability to recognize objects with touch
Figure-ground Inability to visually distinguish a figure from Circumlocution Can not retrieve name, can describe objects
discrimination d/o the background but can not name
(R)-(L) discrimination Inability to identify left & right side Alexia Inability to read
d/o Agraphia Inability to write
Topographical Difficulty remembering relationship of places Word deafness Cant perceive a word heard but can
disorientation with one another understand the word if read
Vertical disorientation Disoriented orientation of what is vertical Gertsmann syndrome
Stereopsis Inability to visualize depth

11
 8/23/2015

Gaze Impairments

PONTINE GAZE FRONTAL GAZE

Vertebrobasilar territory ACA, MCA
Pontine nuclei Area 8
Looks away from the lesion Looks towards the lesion
Looks towards the Looks way from the
hemiplegic side hemiplegic side

Hemispheric Behavior Differences

Behavior LEFT RIGHT
COGNITIVE Linear manner of Simultaneous/ holistic
processing information
PERCEPTION Language Non-verbal stimuli,
inferences
ACADEMICS Reading recognition and Reasoning in math
comprehension Judgment
Math
MOTOR Movement on command Sustaining a movement
EMOTIONS Positive emotions Negative emotions

Hemispheric Behavior Differences

LEFT CVD RIGHT CVD
Communication Impairment Visual & motor deficits
Depressed, labile Loss of visual memory
Learn by demonstration Impulsive, impatient
Requires supervision Lack of insight and judgement
Traumatic Brain Injury

12
 8/23/2015

Traumatic Brain Injury TBI

•Injuries to the brain caused by an external •Single, largest indirect cause?

force •M>F, 15-25 years old
•No.1 killer of children & young adults •Falls>Assualt>Sports
•Sports
1.
2.

Mechanism of Injury Mechanism of Injury

•Acceleration Injury •Coup injury

• When a moving force hits the head • Injury of the brain is on the site of impact
• Most common cause?
•Deceleration Injury •Counter-Coup Injury
• When a moving head meets a stationary • Injury of the brain is on the opposite side
object of the brain
• Most common cause?

Primary Brain Injury Closed TBI/ Concussion

• Direct result of the MOI •Injury induced alteration of mental

• Local Brain Damage function
• CLOSED TBI aka Concussion or Brain Shake
•AKA mild TBI or minor head trauma
• OPEN TBI •Criteria: No Gross Changes in the brain
• Penetrating Injury
•Hallmark: Amnesia

13
 8/23/2015

Concussion Classification Cantu Guidelines for Concussion

Confusion Loss of Consciousness Amnesia Grade Post-Traumatic Amnesia LOC
I + 0 0 I or Mild <30 min None
II + 0 5’ II or Moderate 30 min- 24 hours <5 min
III + 5’ 5’ Retrograde III or Severe >24 hours >5 min
IV + 10’ 5’ Retrograde
V + 15’ 5’ Retrograde

•Grade 1 – patient may return to contact sports in 20 min

•Grade 2 & 3 – patient may return after 1 week of being
asymptomatic
•Grade 4 & 5 – patient may return after 1 month

American Academy of Neurology

Colorado Medical Society Guidelines
Classification
Grade LOC PTA Grade description
I (-) <15min I Confusion
II (-) >15min II Confusion + Post-traumatic Amnesia
III (+) III LOC

Primary Brain Injury Primary Brain Injury

•Diffuse Axonal Injury •Polar Brain Damage

• Shearing of subcortical axons within the
myelin sheath
• Most distinguishing feature of TBI
• Manifestation: LOC leading to Coma
• Most common affected: Subcortical white
matter
• Damage to the poles of the brain
secondary to acceleration injuries and
deceleration injuries
• Most common site: inferomedial aspect
of frontal and temporal lobe
• Second most common: occipital lobe

14
 8/23/2015

Primary Brain Injury Secondary Brain Injury

•Cranial Nerve Injury •Indirect result of MOI

Cranial Nerve Injury
•Not directly due to impact but as a
I Rhinorrhea
Affect both sides result of changes in the hemodynamics
II Racoon’s Eyes or Panda Bear sign and other functions of the brain
III 2nd most common injured
Anisocoria •Occurs after an hour to days post-
IV, VI Diplopia impact
VII Most common injured
VIII Battle’s Sign; Otorrhea

Secondary Brain Injury Secondary Brain Injury

•Hypoxic-Ischemic Injury •Intracranial hematoma

• Due to lack of oxygen and blood supply, • Epidural, subdural & intracerebral
the tissues undergoes death or infarction • Talk & Die Phenomenon
• Caused by vessel disruption •Increased Intracranial Pressure
• Pulmonary embolus, arrhythmia, arterial • Normal ICP?
hypotension
• Cushing’s Triad
• Herniations

Brain Herniations
Compressed
Types Herniating structure
structure

Uncal or tentorial
Uncus of temporal lobe thru
Cerebellum 1. Uncal
the tentorial notch
2. Central
Diencephalon or of temporal
Central or
lobe squeezed thru a notch in Medulla 3. Cingulate/subfalcine
transtentorial
the tentorium cerebelli
4. Transcalvarial
Cerebellar tonsils through the
Tonsilar Brainstem 5. Upward
foramen magnum

Subfalcine
Cingulate gyrus is pushed Brain tissue 6. Tonsillar
under falx ipsilateral ACA
Cerebellum upward d/t inc
Upward Midbrain
pressure in posterior fossa
Transcalvarial

15
 8/23/2015

Post-Traumatic Amnesia Post-Traumatic Amnesia

•Interval of permanently lost memory Duration Severity

<5 min Very mild
that occurs following the injury 5-60 min Mild
•Duration of PTA has a proportional 1-24 hours Moderate
relationship to coma duration 1-7 days Severe
1-4 weeks Very severe
> 4 weeks Extremely severe

Clinical Rating Scales Glasgow Coma Scale

•For prognosis and diagnosis Eye Opening Motor Verbal

•The higher the score, the better the 4 Spontaneous 6 Follows 5 Oriented

prognosis 3 Upon command 5 Localizes to pain 4 Confused

2 Pain 4 Withdraws to pain 3 Inappropriate words

1 NR 3 Decorticate 2 Incomprehensible sounds

2 Decerebrate 1 NR

1 NR

Glasgow Coma Scale Glasgow Coma Scale for Children

•13-15: mild TBI or concussion Eye Opening Motor Verbal

•9-12: Moderate TBI 4 Pursuit 4 Flexes & Extends 3 Cries

•3-8: Severe TBI, declared comatose 3 EOM intact, reactive

pupils
3 Withdraws to pain
2 Spontaneous
Respiration
when?
2 Fixed pipils or EOM
2 Hypertonic 1 Apnea
impaired

1 Fixed pipils or EOM

1 Flaccid
paralyzed

16
 8/23/2015

Glasgow-Liege Scale Rappaport Disability Rating Scale

• Severity of coma • Classify level of disability

• Death to no disability
• Assessment of brainstem reflexes • The higher the score, the more disabled
Reflex Description
Fronto-orbicular Reflex Orbibularis oculi contraction upon percussion SCORE Description SCORE Description
of glabella 0 No disability 17-21 Extremely severe
Vertical & Horizontal Doll’s Eye movement 1 Mild 22-24 Vegetative state
Oculocephalic/ Horizontal – move head from side to side 2-3 Partial 25-26 Extreme vegetative state
Oculovestibular Reflex Vertical – move head up & down
4-6 Moderate 30 DEATH
Oculocardiac reflex Bradycardia induced by increase pressure on
7-11 Moderately severe
eyeball
12-16 Severe
Pupillary light reflex

Galveston Orientation & Amnesia Test Functional Independence Measure

(GOAT) (FIM)
•Standard technique for assessing PTA • Independent
• 7 – help not needed
•0-100 • 6 – modified independent (c AD, longer, safety
•Normal score is > or equal to 75 considerations
•End of PTA: normal score for 2 days • Dependent
• 5 – supervision
• 4 – min contact assist, 75% indep
• 3 – mod contact assist, 50-75% indep
• 2 – max contact assist, 25-50% indep
• 1 – total assist

Glasgow Outcome Scale Glasgow Outcome Scale- Extended

Description
Grade DESCRIPTION I Death
I Death II Vegetative state Has sleep-wake cycles
II Persistent vegetative state III Lower severe disability Needs full assist in ADLs
III Severely disabled (conscious but disabled) IV Upper severe disability Needs supervision
IV Moderately disabled (disabled but indep) V Lower moderate disability Indep in ADLs, can shop & travel
V Good recovery Can return to work, needs
VI Upper moderate disability
modifications
Return to work s modifications
VII Lower good recovery
but reports difficulty
VIII Upper good recovery No difficulty

17
 8/23/2015

Ranchos Los Amigos Level of Ranchos Los Amigos Level of

Cognitive Functioning Cognitive Functioning
RLA Description
RLA Description IV Confused Patient exhibits bizarre, non purposeful, incoherent or
I No Response Unresponsive to any stimuli, comatose Agitated inappropriate behaviors, ha NO SHORT TERM RECALL,
II Generalized Response Non-purposeful inconsistent movement & attention is short and nonselective
verbalization Heighten state of activity
Have same response to varying stimulus Emotionally disinhibited or labile
NO respect for rules
III Localized Response Reacts specifically but inconsistent stimuli
CONFABULATION
Follows one step command but delayed and
Outbursts – changes, inconsitensies, restraint, talking
inconsistent
down on him

•Prevent risk of immobility

•Maintain functional capabilities, limit learning & outbursts
•No carryover of task; structured environment, consistensies
•Offer options

Ranchos Los Amigos Level of Ranchos Los Amigos Level of

Cognitive Functioning Cognitive Functioning
RLA Description RLA Description
V Confused Patient gives random, fragmented, and nonpurposeful VI Confused Shows goal-directed behavior but dependent on
Inappropriate responses to complex or unstructured stimuli Appropriate external output
Simple commands are followed consistently, memory Starts carry-over of simple tasks
and selective attention are impaired, and new Follows simple direction consistently
information is not retained
Severe memory impairment*
Gross attention but highly distractable • Increase motor control, strength, endurance, balance
May perform previously learned task • Motor learning approach
Unable to learn new information
•Use of memory aids
•Structured treatment – step by step procedure
•Feed back

Ranchos Los Amigos Level of Ranchos Los Amigos Level of

Cognitive Functioning Cognitive Functioning
RLA Description RLA Description
VII Automatic Able to recall and integrate past and recent events VIII Purposeful Patient oriented and responds to the environment
Appropriate Shows carry-over for new learning Appropriate but abstract reasoning abilities are decreased relative
needs no supervision once activities are learned to premorbid levels
May have decrease ability in abstract reasoning,
judgment, and tolerance to stress
Judgment still impaired
•Has judgement and problem solving abilities
•Increase coplexity of exercise or activity
•Weaning off from structured environment
•Ensure carry-over to new environment

18
 8/23/2015

Prognosis Other Impairments

Poorer Better •Behavioral changes
GCS <7 >7
Large blood clot
• Most enduring and socially disabling
CT SCAN Massive hemispheric Normal •Heterotrophic Ossification
bleeding
Age OLD YOUNG
• Most common site in TBI?
Pupillary reflex Remains dilated Pupils constrict • Most common cause?
Doll’s Eye sign Impaired Intact
Duration of PTA > 2 weeks < 2 weeks

Thank You.

19