Traumatic Brain Injury (TBI)

HESP406
Henk J. Haarmann, Ph.D.

What is it?
What causes it?
• Traumatic Brain Injury (TBI)
– Brain injury due to abrupt external force to the head
• Causes of TBI
– most frequent cause
• car accident
– 2nd most frequent cause
• falls
– 3rd most frequent cause
• assaults

Overview
• Neurology of TBI
– Incidence & Risk factors
– subtypes
– effects on the brain
– Prognostic factors
• Cognitive & communicative abilities
– attention
– memory
– visual processing
– abstract thinking, reasoning, problem solving
– language communication
– overlap with Right Hemisphere syndrome

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 Incidence & importance to SLP
• Incidence:
– 7,000,000 in US
– Leading cause of neurologic disability under age 50
• Why must the SLP know about it?
– In adult neurogenic approx. 50% of case load involves TBI
– SLP helps with language communication problems of TBI patients
• due to aphasia secondary to TBI
• due to attention, memory, & abstract thinking problems
– note SLP also expected to help with these problems perse, that is, outside
domain of language & speech
– Team-based rehab approach
• requires SLP to take part in treatment of TBI clients
– for example, sensory stimulation of TBI patients in coma, dysphagia

Risk factors (part 1)

• Gender:
– TBI more likely in male than female (2:1)
• Age: 15-20, then, infants, & older adults
– Leading cause of neurologic disability under age 50: TBI
• Alcohol & drugs (4 X risk)
• Car accidents, falls, & assaults
• Academic performance
• Socioeconomic status
• Population density

Risk factors (part 2)

• Personality type
– Type A > Type B
– Type A: competitive, impulsive, hostile
– Type B: co-operative, deliberate, helpful
• History of TBI
– Previous TBI (3 X risk)
– Second TBI (8 X risk)
• Sporting activity
• Motorcycling
• Bicycling (wearing helmet reduces risk by 88%)
• Driving a snow mobile
• Rock climbing

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 Risk factors (part 3)
• Can one isolate a risk factor and claim it has causative status?
– No, many risk factors interact / are correlated
• for example, use of alcohol & drugs & socioeconomic status are correlated

Types of TBI & effects on brain

TBI

Open head injury Closed head injury

Non-Accelerating Accelerating

Linear & Non-linear/

Angular
&coup versus contra-coup

Open-head injury
• Alternative term: penetrating head injury
– high velocity: gunshots, explosions
– low velocity: blow to head, motor vehicle accident
• Effect:
– skull fractured or perforated
– meninges torn or lacerated
– tissue destruction, bone, tissue, hair carried into brain, potential bacterial
infections
– Local damage rather than diffuse
• Survival: high mortality
– first day: if brain stem affected, then interference with respiration, cardiac &
other vital functions
– next days: infection, bleeding, intracranial pressure

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 Closed-head injury
• Alternative term:
– non-penetrating head injury
• Frequent causes:
– motor vehicle accidents, falls
• Effect: Skull?
– => intact
• Effect: Meninges?
– => not torn or lacerated
• Sub-types of closed-head injury:
– non-accelerating
– accelerating: linear versus non-linear/angular

Non-acceleration closed head injury

• Alternative term: fixed head injury
• Definition: no acceleration of head
– Moving object hits restrained (=fixed) head
– e.g., club or baseball strikes head
• Effect 1: impression trauma
– skull depressed against brain surface (brain is slighly elastic)
– localized damage to meninges and cortex
• Effect 2: ellipsoidal deformation
– change from oval to more circular shape
– stretching & shearing of ventrical walls, Corpus Callosum, Basal
Ganglia

Acceleration closed head injury

• Definition: sudden accelerating and stopping of head
– moving head suddenly accelerates and strikes stationary
object
• someone is driving, so their head is moving, their car is hit, driver’s
head accelerates in direction of windshield and bumps into
stationary windshield
• some suddenly falls and bumps their head into the sidewalk
• someone skies into a tree
– moving object strikes stationary but unrestrained head
• boxer strikes with boxing glove and hits opponent’s head
– head is violently shaken and undergoes abrupt changes in
moving direction
• shaken baby syndrome

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 Linear versus non-linear (acceleration
closed head injury)
• Linear:
– Direction of force
• a line passing through the central axis of the head and perpendicular to the
skull
• Result: head moves in direction of the force
• Non-linear:
– Direction of force
• a line that does not pass through the central axis of the head and that is at a
non-perpendicular angle to the skull
• Result: head moves away from the point of impact

Unique effects of non-linear acceleration

• Effect 1: when skull rotates and brain is still at rest

– twisting and shearing in axial structures (brain stem, cerebrum [in
particular, basal ganglia])
• Effect 2: when skull stops and brain still rotates
– more twisting and shearing

CNS Parts Cerebrum

* 2 hemispheres
* basal ganglia
Thalamus:
* hippocampus
relay station, attention
* limbic lobe
Cerebellum:
* motor
Hypothalamus: coordination
autonomous NS * balance

Brain stem:
* midbrain
* pons Reticular formation
* medulla arousal/sleep/wake

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 Unique effects of linear acceleration:
coup
• The brain is suspended inside skull

• When an external force impacts on the head,

– skull starts to move first
– the brain is inert and stays behind for few ms,
– so that skull moves into brain at point of impact of the force

Unique effects of linear acceleration:

contra-coup
• Brain picks up same speed as skull after few ms

• When an external barrier stops head

– skull suddenly stops
– the brain is inert and keeps moving for few ms,
– so that brain moves into skull opposite point of impact of the force

Unique effects of linear acceleration:

coup & contra-coup
• bruising and abrasions on surface of brain where it strikes
skull
• stretching and tearing
• more likely with frontal and posterior blows to head (more
epidural space between skull & brain)

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 Effects common to linear & non-linear
acceleration
• Effect 1: diffuse axonal injury, resulting in diffuse cognitive
and behavioral impairments
• Effect 2: abrasions and lacerations
– location: bottom surfaces frontal lobe & anterior temporal
lobe
• brain moves within cranial vault
• cranial vault has bony ridges and projections
• and much more so at floor of cranial vault
• bottom surfaces of frontal lobe & anterior temporal lobe
are right above floor of cranial vault
• parietal, occipital, & other parts of frontal lobe are
spared from effect 2

Secondary consequences of tbi - a

• 1) Traumatic hemorrhage
– Cause: laceration of meningeal or cerebral blood vessels
– Result: hematoma = accumulation of blood (4 types)
• Epidural hematoma: between dura mater and skull
• Subdural hematoma: between dura and arachnoid
• Subarachnoid hematoma: Rupture of pial vessels: less common
• Intracerebral hematoma: Rupture of blood vessels inside brain
• Time course: develop wihtin few hours - week after injury

Secondary consequences of tbi - b

• 2) Cerebral edema
– definition: accumulation of fluid
– location: between brain & skull, ventricles, brain tissues
– effect: increases intra-cranial pressure

• 3) Traumatic Hydrocephalus
– definition: expansion of ventricles
– note the very dangerous vicious cycle:
• compression of ventricles =>
• rise in cerebrospinal fluid pressure =>
• expansion of ventricles =>
• compression of brain structures =>
• increased intra-cranial pressure etc

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 Secondary consequences of tbi - c

• 4) Increased intra-cranial pressure

– cause: cerebral edema & traumatic hydrocephalus
– effect: compression and displacement of brain structures,
damage to cell walls, & blood vessels, coma & death if
uncontrolled
– measurement: surgically drill hole in skull & insert
pressure transducer into cerebrospinal fluid
– medical treatment:
• hyperventilation (decreases cerebral blood volume),
• steroids (reduces inflammation)
• diuretics (increases fluid release by body)
• barbituate-induced coma (decreases cerebral blood volume)

Secondary consequences of tbi - d

• 5) Ischemic brain damage

– definition: deprivation of oxygen carried in blood stream
– causes
• injury to cardiovascular and pulminary system => reduced blood supply to
brain
• elevated intracranial pressure => reduced blood supply to brain
• cerebral vasospasm => decrease carrying capacity of cerebral vessels
– most common site of damage: basal ganglia, watershed areas adjacent
to MCAs
• 6) Cerebral vasospasm
– definition: contraction of muscular layer surrounding blood vessels (15
to 20% of cases)

Prognostic factors (part 1)

• Survival
– time post onset: 50 to 75% of deaths occur within 72 hours
• Type of injury
(> ~ more severe damage ~ poorer prognosis)
– open > closed head injury (Luria, 1970)
– diffuse > focal
– closed head injury: accelerating > non-accelerating (X 20)
– closed head injury: acceleration: angular > linear
– closed head injury: non-acceleration: skull fractures ?
• There absence or presence does not predict severity of brain damage
• Reliable indicator of severity:
– depth and duration of coma

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 Glasgow Coma Scale (GCS, Teasdale &
Jenett, 1974)
• rates level of consciousness rated on basis
– of eye-opening , verbal responses, motor responses
GCS score Duration of coma
mild 13-15 20 minutes or less
moderate 9-12 in between
severe 8 or less 24 hours or more
&mild = post-concussive syndrome
• highly reliable but somewhat insensitive
– (e.g., failure to open eyes may be due to
facial swelling and no correction is made for this)

Post-traumatic amnesia (PTA)

• failure to remember events before and after accident
– retrograde (before)
– anterograde (after)
– the closer the event is in time to the accident the more likely it is to be
forgotten
– temporary, usually lasts longer than the coma
• possibly better predictor of recovery than duration of
coma:
– PTA from 1 to 4 weeks: 30% of patients (early rapid recovery)
– PTA > 1 month: 60% (permanent memory deficits)
– PTA > 3 months (permanent wide-range cognitive deficits)
• Test: Galveston Orientation and Amnesia Test (GOAT)
– Location & time, memory for events

Prognostic factors (part 2)

• Time post onset: 6-12 month period of spontaneous recovery
– recovery of functional language communication by 4 months (Groher,
1977)
– normal levels on aphasia battery by six months (Levin et al., 1981)
– below normal language expression after a year in adolescents (Campbell
& Dollaghan, 1990)
– most improvement on WAIS within 6 months (Bond, 1975)
– improvement in memory up to a 1 year (Lezak, 79)
– painstakingly slow progress after spontaneous recovery has reached its
plateau (6-12 months)

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 Prognostic factors (part 2)
• other factors (much less important)
– age (60 yrs old 2X mortality 20 yrs old)
– intelligence
– socio-economic status
– pre-morbid personality
– emotional problems

Cognitive deficits in TBI

• Post-traumatic amnesia
• Alertness
– tonic versus phasic alertness
• Attention
– different types of attention
• definition, example, test, brain basis
– effect of attention deficit on language communication
– implications of attention deficit for treatment,
including compensatory treatments
• Central executive
– Wisconsin card sorting test
• Language problems in TBI

Tonic alertness

• Definition:
– slowly changing level of an individual's overall state of arousal,
determining ongoing receptivity to stimulation
• Examples:
– diurnal rhythms
• shifts in level of arousal during the day, e.g., becoming tired in
the middle of the afternoon ("mid afternoon slump")
– becoming drowsy during the execution of a monotonous task
• Deficit in TBI:
– lower-than-normal resting level of tonic alertness
– causing patients to drift off or fall asleep
during testing or treatment

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 Phasic alertness
• Definition
– rapidly changing level of an individual's receptivity to stimulation,
with an onset as fast as milliseconds, enabling:
• perception of short duration stimuli
– use WS with TBI patients to alert them of stimulus
• perception of subtle changes in stimuli
– may not be perceived by TBI patient
• rapid recruitment of task appropriate processing resources
– TBI patients may do poorly on initial portion of task or when task is
changed to a new one
• perception and response to rapidly changing stimuli
– TBI patients may fail to perceive changes in e.g., traffic lights

Types of attention
• Selective attention
• Sustained attention
• Divided attention
• Alternative attention

• All of these can be impaired in TBI

Selective attention
• Definition:
– Ability to select and focus on a subset of several competing,
distracting stimuli
• Examples:
– focus on conversation with other conversations, radio programs, or
music in the background
– select one of many cards in a wallet
– select one of many items on a menu
• Result of impairment:
– Distraction by the competing, irrelevant stimuli

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 Effects of selective attention deficit on
language communication
• Difficulty separating what is important from what
is not in both comprehension and production
• Results in spoken discourse that is intermittently,
– irrelevant
– circumlocutory
– tangential
– fragmented
– non-cohesive
– but usually linguistically acceptable

Tests of selective attention

• sustained attention test with competing stimuli

– Subject's task: detection of each occurrence of a target stimulus among
a temporal sequence of target and non-target stimuli.
– For example, a tone of a certain frequency is the target stimulus and
other tones serve as non-target, distracting, competing stimuli. The
time and location of occurrence of target and non-target
stimuli is made unpredictable.
• cancellation test
– Subject's task: detection of each occurrence of a target stimulus among
a simultaneous display of target and several competing non-target
stimuli.
– Example, cross out all odd digits among a display of odd and even
digits.

Tests of selective attention:

Classic Stroop Test
• Stimuli: color names printed in ink colors
– BLUE RED GREEN BLUE RED GREEN
• Task 1: Read aloud color names
• Task 2: Read aloud ink names
• What did you notice?
– Interference effect:
• It takes longer to read aloud ink names with conflicting than matching
color names
• Selective attention deficit
• indicated by size of interference deficit
• large interference deficit ~ large attention deficit

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 Tests of selective attention: Variants of Stroop
Test
• High Low
Low High
• Task 1: name word itself
• Task 2: name height of word
• Interference effect: Naming height of word takes longer in
conflicting than matching condition
• BIG SMALL big SMALL
• Task 1: name word itself
• Task 2: name size of print
• Interference effect: Naming print size takes longer in
conflicting than matching condition

Selective attention & brain

• Brain areas contributing to selective attention
– posterior superior parietal cortex (BA 7)
• especially important in directing visual-spatial attention
– anterior cingulate (BA 32)
• mid sagital brain structure, above corpus callosum, connects limbic
brain to frontal lobe, brings emotion to bear on volitional planning,
thereby deciding focus of attention (I.e., on what is of interest)
– reticular nucleus of thalamus
• may provide a spotlight of attention
(e.g., Francis Crick, 1993)
• Effects of selective attention on brain
– intensifies and speeds up neuronal activity in those brain areas that
process the target stimulus that is in focus

Sustained attention
• Definition: Ability to maintain attention on selected stimuli
over a period of time without significant changes in
performance
• Example:
– Maintaining attention on test stimuli for duration of test
– Monitoring for door bell, phone ring, or buss stop
• Appearance of sustained attention deficit
– Performance drops off across time, especially with long time intervals
– Diagnostic test of some other ability may show below normal
performance due to sharp drop off in performance on later items of test

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 Tests for sustained attention: vigilance
test
• Subject's task:
– detection of each occurrence of a target stimulus during a
time period in which mostly other, non-competing non-
target stimuli occur and only infrequently at unpredictable
moments, the target stimulus (also called vigilance test).

• Difference with a selective attention test:

• target stimulus occurs less frequently over time
• non-target stimuli are not as competitive
– not as similar (e.g., target letter and non-target numbers)
– not as many competitors (e.g., target letter and fewer other non-target
letters)

Tests for sustained attention:

cancellation & trail making tests
• cancellation tests:
– Subject's task:
• detection of each occurrence of a target stimulus among a simultaneous
display of target and non-target stimuli. For example, cross out all odd
digits among a display of odd and even digits.
– Difference with a selective attention test
• less frequent target, less competitive non-targets
• trail making tasks
– Example: connect letters or numerals in sequence,
according to a rule (e.g., A-1-B-2, etc).

Alternating attention
• Definition:
– ability to shift attention from one stimulus (type of stimulus, stimulus
characteristic) or task to another
• Example:
– switching attention from one conversational partner to another
• Appearance of alternating attention deficit:
– inability to switch attention from one stimulus/task to another

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 Tests for alternating attention
• sustained attention test in which response criterion is changed
after subject's performance on another response criterion has
stabilized
• Example 1:
– even-odd alternation in number cancellation test
• Example 2:
– subtract5-add5 alternation in serial calculation task starting with
specified number e.g 76.
• Example 3:
– alternate between easy (e.g., reading color name) and difficult stimulus
dimension (e.g., naming ink color) in Stroop task

Laboratory test for alternating attention

• alternating semantic categorization - rhyming task
– series of trials
– each trial a word is shown
– two conditions: single task condition versus alternating task condition
– single task condition (intact task performance):
• semantic categorization (100% of trials)
– e.g., is word a clothing article?
– shirt-yes, book-no, stairs-no, sock-yes
• phonemic categorization (100% of repetition of same words)
– e.g., starts with a "b”
– shirt-no, book-yes, stairs-no, sock-no
– alternating task condition (impaired task performance)
• semantic and phonemic categorization trials alternating in unpredictable fashion in
same list of trials
• subject receives cue each trial what task to perform on word

Divided attention
• Definition
– Ability to direct performance in more than one task simultaneously OR
ability to simultaneously attend to two aspects of a single task
• Examples
– during a conversation do all of the following simultaneously
• maintain eye contact, stay on topic, get and retain information
– driving a car while maintaining a conversation
• Appearance of divided attention deficit
– focussing on one stimulus/task, while
ignoring the other stimulus/task

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 Tests of divided attention
• dual-task: simultaneous performance of two tasks
– E.g., visual letter cancellation and auditory number detection task
• tasks which require simultaneous retention and computation
– Paced Auditory Serial Addition Test (PASAT; Cronwall, 1977)
• Series of digits is shown (e.g., 6-4-1-7-3-5)
• Subject must say aloud the sum of the previous and current digit (e.g., 10, 5,
8, 10, 8).
• This requires retention of previous and current number, while computing
their sum.
– serial subtraction
• E.g., start with 100 and subtract 6: 100-94-88-82-76-70-64 etc
– E.g.: digits backwards: examiner says a string of randomly arranged
single-digit numbers and the patient repeats them in reversed order
– orally spelling words backwards

Effects of attention deficits on language

communication
• poor comprehension of spoken or written materials,
– especially when they are long
• missing details in spoken and written materials
• fragmented, disjointed, incoherent spoken discourse
• failure to observe turn taking rules and conventions
• weak or inappropriate topic maintenance
• problems in following shifts in topic
• failure to appreciate and respond appropriately to social rules in
conversational interactions

Treatment of attention deficits in TBI

• Attention supports other cognitive processes

– visual perception, reasoning, planning, problem solving
• Cognitive treatment of TBI patients therefore often
focuses on training the 4 major types of attention
• The therapies consist of drill on basic attention tasks
• Attention Process Training (APT; Sohlberg & Mateer,
1989)
– a well known treatment program for attention problems in
TBI.

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 Implication of attention deficit for treatment
of other cognitive deficits
• Two types of information processing
– controlled: serial, slow, demands attention resources, attention deficit
interferes
– automatic: parallel, fast, does not demand attention resources, attention
deficit does not interfere
• Patient can be taught strategies that compensate for cognitive
deficits
– initial execution of strategy is controlled.
• attention deficit of TBI patient may interfere
– with lots of learning execution of strategy is automatic
• attention deficit of TBI patient less likely to interfere
• loss of flexibility in employing automized strategy in a novel situation
• therefore train strategy in all relevant daily-life situations

Environmental compensation
• Definition: Changes external environment to facilitate the acquisition of automatic
behavioral pattern
• Create a stable and highly structured daily environment to help develop a daily
routine (e.g., therapy appointments, meals, and visits)
• Eliminate distractions from the workspace (e.g., turn down radio and tv, close doors
and windows to reduce noise from outside)
• Print maps or diagrams showing routes to and from familiar destinations, to help
patients who get lost easily
• Provide photographs of people who are significant participants in daily-life
activities, with printed names attached, to help the patient's orientation to person
• Post Symbols or printed reminders posted in prominent places as cues to perform
certain activities (e.g., mirror, label of contents of cupboard, shelves, and drawers
• Setting time limits for working at difficult tasks to avoid fatigue and minimize
mistakes (e.g., due to inability to sustain attention)

Other compensations to cognitive

deficits in tbi
• Situational compensation:
– Patient can be given a checklist whenever performing a a common daily-life procedure so
as to avoid missing certain steps (especially if patient is aware of problems but does not
recognize problems when they occur)

• Recognition compensation:
– Patient is taught to evoke a strategy whenever they perceive that a problem occurs
(especially if patient is aware of problems, recognizes them but cannot anticipate them).
– E.g., write down key points when confusion arises during reading.

• Anticipatory compensation:
– Patient is taught to evoke a strategy whenever they anticipate that problem will occur
– E.g., asking others to repeat / clarify / write down / speak more slowly what they say,
requesting extra time for performing tasks or taking tests

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 Central executive function
• TBI patients with frontal involvement suffer from central executive
impairment
• Functions of central executive
– goal setting & prioritization
– generating alternative courses of action
– anticipating future consequences of a course of action
– making choices
– initiate cognitive activity
– sequencing, temporal ordering
– monitoring cognitive activity (error monitoring)
• inhibition of pre-potent responses
– inhibition failure results in perseveration, cursing, violent, inappropriate behavior
– coordinating cognitive activity (dual task performance)
• Specific brain areas in frontal lobe
– Dorso-lateral pre-frontal cortex

Wisconsin card sorting test

A test of central executive function: Wisconsin

Card Sorting Test
• Stimuli: Deck of cards differing among 3 dimensions:
– 1.number of forms on a card (1 to 4)
– 2.kind of form (triangle, cross, star, circle)
– 3.color of form (red, green, yellow, blue)
• Task of subject:
– Task 1: sorting cards along the color dimension
– Task 2: sorting cards along the form dimension
– Task 3: sorting cards along the number dimension
• Important: The subject is never explicitly told the name of the relevant
dimension, but must infer it from right/wrong feedback provided by the
examiner. After 10 correct sorts the examiner switches to another
dimension.
• TBI patients with frontal lobe deficit tend to perseverate
– failure to change sorting responses to match changes in the sorting principal

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 A test for visual thinking

• progressive matrices (Raven, 1960)

– IQ test/Reasoning test with low verbal components
– Stimuli: target pattern with part missing, alternative patterns with
missing part
– Subject task: select the pattern that corresponds to the missing part

Effect of abstract thinking & problem solving

deficits on language communication

• universal consequence of brain damage, including in TBI:

impaired abstract thinking
• Concrete language and inability to appreciate inferences and indirectly
stated material
• Inability to appreciate relationships in spoken or written discourse
• Egocentrism in social interactions, and inability to appreciate others'
point of view
• Failure to implement prescribed strategies to enhance communicative
effectiveness
• Inappropriate conversational content and maladaptive interpersonal
behaviors

Language problems in TBI

• Literal language:
– Most TBI patients have no problems with the comprehension and
production of the literal linguistic aspects of language, that is, the
phonology, syntax, and semantics of literal expressions are within normal
limits
– Some TBI patients with left perisylvian damage may be aphasic
• Non-literal language
– Most TBI patients, resemble right-hemisphere damaged patients in having
problems with the compehension of non-literal language (i.e., sarcasm,
humor, metaphor) and with the expression of relevant cohesive language
(i.e., due to circumlocutions, confabulations and irrelevant, fragmentary,
and non-cohesive language).
– Note. Frontal lobe damage has a high probability of occurring in both
right-hemisphere damaged and tbi patients, possibly explaining the
resemblance in problems with non-literal language.

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 Aphasia batteries & TBI
• Aphasia batteries underestimate the language problems of
TBI patients
– controlled testing environment reduces attention challenges
– amounts of language often too small to reveal organizational
weakness
– emphasis on literal language, so that problems with non-literal
language are not revealed

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