Nabeel Kouka, MD, DO, MBA

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Traumatic Brain Injury TBI
Nabeel Kouka, MD, DO, MBA www.brain101.info
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Brain Injuries
Congenital brain injury Pre-birth During birth
Acquired Brain Injury After birth process
Traumatic Brain Injury (external physical force)
Non-traumatic Brain Injury
Open Head Injury
Closed Head Injury
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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.

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Epidemiology
Percentage of Average Annual Traumatic Brain
Injury-Related Emergency Department Visits,
Hospitalizations, and Deaths, by External Cause,
United States, 1995-2001
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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 Alzheimers Disease
5 million with persistent mental illness
5.3 million with TBI disability
7.3 million Americans with mental retardation
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TBI in the United States (by Cause)
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Two types of TBI

• OPEN-HEAD INJURY (penetrating)
• Example
• Skull fracture that penetrates the brain
• Gunshot wound

• CLOSED-HEAD INJURY
• Example
• Coup-Contra Coup
• Diffuse axonal injury

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Two Classes of Brain Injury

• PRIMARY
• THE INJURY IS MORE OR LESS COMPLETE AT THE TIME
  OF IMPACT
• SKULL FRACTURE
• CONTUSION/ BRUISING OF THE BRAIN
• HEMATOMA/BLOOD CLOT ON THE BRAIN
• DIFFUSE AXONAL INJURY

• SECONDARY
• THE INJURY EVOLVES OVER A PERIOD OF HOURS TO
  DAYS AFTER THE INITIAL TRAUMA
• BRAIN SWELLING/EDEMA
• INCREASED INTRACRANIAL PRESSURE
• INTRACRANIAL INFECTION
• EPILEPSY
• HYPOXEMIA (LOW BLOOD OXYGEN)
• HIGH OR LOW BLOOD PRESSURE
• ANOXIA/HYPOXIA (LACK OF OXYGEN TO THE BRAIN)

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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.

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TBI in children can be especially devastating,
as a childs brain is in an almost constant
state of development.
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Brain Rates of Development
5 Distinct Periods of Maturation P - O parietal/
occipital C central (limbic brainstem) T
temporal F - T frontal/ temporal
P-O C T F-T
T C
P-O C F-T
F-T
P-O
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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
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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

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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
a. Subarachnoid Hemorrhage b. Transtentorial
herniation c. Intraventricular hemorrhage e.
Diffuse axonal (shearing) injury
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Intracranial Haematomas

• Epidural
• arterial bleeding
• quick onset
• less common
• Subdural
• venous bleeding
• wide range of onset time
• can build on each other without symptoms

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Acute Subdural Haematoma
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Acute Subdural Haematoma w/Midline Shift
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Chronic Subdural Haematoma

• Heterogeneous mass
• Focal convexity of medial margin
• Dilated Ipsilateral Ventricle
• Midline Shift
• Diffuse Brain Edema
• Scalp Hematoma

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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

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Significant Head Injuries

• Signs of increased intercranial pressure
• Visual difficulties
• Vomiting
• Dyspnea
• Decreased pulse

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Glascow Coma Scale
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Intracranial Pressure (ICP)
v.Intracranial (constant) v.Brain v.CSF
v.Blood v.Mass Lesion
CPP MAP - ICP CPP Cerebral Perfusion
Pressure MAP Mean Arterial Pressure ICP
Intracranial Presure
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Indications for ICP Monitoring
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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 gt 20 mm Hg, but
  maintenance of CPP is probably more important.

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How Brain Injuries treated?
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How Brain Injuries treated?