The following lecture has been approved for

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The following lecture has been approved for
University Undergraduate Students This lecture
may contain information, ideas, concepts and
discursive anecdotes that may be thought
provoking and challenging It is not intended
for the content or delivery to cause
offence Any issues raised in the lecture may
require the viewer to engage in further thought,
insight, reflection or critical evaluation
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Introduction to Brain Injury Dr. Craig
Jackson Senior Lecturer in Health
Psychology School of Health and Policy
Studies Faculty of Health BCU
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What was Michael Angelos Hidden Message?
Michelangelo. The Creation of Adam
(detail, Sistine Chapel). 1510. Fresco, Sistine
Chapel, Vatican, Rome.
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Objectives List major structures and function of
nervous system Name types of head and spine
injuries describe clinical features Describe
mechanisms of neurological injury Describe
assessment of head injuries Describe functional
affects and symptoms Describe imaging techniques
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Neurological Injuries Responsible for 50 of
trauma deaths Approx. 1,000,000 patients in UK
attend AE with head injury per year Can be
prevented (some extent) by helmets and
PPE Major cause of chronic disability Mostly
from Falls, RTAs and Assaults
Flannery Buxton, 2001
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Anatomy Principles Neuron specialized nerve
cell Dendrites and Axons short and long
processes of neurons Peripheral neurons
sheathed with myelin Impulses transmitted from
synapses to dendrites
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Anatomy Principles 2 Central Nervous System
brain, spinal cord Peripheral Nervous System
nerves, branches Meninges protective triple
layer cover Dura matter outer
layer Arachnoid middle layer Pia
matter inner layer Cerebral Spinal Fuid (CSF)
circulates in middle layer
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Anatomy Principles 3 Cerebrum (hemispheres) Cereb
ellum, brainstem Cranial nerves originate at
base of brain Sensory / motor supply to head
and face Motor nerves brain to muscle
units Sensory nerves skin back to
brain Somatic Nervous System voluntary
action Automatic Nervous System involuntary
action
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Anatomy Principles 4
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RTA figures In 1990, road traffic crashes
caused 5,563,000 Intra-cranial injuries
worldwide Murray CJL, et al. 1996 HI major cause
of death and injury in RTAs(80 of serious RTA
injury is to head)1 concussion every 15
seconds in USA15,000,000 Brain Injuries per
year in USACar injuries Playgrounds Sports
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RTA figures
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RTA figures
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RTA figures 1,200,000 killed per year in
RTAs 10,000,000 injured per year in RTAs Most
Head Injuries are mild, but any lefy with
long-lasting problems RTA most common cause of
HI Young males at biggest risk Alcohol
implied Data suggests female drinking catching up
with male Implications for Female RTAs?
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RTA figures
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RTA figures
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Mechanics of RTAs Occupant RTAs Driver Hazards
Steering wheel / column Instrument
panel Seatbelt Windscreens Passenger
Hazards
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Mechanics of RTAs Pedestrian RTAs
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RTA Brain injuries Skull Fractures Open Head
Injury Closed Head Injury
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RTA Brain injuries Contusion /
Concussion Contre-Coup Epidural
haematoma Diffuse axonal injury
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RTA Brain injuries Subdural haematoma Intrac
erebral haemorrhage Epidural haematoma
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Swelling Brain matter pushed and
swollen Painful Exacerbates
affects Accelerates symptoms
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• How are brain injuries assessed?
• PTA
• Post Accident Amnesia memory problems when
  regaining consciousness
• Minor Brain Injury Unconscious for lt 15 mins
• Moderate Brain Injury
• Unconscious gt 15 mins but lt 6 hrs PTA lt 24
  hrs
• Severe Brain Injury
• Unconscious gt 6 hrs OR PTA gt 24 hrs
• Very Severe Brain Injury
• Unconscious gt 48 hrs OR PTA gt 7 days

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How are brain injuries treated? Trepanning (Gk
trupanon borer) Popular Japanese
treatment George Morland.
Trepanning a Recruit. c.1790 Oil on canvas
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How are brain injuries treated?
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How are brain injuries treated? Stop
bleeding Prevent ICP Control pressure Maintain
blood flow Remove any blood clots Positioning
(head up) Fluid restriction (of
patient) Medication barbiturate
(coma) anticonvulsants diuretics
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How are brain injuries treated? Ventricular
drain (Ventriculostomy) Ventilator Surgery Cran
iotomy Burr holes Bone flap removal
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Injury Development Recovery from Brain Injury is
possible Less likely as severity of injury
increases Permanent brain problems from minor
head injury are rare Post-concussional symptoms
/ Post-concussion syndrome Headache Dizziness Sens
itive to loud noise or bright light Insomnia Slow
thinking Tinnitus Blurred vision Tiredness Irritat
ion PCS usually pass within 3 months
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Injury Development Focal Brain
Injury
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• Development of mood problems
• Memory
• Headache
• Overload
• Sleep disorders
• Fatigue
• Anger
• Depression
• Cognitive loss and muddle
• 33 of head injury patients develop depression
  within lt 1 year
• Only 20 for non-head injury patients
• Neuro-Rehab services need to plan ahead

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Development of mood problems PTSD in kids after
accident 34 of children in RTAs suffer
PTSD Within 6 weeks of RTA Stallard, P et al.
1998 20 suffer acute stress reaction
afterwards 25 suffer psychiatric problems within
1 year Mayou et al. Mood disorder Phobic travel
anxiety all common PTSD Psychological
de-briefing after RTAs may help Hobbs et al. 1996
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Traumatic Brain Injury Physical force causes
nerve cells to stretch, tear and pull
apart Unable to relay messages through
brain Force causes brain to slam against skull
interior Traumatic Brain Injury Injury to
brain cells affects processing thinking r
emembering seeing control coordination mood
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Traumatic Brain Injury TBI ranges from mild to
severe degree of force multiple
trauma neurological complications speed of
assistance
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Head Injuries Severity depends on amount of
Primary and Secondary brain injury Main cause
of Secondary injury hypoxia Categories Open
or Closed Forces Shearing and Compression
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Non Loss of Function 41 yr old Mike
Hill Attacked from behind Full recovery after
removal No infection Left hospital 1 week
after removal Epileptic medication and some
memory problems
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Functional Status SPECT image
with Technetium (T99)
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Pathophysiological Disturbance Involve scalp,
cranium, or underlying brain Depends on
mechanism of injury Scalp lacerations,
contusions, abrasions Skull fractures vault /
base, simple or compound, depressed or
planar Primary Brain Injury Focal
(intra-cranial haematoma, contusion) Diffuse
(diffuse axonal injury) Categories Open or
Closed Forces Shearing and Compression
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Closed or Open Head Injury Closed Head
Injury (CHI) No penetration of the
skull Usually a TBI Not always
though Open head Injury (OHI) Bullet, Knife,
or Fracture Skull breeched Brain injury
depends on power of physical force injury If
great enough, forces radiates through skull,
causes sudden brain movement Results in damaged
nerve cells May result in soft tissue
injury - cervical strain myofascial trauma
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Mild Traumatic Brain Injury Head injury graded
on (i) length of unconsciousness (ii)
length of amnesia Both caused by sudden trauma
and nerve cell tearing Brain cannot maintain
functioning and shuts down either fully
(unconsciousness) or partially (dazed) MBI
refers to loss of consciousness for 30 mins or
less Unconscious Amnesia Any of these
Diffuse Axonal Altered consciousness indicates
MBI Injury neurological deficits MBI
can result in life changing consequences
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Diffuse Axonal Injury Thinking slows
down Memory poor Mild Brain Injury Processing
slower Concentration haphazard Roadblocks of
damaged unconnected neurons Individual
feels Incomplete emotional
problems Unconfident Frustrated Described as
mental fog Irritable Struggling cognitive
problems
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Brain Injury without Direct Trauma Whiplash
Shaking Sudden movement inside cranium damages
neurons Acceleration Deceleration RTAs even
with airbag deployment can cause brain
injury Brain is torn, squashed,
bruised Rollercoasters
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Types of Head Injuries Concussion Temporary
alteration in neurological function or
LOR Cerebral Contusion Bruised
brain Cerebral Haemotoma or bleed epidural s
ub-dural sub-arachnoid intra-cerebral
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Signs and Symptoms Headache Dizziness Nausea /
Vomiting Amnesia Decreased responsiveness Confu
sion Combativeness Loss of responsiveness
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Assessment First impression Responsive or
Unresponsive Urgent Survey LOR ABCs Open
airway with C-spine Check breathing Ventilate
Oral airway O2 when available Check carotid
artery pulse CPR if indicated Control any
major bleeding
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Assessment continued Rapid Body Survey Sample,
DCAP-BTLS Stabilize head between knees Call for
equipment, assistance, transport Maintain body
temp. Transport (head uphill) Non-Urgent
Survey Ongoing Survey seizures, vomiting,
change in LOR
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• Assessment continued
• Brain Swelling
• ?
• Increased Intracranial Pressure (ICP)
• ?
• Hypoxia
• ?
• Further Secondary Brain Injury
• ?
• More Swelling
• ?
• Increased ICP

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Localised Neurological Signs (ICP) GENERAL SIGNS
PLUS Change in pupil size / light
reactivity Slowing pulse Rising BP Change in
respiration Unilateral weakness Incontinence Se
izure
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Urgent Interventions - ATLS Presume C-Spine
injury Immobilize neck Open airway administer
oxygen Treat bleeding and shock Prevent
aspiration of vomit / secretions Transport
immediately Elevate head 6 Transport head
uphill
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Imaging Xray, MRI and CT cannot show traumatic
brain injury Techniques rely on tissue
density Diffuse damage will not show on these
techniques SPECT or PET measure brain cell
metabolism Can detect changes in function due
brain injury
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Behavioural Changes Speech Cognition Memory Mood
Mental health psychoses delirium Tremor Gait Sym
metry of function Gross over-simplification Visu
al Auditory Positive and negative symptoms
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Other Causes of Brain Injury Drug
effects Tumor Metastases Physical
assault Surgery Traumatic birth Hypoxia
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Glasgow Coma Scale Scores 8 or
less needs urgent anaesthetic assessment.
Danger of airway compromise 13-15 mild
9-12 moderate 3-8 severe
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Queens Medical Centre
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Cerebral Asymmetry of Function Hemispheric
asymmetry of function is relative Asymmetries
have been overblown by popular media into fads
(e.g. golf with your right brain) Anterior-post
erior differences far outweigh left-right
differences Asymmetry is not uniquely human

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Cerebral Asymmetry of Function LEFT
HEMISPHERE Convolutions mature more rapidly
Extends further posteriorly Higher in density
(more gray matter more neurons) Planum
temporale larger on left (in 60-90) of cases
Larger insula Longer Sylvian fissure (gentler
slope) Double cingulate gyrus Larger lateral
posterior nucleus (to parietal cortex) Wider
occipital lobe Larger total area of frontal
operculum (much buried in sulci) Larger inferior
parietal lobule
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Cerebral Asymmetry of Function RIGHT
HEMISPHERE Convolutions mature less rapidly
Extends further anteriorly Larger and heavier
Primary auditory (Heshl's gyrus) larger on
right Shorter (steeper slope) Single Larger
medial geniculate nucleus Narrower Larger area
of convexity in frontal lobe wider frontal lobe
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Cortical Lesions Human cognitive and sensory
dysfunction different following lesions (due to
strokes, surgery, accident, etc.) Differences
noted in lesions to left and right
hemispheres Lesions can provide clues about
brain organization Do specific areas possess
special unique functions? Does a lesion to a
specific area demonstrate a dysfunction Lesions
to other brain locations do not cause a similar
dysfunction
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Dissociation Lesion site Reading Writing Spea
king 100 normal normal impaired 102 impa
ired normal normal 104 normal impaired
normal Allows understanding of specific sites
and impairments
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Hemispherical Function Left Right Vision
linguistic stimuli patterns
faces steropsis Audition language
sounds rhythm Somatosensation tactile
recognition Motor complex movement spatial
movement Memory verbal memory non-verbal
memory Language speech reading prosody
writing arithmetic Emotion social
emotions primary emotions Spatial
processes geometry spatial images orientation
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Split Brain and Commissurotomy Corpus Callosum
joins hemispheres Sever corpus callosum Two
hemispheres cannot communicate
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Brain Injury - Summary 1. The main cause of
secondary damage to the brain is _ _ _ _ _ _ _
? 2. Head injury alone rarely causes damage. T
/ F? 3. Temporary loss of consciousness or
function from a head trauma is a _ _ _ _ _ _ _ _
_ _ ? 4. Brain injury can occur without any
impact trauma. T / F 5. Axons being damaged /
shredded is the simple reason for cognitive
problems in head injury patients. T / F