HEAD TRAUMA 102 Norton Winer MD Director: Department of Neurology UH Richmond Medical Center Asst. Clinical Professor of Neurology CWRU School of Medicine

Head Trauma classification (closed Head injury) Concussion – temporary disruption of brain activity Contusion - bruising of brain tissue Intracranial hematoma Diffuse axonal injury – permanent injury to brain tissue

Concussion definitions 1. biomechanical injury 2. brain imaging is normal (CT or MRI) 3. no gross structural injury to brain 4. microscopic injury? Axonal shearing, cellular injury etc.

Incidence of head trauma Concussions

Concussion by age

Assessing head trauma (in the field) Glasgow Coma Scale (GCS) Scale of 0 (most severe) to 15 (least severe) Three parameters Eyes (4 grades), verbal (5 grades) and motor 6 grades) Interpretation Severe GCS < 9 Moderate GCS 9-12 Mild GCS > 12

Assessing Head Trauma (in my office) PTA (post traumatic amnesia probably more important factor than LOC Duration of PTA correlates well with length of disability Patient’s claim of memory loss usually not document with cognitive testing

American Academy of Neurology (AAN) concussion parameters grade 1: no LOC, back to normal <15 minutes; transient confusion, back into game? 2. grade 2: no LOC, back to normal > 15 minutes; perform CT/MRI brain, usually out of athletics >one wk 3. grade 3: LOC, pt. must be seen in ER, usually out of athletics > one month

Head trauma facts 300,000 sports related concussions/yr 570,000 closed head injuries/yr 15% death rate 38% head injuries related to alcohol 90,000 patients disabled annually from head injuries MVAs and sports most common etiologies

Head injury causes Whiplash with secondary head trauma Direct blow to head Sports injuries Penetrating injuries (most severe) GSW, projectiles etc

Concussion mechanisms

Cellular effects of concussion

Concussion and sports

Tennis!!

Military injuries

Military head injuries

Concussive symptoms 1. headache 2. nausea/vomiting 3. photo/sonophobia, blurred and/or diplopia 4. amnesia, disorientation and decreased concentration 5. emotional lability

Cerebral Concussions 1. Athletes are reluctant to disclose injury 2. 30-50% of concussions never receive medical attention 3. Loss of Consciousness LOC doesn’t have to occur

Functional MRI in concussion

King Devick Concussion testing

Sequelae to head injuries Post traumatic headaches Cognitive and memory issues PTSD Seizures Neurologic deficits hemiplegia, visual, speech, gait etc Chronic traumatic encephalopathy (CTE)

Second Impact Syndrome Involves 2 episodes of head trauma Usually an initial concussion followed by a second concussion a few weeks later Catastrophic brain edema, herniation and death Seen mainly in athletic injuries Fortunately very rare

What I see in the office

Post traumatic headaches - one 1. Civilians – whiplash injury with acceleration/deceleration 2. Military – blast injuries (36% of Iraq and Afghanistan soldiers injured have h/a on a chronic basis)

Post traumatic headache - two 1. associated with insomnia, PTSD, anxiety, slowed reactions and cognitive issues 2. genetic predisposition ? 3. migraine with aura is common 4. Increased risk of medication misuse

Post traumatic headache - three Must be treated with medications vs. increased risk of chronic daily h/a Avoid narcotic Botox injections maybe useful

PTSD 1. may develop after trauma, witnessing trauma or repeated exposure to trauma 2. re-experience of trauma; intrusive thoughts 3 10% of population (usually related to trauma, but not always 4. associated with substance abuse, female sex and lower socio-economic status 5. negative changes in cognition and mood

PTSD -2- Treatment 1. separate the treatment of physical and behavioral symptoms 2. Cognitive and behavior therapy very helpful 3. SSRI but not SNRI therapy 4. Sympathetic blockers (e.g. beta or alpha blocker drugs) ``1

Post head trauma seizure

Lethal sequela to head trauma CTE, DEMENTIA etc

CTE (Chronic traumatic encephalopathy) brain changes

Tau accummulation in CTE

PET scan in CTE

PET SCANS - similar CTE findings in 5 NFL players

CTE vs. AD

TBI and dementia incidence

CERVICAL SPINE and SKULL INJURIES

Skull Fractures Linear skull fracture – least clinical significance Depressed skull fracture – damage to underlying brain; increased ICP and/or bleeding Basilar skull fracture – greater blunt trauma; CSF leaks, etc Diastatic skull fracture – fx across cranial suture

Temporal bone fracture

Battle’s Sign

Battle’s Sign

Epidural Hematoma secondary to skull fracture

Head and neck injuries 10-20% of head injuries associated with neck injuries 15-20% cervical spine injuries are missed at the time of trauma Majority of cervical spine injuries usually at 2 spinal levels: C2 or C6-7 level

Axial loading of the cervical spine Involves trauma to top of head (vertex area of skull) Force vector is parallel to central axis of cervical spine Result is trauma to brain and cervical spinal cord

Axial loading

IMPORTANCE OF HEAD POSITION

Displacement of C6/C7 secondary to axial loading

Burst fracture of cervical spine

CERVical spine disc injury secondary to head trauma

Cervical spinal cord injury: Bleeding vs edema

Cervical spinal cord injury secondary to head trauma

MRI cervical spinal injury