MILD TRAUMATIC BRAIN INJURY IN PATIENTS WITH VASCULAR DEMENTIA Yuri Alekseenko Department of Neurology and Neurosurgery Vitebsk Medical University Vitebsk, Belarus Istanbul, Turkey, 2005

Traumatic Brain Injury the incidence of TBI is high - between 229 and 1967 per 100,000 the incidence of TBI is high - between 229 and 1967 per 100,000 the highest incidence occurring in men, aged 15 to 24 years the highest incidence occurring in men, aged 15 to 24 years 90-95% of all traumatic brain injuries are considered mild (MTBI) 90-95% of all traumatic brain injuries are considered mild (MTBI) Mild Traumatic Brain Injury. Revised Guidelines on Early Management. EFNS Task force on MTBI, Scientific Panel of Neurotraumatology, 2005

MTBI in patients with VD The diagnosis of mild traumatic brain injury (MTBI) and general assessment of neurological functions in patients with vascular dementia (VD) is usually complicated The diagnosis of mild traumatic brain injury (MTBI) and general assessment of neurological functions in patients with vascular dementia (VD) is usually complicated The assessment and interpretation of main MTBI or VD symptoms and history in such circumstances remains a challenge The assessment and interpretation of main MTBI or VD symptoms and history in such circumstances remains a challenge The distinction between traumatic and primary or secondary cerebral vascular effects is rather difficult The distinction between traumatic and primary or secondary cerebral vascular effects is rather difficult

MTBI + VD HI + VD HI + VD MTBI + VD MTBI + VD MTBI  VD decompensation MTBI  VD decompensation Cerebrovascular disorders  secondary MTBI (syncope, epileptic seizure, vertigo and imbalance disorders …) Cerebrovascular disorders  secondary MTBI (syncope, epileptic seizure, vertigo and imbalance disorders …)

VD and/or TBI MTBI and/or MTBI and/or VD decompensation and/or VD decompensation and/or Traumatic intracranial complications (extracerebral haematoma, malignant brain oedema with diffuse brain swelling …) Traumatic intracranial complications (extracerebral haematoma, malignant brain oedema with diffuse brain swelling …)

MTBI diagnostic criteria trauma history trauma history hospital admission Glasgow Coma Score (GCS) of 13–15 hospital admission Glasgow Coma Score (GCS) of 13–15 brief (min/sec) loss or/and any alteration of consciousness (disorientation, confusion) at the time of the accident brief (min/sec) loss or/and any alteration of consciousness (disorientation, confusion) at the time of the accident posttraumatic amnesia – several minutes/hours posttraumatic amnesia – several minutes/hours physical symptoms (nausea, vomiting, dizziness, headache, autonomic disorders, etc) physical symptoms (nausea, vomiting, dizziness, headache, autonomic disorders, etc)

MTBI+VD To clarify the reciprocal influence of such conditions and improve the standard diagnostic protocols we compared the structure of clinical signs and the natural course of recovery in MTBI young patients with those of MTBI+VD patients

Materials and methods 61 young males with MTBI (aged 16-39) and 56 patients with MTBI (aged 56-78) on the background of mild and moderate VD The quantitative analysis (duration/intensity) of main MTBI symptoms was carried out

VD patients Underlying chronic cerebrovascular pathology: hypertensive encephalopathy (43%) hypertensive encephalopathy (43%) arteriosclerotic encephalopathy (31%) arteriosclerotic encephalopathy (31%) combined (H+A+ toxic and metabolic) (26%) combined (H+A+ toxic and metabolic) (26%)

MTBI diagnosis The criteria for selecting MTBI patients were as follows: The criteria for selecting MTBI patients were as follows: brief (min/sec) loss or/and any alteration of consciousness (disorientation, confusion) at the time of the accident brief (min/sec) loss or/and any alteration of consciousness (disorientation, confusion) at the time of the accident posttraumatic amnesia – several minutes/hours posttraumatic amnesia – several minutes/hours physical symptoms (nausea, vomiting, dizziness, headache, vegetative disorders, etc) physical symptoms (nausea, vomiting, dizziness, headache, vegetative disorders, etc) absence of focal neurological deficit absence of focal neurological deficit absence of scull fracture absence of scull fracture normal CT or MRI scan of the brain normal CT or MRI scan of the brain recovery preferably in 1-2 weeks (young patients) recovery preferably in 1-2 weeks (young patients) patients with significant concomitant neurological and internal diseases were excluded from this study (young patients) patients with significant concomitant neurological and internal diseases were excluded from this study (young patients)

MTBI+VD MTBI+VD patients demonstrated more extensive and frequent disorders of consciousness and amnesia and their different structure in comparison with young MTBI patients at the time of accident MTBI+VD patients demonstrated more extensive and frequent disorders of consciousness and amnesia and their different structure in comparison with young MTBI patients at the time of accident

Disorders of consciousness and amnesia in patients with MTBI

MTBI symptoms LOC and amnesia at the time of accident: LOC and amnesia at the time of accident: Only 45% of MTBI+VD patients were able to confirm such disturbances by themselves in comparison with young MTBI patients (68%)

TBI signs The signs of head trauma (abrasions, bruises) as an indirect evidence of a probable brain injury were objectively observed in 84% of MTBI+VD patients compared with 72% of young MTBI patients The signs of head trauma (abrasions, bruises) as an indirect evidence of a probable brain injury were objectively observed in 84% of MTBI+VD patients compared with 72% of young MTBI patients

MTBI symptoms Such symptoms as headache, dizziness, nausea, vomiting, fatigue and some other autonomic disorders (orthostatic dysregulation and thermodysregulation) were the most common manifestations of MTBI Such symptoms as headache, dizziness, nausea, vomiting, fatigue and some other autonomic disorders (orthostatic dysregulation and thermodysregulation) were the most common manifestations of MTBI Besides, MTBI and MTBI+VD patients demonstrate a wide variety of duration and intensity of such symptoms Besides, MTBI and MTBI+VD patients demonstrate a wide variety of duration and intensity of such symptoms

MTBI symptoms MTBI+VD patients had more frequent nausea (92% and 79%) but at the same time they had less frequent vomiting in comparison with young MTBI patients (43% and 58% accordingly)

MTBI symptoms Different types of headache were observed in all young patients and only in 82% of MTBI+VD patients. At the same time headache and some other subjective disorders in patients with VD were less intensive, but went on a longer time Different types of headache were observed in all young patients and only in 82% of MTBI+VD patients. At the same time headache and some other subjective disorders in patients with VD were less intensive, but went on a longer time

MTBI symptoms - headache

In all MTBI and only in 79% of MTBI+VD cases the headache appeared just after the trauma and gradually decreased during the first or the second week after the accident In all MTBI and only in 79% of MTBI+VD cases the headache appeared just after the trauma and gradually decreased during the first or the second week after the accident In 30% of all MTBI patients the most intensive headache, dizziness and nausea were observed on the next day after the trauma In 30% of all MTBI patients the most intensive headache, dizziness and nausea were observed on the next day after the trauma

MTBI symptoms - headache In case of headache appearing some time after the trauma its interpretation as a MTBI symptom still remains controversial In case of headache appearing some time after the trauma its interpretation as a MTBI symptom still remains controversial Remote headache in patients with MTBI might to a greater extent be associated with the influence of additional factors and other mechanisms (psychological reactions to physical or emotional stress and other causes) Remote headache in patients with MTBI might to a greater extent be associated with the influence of additional factors and other mechanisms (psychological reactions to physical or emotional stress and other causes)

MTBI+VD In 74% of MBI+VD patients it could be considered as a decompensation of an underlying cerebrovascular pathology (chronic hypertensive or arteriosclerotic encephalopathy) on the background of MTBI In 74% of MBI+VD patients it could be considered as a decompensation of an underlying cerebrovascular pathology (chronic hypertensive or arteriosclerotic encephalopathy) on the background of MTBI

Conclusion The distinction between primary and secondary traumatic brain injury (due to syncope, seizure or vertigo, etc) in patients with VD as well as between neurological disorders of traumatic and secondary vascular origin remains rather difficult The distinction between primary and secondary traumatic brain injury (due to syncope, seizure or vertigo, etc) in patients with VD as well as between neurological disorders of traumatic and secondary vascular origin remains rather difficult Persistent neurological dysfunctions including cognitive deficit after the MTBI in patients with VD could be interpreted in most cases as a complex clinical condition with predominance of the existing cerebrovascular pathology Persistent neurological dysfunctions including cognitive deficit after the MTBI in patients with VD could be interpreted in most cases as a complex clinical condition with predominance of the existing cerebrovascular pathology

Conclusion Chronic cerebrovascular pathology seem to decrease the "concussion threshold", simultaneously producing some disorganisation influence on brain mechanisms and contributing to patients’ decompensation after the MTBI, the spectrum of symptoms after the trauma may be wider Chronic cerebrovascular pathology seem to decrease the "concussion threshold", simultaneously producing some disorganisation influence on brain mechanisms and contributing to patients’ decompensation after the MTBI, the spectrum of symptoms after the trauma may be wider CT or MRI should be considered in MTBI diagnostic protocol for patients with VD CT or MRI should be considered in MTBI diagnostic protocol for patients with VD