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

2. 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

3. 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.

4. Incidence of head trauma Concussions

5. Concussion by age

6. 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

7. 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

8. 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

9. 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

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

11. Concussion mechanisms

14. Cellular effects of concussion

17. Concussion and sports

22. Tennis!!

23. Military injuries

24. Military head injuries

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

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

27. Functional MRI in concussion

28. King Devick Concussion testing

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

31. 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

32. What I see in the office

33. 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)

34. 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

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

36. 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

37. PTSD
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

38. Post head trauma seizure

39. Lethal sequela to head trauma
CTE, DEMENTIA etc

42. CTE (Chronic traumatic encephalopathy) brain changes

43. Tau accummulation in CTE

44. PET scan in CTE

45. PET SCANS - similar CTE findings in 5 NFL players

46. CTE vs. AD

47. TBI and dementia incidence

48. CERVICAL SPINE and SKULL INJURIES

50. 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

51. Temporal bone fracture

52. Battle’s Sign

53. Battle’s Sign

54. Epidural Hematoma secondary to skull fracture

55. 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

56. 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

57. Axial loading

58. IMPORTANCE OF HEAD POSITION

59. Displacement of C6/C7 secondary to axial loading

60. Burst fracture of cervical spine

61. CERVical spine disc injury secondary to head trauma

62. Cervical spinal cord injury: Bleeding vs edema

63. Cervical spinal cord injury secondary to head trauma

64. MRI cervical spinal injury