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HEAD TRAUMA 102 Norton Winer MD Director: Department of Neurology
UH Richmond Medical Center Asst. Clinical Professor of Neurology CWRU School of Medicine
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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
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Incidence of head trauma Concussions
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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.
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Assessing head trauma 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
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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
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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
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Head injury causes Whiplash with secondary head trauma
Direct blow to head Sports injuries Penetrating injuries (most severe) GSW, projectiles etc
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Military injuries
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Military head injuries
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Concussive symptoms 1. headache 2. nausea/vomiting
3. photo/sonophobia, blurred and/or diplopia 4. amnesia, disorientation and decreased concentration 5. emotional lability
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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
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Functional MRI in concussion
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King Devick Concussion testing
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Sequelae to head injuries
Post traumatic headaches Cognitive and memory issues PTSD Seizures Neurologic deficits hemiplegia, visual, speech, gait etc Chronic traumatic encephalopathy (CTE)
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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
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What I see in the office
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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)
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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
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Post traumatic headache - three
Must be treated with medications vs. increased risk of chronic daily h/a Avoid narcotic Botox injections maybe useful
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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
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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
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Post head trauma seizure
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CTE (Chronic traumatic encephalopathy) brain changes
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Tau accummulation in CTE
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PET scan in CTE
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PET SCANS - similar CTE findings in 5 NFL players
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CTE vs. AD
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TBI and dementia incidence
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CERVICAL SPINE and SKULL INJURIES
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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
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Temporal bone fracture
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Battle’s Sign
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Battle’s Sign
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Epidural Hematoma secondary to skull fracture
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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
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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
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Axial loading
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IMPORTANCE OF HEAD POSITION
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Displacement of C6/C7 secondary to axial loading
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Burst fracture of cervical spine
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CERVical spine disc injury secondary to head trauma
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Cervical spinal cord injury: Bleeding vs edema
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Cervical spinal cord injury secondary to head trauma
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MRI cervical spinal injury
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