1. Traumatic Brain Injuries (TBI) “Concussions”

2. Meninges Collectively, support and protect brain and spinal cord
Provide vascular supply and production of CSF
Dura mater
Arachnoid mater
Pia mater

3. Meninges

4. Cerebrospinal Fluid Originates in choroid plexuses deep within brain
Circulates around entire CNS
Ventricle system
Allows CNS to “float” in subarachnoid space
Protects against injury

5. CSF Circulation

6. Brain Blood Supply

7. Abnormal Postures – Think CNS/Brain Treatment???

8. Bony Structures Position of head Cervical vertebrae Mastoid processes
Should be centered - if rotated/laterally flexed, may indicate cervical dislocation
Cervical vertebrae
Observe spinous processes for normal alignment - if displaced or rotated, may indicated cervical dislocation
Mastoid processes
Ecchymosis indicative of basilar skull fracture - “Battle’s sign”
Skull and scalp
Evaluate for deformity, swelling and bleeding

9. Bony Injuries

10. Eyes Dazed stare may indicate abnormal function Nystagmus Pupil size
Presence of involuntary flutter and/or eye movements
May indicate cranial nerve and/or inner ear injury
Pupil size
Unilaterally dilated pupil indicative of intracranial bleeding
Must be aware of anisocoria – “normal” unequal pupils
Pupils reaction to light
Should be ipsilateral and contralateral constriction with exposure to light
Absence may indicate cranial nerve injury

11. Pupil Reaction

12. Nose and Ears
Bleeding from nose may indicate nasal and/or skull fracture
Bleeding from ears may indicate skull fracture
Halo test – gauze placed in ear to absorb leaking fluids, if “halo” forms around sample it indicates leakage of CSF = skull fracture
Ecchymosis around eyes (“raccoon’s eyes”) may indicate nasal and/or skull fracture

13. Eye Ecchymosis

14. Palpation of Bony Structures
Skull
Palpate all cranial bones for pain and deformity
Spinous processes
Palpate cervical spinous processes for pain and crepitus associated with fracture
Transverse processes
Can only directly palpate C1, but palpate area over remaining transverse processes for pain and crepitus

15. Special Tests Functional testing – evaluates function of CNS
Memory
Cognitive function
Neuropsychological testing
Balance and coordination
Vital signs
Neurological testing
Cranial nerve function
Nerve root evaluation

16. Memory Retrograde amnesia Anterograde amnesia
Difficulty or inability to remember events preceding the injury – more severe if can’t remember events of day before as opposed to more recent events
Some assessed with orientation x 4, pre-game meal?, who played last game?
Anterograde amnesia
Difficulty or inability to remember events after the onset of injury
Athlete given verbal list of items and asked to repeat them serially over time

17. Cognitive Function
Brain injury can present as abnormal behavior, personality changes, inability to process information accurately
Behavior
May become violent, belligerent, etc. - abnormal
Analytical ability
Typically assessed with serial number repetitions
Information processing
Cannot follow simple instructions

18. Neurological Testing Cranial nerve function Nerve root evaluation
Serial evaluations must be performed initially to evaluate for changes
Cranial nerves arise from brain and are susceptible to impairment secondary to intracranial bleeding and resulting pressure
Nerve root evaluation
Sensory (dermatome), motor (myotome) and reflex testing necessary to rule out or identify level of spinal cord injury

19. Cranial Nerve Evaluation
Olfactory
Optic
Oculomotor
Trochlear
Trigeminal
Abducens
Facial
Acoustic/Vestibulocochlear
Glossopharyngeal
Vagus
Accessory (spinal)
Hypoglossal On
Old
Olympus
Towering
Top A
Fin
And
German
Viewed
Hop

20. Post-Concussion Syndrome
Individuals may present with concussion symptoms long after “normal” resolution would have occurred
Common symptoms include
Decreased attention span
Difficulty concentrating
Memory impairment
Prolonged headaches
Balance impairments
Decreased cognitive function

21. Second Impact Syndrome
Defined as symptoms resulting from second concussive episode before symptoms of first concussive episode have resolved
Entirely preventable, return to play considerations
Second trauma typically not as violent as initial injury – thought to affect brain blood supply causing increased intracranial pressure which impacts brainstem function
Quick progression from mild concussive symptoms to comatose state
Even if treated appropriately, has ~50% mortality rate

22. Intracranial Hemorrhage
Named for location relative to meningeal layers
Caused by injury to blood vessels supplying brain blood supply
Increased pressure from bleeding in confined space compresses neural tissue
Onset of symptoms associated with nature of bleeding – venous vs. arterial (lucid interval)
Epidural hematoma
Subdural hematoma

23. Epidural Hematoma Arterial bleeding between skull and dura mater
Initially may present with concussive symptoms
Short lucid interval (typically <48 hours)– individual appears “OK”
Due to arterial nature of bleeding
Subsequently may c/o disorientation, confusion, drowsiness, increasing headache intensity, signs of cranial nerve changes (esp. pupil changes)
If untreated, can be fatal

24. Epidural Hematoma

25. Subdural Hematoma Venous bleeding between brain and dura mater
May not present with symptoms of concussion
Longer lucid interval – may be hours, days or weeks before symptoms present
Due to venous nature of bleeding
Subsequent development of headaches, confusion, changes in cognitive/motor abilities, cranial nerve changes
More likely to cause death due to lack of recognition of nature/source of symptoms and delay in subsequent treatment

26. Subdural Hematoma