1 HEAD TRAUMA 102 Norton Winer MD Director: Department of NeurologyUH 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 definitions1. 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 parametersgrade 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/yr570,000 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 traumaDirect blow to head Sports injuries Penetrating injuries (most severe) GSW, projectiles etc

11 Concussion mechanisms

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14 Cellular effects of concussion

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17 Concussion and sports

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22 Tennis!!

23 Military injuries

24 Military head injuries

25 Concussive symptoms 1. headache 2. nausea/vomiting3. 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

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

31 Second Impact SyndromeInvolves 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 - one1. 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 - two1. 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 - threeMust 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 traumaCTE, DEMENTIA etc

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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

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50 Skull Fractures Linear skull fracture – least clinical significanceDepressed 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 spineInvolves 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

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