Brain injury

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Introduction to Introduction to Brain InjuryBrain Injury

Dr. Craig JacksonSenior Lecturer in Health Psychology

School of Health and Policy StudiesFaculty of Health & Community Care

University of Central England

[email protected]@uce.ac.uk

What was Michael Angelo’s Hidden Message? What was Michael Angelo’s Hidden Message?

Michelangelo. Michelangelo. The Creation of Adam The Creation of Adam (detail, Sistine Chapel). (detail, Sistine Chapel).

1510. Fresco. Sistine Chapel, Vatican, Rome.1510. Fresco. Sistine Chapel, Vatican, Rome.

ObjectivesObjectives

List major structures and function of nervous systemList major structures and function of nervous system

Name types of head and spine injuries; describe clinical featuresName types of head and spine injuries; describe clinical features

Describe mechanisms of neurological Describe mechanisms of neurological

injuryinjury

Describe assessment of head injuriesDescribe assessment of head injuries

Describe functional affects and symptomsDescribe functional affects and symptoms

Describe imaging techniquesDescribe imaging techniques

Neurological InjuriesNeurological Injuries

Responsible for 50+% of trauma deathsResponsible for 50+% of trauma deaths

Approx. 1,000,000 patients in UK attend A&E with head injury per yearApprox. 1,000,000 patients in UK attend A&E with head injury per year

Can be prevented (some extent) by helmets and PPECan be prevented (some extent) by helmets and PPE

Major cause of chronic disabilityMajor cause of chronic disability

Mostly from Falls, RTAs and AssaultsMostly from Falls, RTAs and Assaults

Flannery & Buxton, 2001Flannery & Buxton, 2001

Anatomy PrinciplesAnatomy Principles

NeuronNeuronspecialized nerve cellspecialized nerve cell

Dendrites and Axons Dendrites and Axons short and long processes of neuronsshort and long processes of neurons

Peripheral neurons sheathed with myelinPeripheral neurons sheathed with myelin

Impulses transmitted from synapses to dendritesImpulses transmitted from synapses to dendrites

Anatomy Principles 2Anatomy Principles 2

Central Nervous System = brain, spinal cordCentral Nervous System = brain, spinal cord

Peripheral Nervous System = nerves, branchesPeripheral Nervous System = nerves, branches

Meninges = protective triple layer coverMeninges = protective triple layer cover

Dura matter Dura matter = = outer layerouter layerArachnoidArachnoid == middle layermiddle layerPia matterPia matter == inner layerinner layer

Cerebral Spinal Fuid (CSF) circulates in middle layerCerebral Spinal Fuid (CSF) circulates in middle layer

Anatomy Principles 3Anatomy Principles 3

Cerebrum (hemispheres)Cerebrum (hemispheres)Cerebellum, brainstemCerebellum, brainstem

Cranial nerves Cranial nerves originate at base of brainoriginate at base of brain

Sensory / motor supply to head and faceSensory / motor supply to head and face

Motor nerves = brain to muscle unitsMotor nerves = brain to muscle units

Sensory nerves = skin back to brainSensory nerves = skin back to brain

Somatic Nervous System = voluntary actionSomatic Nervous System = voluntary action

Automatic Nervous System = involuntary actionAutomatic Nervous System = involuntary action

Anatomy Principles 4Anatomy Principles 4

Traumatic Brain InjuryTraumatic Brain Injury

Physical force causes nerve cells to stretch, tear and pull apartPhysical force causes nerve cells to stretch, tear and pull apart

Unable to relay messages through brainUnable to relay messages through brain

Force causes brain to slam against skull interior: “Traumatic Brain Injury” Force causes brain to slam against skull interior: “Traumatic Brain Injury”

Injury to brain cells affects processing:Injury to brain cells affects processing:

thinkingthinkingrememberingrememberingseeingseeingcontrol & coordinationcontrol & coordinationmoodmood

Traumatic Brain InjuryTraumatic Brain Injury

TBI ranges from mild to severe:TBI ranges from mild to severe:

degree of forcedegree of force

multiple traumamultiple trauma

neurological complicationsneurological complications

speed of assistancespeed of assistance

Head InjuriesHead Injuries

Severity depends on amount of Primary and Secondary brain injurySeverity depends on amount of Primary and Secondary brain injury

Main cause of Secondary injury = hypoxiaMain cause of Secondary injury = hypoxia

Categories: Open or ClosedCategories: Open or Closed

Forces: Shearing and CompressionForces: Shearing and Compression

Non Loss of FunctionNon Loss of Function

41 yr old Mike Hill41 yr old Mike Hill

Attacked from behindAttacked from behind

Full recovery after removalFull recovery after removal

No infectionNo infection

Left hospital 1 week after removalLeft hospital 1 week after removal

Epileptic medication and some memory problemsEpileptic medication and some memory problems

Functional StatusFunctional Status

SPECT image with Technetium (T99)SPECT image with Technetium (T99)

Pathophysiological DisturbancePathophysiological Disturbance

Involve scalp, cranium, or underlying brainInvolve scalp, cranium, or underlying brain

Depends on mechanism of injuryDepends on mechanism of injury

Scalp:Scalp: lacerations, contusions, abrasionslacerations, contusions, abrasions

Skull fractures: Skull fractures: vault / base, simple or compound, depressed or planarvault / base, simple or compound, depressed or planar

Primary Brain Injury:Primary Brain Injury: Focal (intra-cranial haematoma, contusion)Focal (intra-cranial haematoma, contusion)

Diffuse (diffuse axonal injury)Diffuse (diffuse axonal injury)

Categories: Open or ClosedCategories: Open or Closed

Forces: Shearing and CompressionForces: Shearing and Compression

““Closed” or “Open” Head InjuryClosed” or “Open” Head Injury

Closed Head Injury (CHI): Closed Head Injury (CHI): No penetration of the skullNo penetration of the skullUsually a TBIUsually a TBINot always thoughNot always though

Open head Injury (OHI): Open head Injury (OHI): Bullet, Knife, or Fracture Bullet, Knife, or Fracture Skull breechedSkull breeched

Brain injury depends on power of physical force injuryBrain injury depends on power of physical force injury

If great enough, forces radiates through skull, causes sudden brain movementIf great enough, forces radiates through skull, causes sudden brain movement

Results in damaged nerve cellsResults in damaged nerve cells

May result in “soft tissue” injuryMay result in “soft tissue” injury -- cervical straincervical strainmyofascial traumamyofascial trauma

““Mild” Traumatic Brain InjuryMild” Traumatic Brain Injury

Head injury graded on:Head injury graded on: (i) length of unconsciousness(i) length of unconsciousness(ii) length of amnesia(ii) length of amnesia

Both caused by sudden trauma and nerve cell tearingBoth caused by sudden trauma and nerve cell tearing

Brain cannot maintain functioning and shuts down either:Brain cannot maintain functioning and shuts down either:

fully (unconsciousness)fully (unconsciousness) oror partially (dazed)partially (dazed)

MBI refers to loss of consciousness for 30 mins or lessMBI refers to loss of consciousness for 30 mins or less

UnconsciousUnconsciousAmnesiaAmnesia Any of these Any of these Diffuse AxonalDiffuse AxonalAltered consciousnessAltered consciousness indicates MBIindicates MBI InjuryInjuryneurological deficitsneurological deficits

MBI can result in life changing consequencesMBI can result in life changing consequences

Diffuse Axonal InjuryDiffuse Axonal Injury

Thinking slows downThinking slows down

Memory poorMemory poor Mild Brain InjuryMild Brain Injury Processing slowerProcessing slower

Concentration haphazardConcentration haphazard

““Roadblocks of damaged unconnected neurons”Roadblocks of damaged unconnected neurons”

Individual feels:Individual feels:

IncompleteIncomplete emotional problemsemotional problemsUnconfidentUnconfidentFrustratedFrustrated Described as “ mental fog”Described as “ mental fog”IrritableIrritableStrugglingStruggling cognitive problemscognitive problems

Brain Injury without Direct TraumaBrain Injury without Direct Trauma

Whiplash & ShakingWhiplash & Shaking

Sudden movement inside cranium damages neuronsSudden movement inside cranium damages neurons

Acceleration – DecelerationAcceleration – Deceleration

RTAs – even with airbag deployment –can cause brain injuryRTAs – even with airbag deployment –can cause brain injury

Brain is torn, squashed, bruisedBrain is torn, squashed, bruised

RollercoastersRollercoasters

Types of Head InjuriesTypes of Head Injuries

Concussion: Temporary alteration in neurological function or LORConcussion: Temporary alteration in neurological function or LOR

Cerebral Contusion: Bruised brainCerebral Contusion: Bruised brain

Cerebral Haemotoma or bleedCerebral Haemotoma or bleed

epiduralepidural

sub-duralsub-dural

sub-arachnoidsub-arachnoid

intra-cerebralintra-cerebral

Signs and SymptomsSigns and Symptoms

HeadacheHeadache

DizzinessDizziness

Nausea / VomitingNausea / Vomiting

AmnesiaAmnesia

Decreased responsivenessDecreased responsiveness

ConfusionConfusion

CombativenessCombativeness

Loss of responsivenessLoss of responsiveness

AssessmentAssessment

First impression: Responsive or UnresponsiveFirst impression: Responsive or Unresponsive

Urgent Survey:Urgent Survey: LORLOR ABC’sABC’s

Open airway with C-spineOpen airway with C-spine

Check breathing: Ventilate; Oral airway; OCheck breathing: Ventilate; Oral airway; O22 when available when available

Check carotid artery pulse – CPR if indicatedCheck carotid artery pulse – CPR if indicated

Control any major bleedingControl any major bleeding

Assessment continuedAssessment continued

Rapid Body SurveyRapid Body Survey Sample, DCAP-BTLSSample, DCAP-BTLS

Stabilize head between kneesStabilize head between knees

Call for equipment, assistance, transportCall for equipment, assistance, transport

Maintain body temp.Maintain body temp.

Transport (head uphill)Transport (head uphill)

Non-Urgent SurveyNon-Urgent Survey

Ongoing Survey – seizures, vomiting, change in LOROngoing Survey – seizures, vomiting, change in LOR

Assessment continuedAssessment continued

Brain SwellingBrain Swelling

Increased Intracranial Pressure (ICP)Increased Intracranial Pressure (ICP)

HypoxiaHypoxia

Further Secondary Brain InjuryFurther Secondary Brain Injury

More SwellingMore Swelling

Increased ICPIncreased ICP

Localised Neurological Signs (ICP)Localised Neurological Signs (ICP)

GENERAL SIGNS + PLUS +GENERAL SIGNS + PLUS +

Change in pupil size / light reactivityChange in pupil size / light reactivity

Slowing pulseSlowing pulse

Rising BP.Rising BP.

Change in respirationChange in respiration

Unilateral weaknessUnilateral weakness

IncontinenceIncontinence

SeizureSeizure

Urgent Interventions - ATLSUrgent Interventions - ATLS

Presume C-Spine injuryPresume C-Spine injury

Immobilize neckImmobilize neck

Open airway: administer oxygenOpen airway: administer oxygen

Treat bleeding and shockTreat bleeding and shock

Prevent aspiration of vomit / secretionsPrevent aspiration of vomit / secretions

Transport immediatelyTransport immediately

Elevate head 6”Elevate head 6”

Transport head uphillTransport head uphill

ImagingImaging

Xray, MRI and CT cannot show traumatic Xray, MRI and CT cannot show traumatic brain injurybrain injury

Techniques rely on Techniques rely on tissue densitytissue density

Diffuse damage will not show on these Diffuse damage will not show on these techniquestechniques

SPECT or PET measure brain cell SPECT or PET measure brain cell metabolismmetabolism

Can detect changes in function due brain injuryCan detect changes in function due brain injury

Behavioural ChangesBehavioural Changes

SpeechSpeech

CognitionCognition

MemoryMemory

MoodMood

Mental healthMental health

psychosespsychoses

deliriumdelirium

TremorTremor

GaitGait

Symmetry of functionSymmetry of function Gross over-simplificationGross over-simplification

VisualVisual

AuditoryAuditory

Positive and negative symptomsPositive and negative symptoms

Other Causes of Brain InjuryOther Causes of Brain Injury

Drug effectsDrug effects

TumorTumor

MetastasesMetastases

Physical assaultPhysical assault

SurgerySurgery

Traumatic birthTraumatic birth

HypoxiaHypoxia

Glasgow Coma ScaleGlasgow Coma Scale

Scores 8 or less = needs urgent anaesthetic assessment. Scores 8 or less = needs urgent anaesthetic assessment. Danger of airway compromiseDanger of airway compromise13-15 = mild13-15 = mild 9-12 = moderate 9-12 = moderate 3-8 = severe3-8 = severe

Queen’s Medical CentreQueen’s Medical Centre

Cerebral Asymmetry of FunctionCerebral Asymmetry of Function

Hemispheric asymmetry of function is relativeHemispheric asymmetry of function is relative

Asymmetries have been overblown by popular media into fads Asymmetries have been overblown by popular media into fads (e.g. golf with your right brain)(e.g. golf with your right brain)

Anterior-posterior differences far outweigh left-right differences Anterior-posterior differences far outweigh left-right differences

Asymmetry is not uniquely human Asymmetry is not uniquely human

Cerebral Asymmetry of FunctionCerebral Asymmetry of Function

LEFT HEMISPHERELEFT HEMISPHERE

Convolutions mature more rapidly Convolutions mature more rapidly

Extends further posteriorlyExtends further posteriorly

Higher in density (more gray matter; more neurons) Higher in density (more gray matter; more neurons)

Planum temporale larger on left (in 60-90%) of cases Planum temporale larger on left (in 60-90%) of cases

Larger insula Larger insula

Longer Sylvian fissure (gentler slope) Longer Sylvian fissure (gentler slope)

Double cingulate gyrus Double cingulate gyrus

Larger lateral posterior nucleus (to parietal cortex) Larger lateral posterior nucleus (to parietal cortex)

Wider occipital lobe Wider occipital lobe

Larger total area of frontal operculum (much buried in sulci)Larger total area of frontal operculum (much buried in sulci)

Larger inferior parietal lobule Larger inferior parietal lobule

Cerebral Asymmetry of FunctionCerebral Asymmetry of Function

RIGHT HEMISPHERERIGHT HEMISPHERE

Convolutions mature less rapidly Convolutions mature less rapidly

Extends further anteriorly Extends further anteriorly

Larger and heavier Larger and heavier

Primary auditory (Heshl's gyrus) larger on rightPrimary auditory (Heshl's gyrus) larger on right

Shorter (steeper slope) Shorter (steeper slope)

Single Single

Larger medial geniculate nucleus Larger medial geniculate nucleus

Narrower Narrower

Larger area of convexity in frontal lobe; wider frontal lobe Larger area of convexity in frontal lobe; wider frontal lobe

Cortical LesionsCortical Lesions

Human cognitive and sensory dysfunction different following lesions Human cognitive and sensory dysfunction different following lesions

(due to strokes, surgery, accident, etc.) (due to strokes, surgery, accident, etc.)

Differences noted in lesions to left and right hemispheresDifferences noted in lesions to left and right hemispheres

Lesions can provide clues about brain organizationLesions can provide clues about brain organization

Do specific areas possess special unique functions?Do specific areas possess special unique functions?

Does a lesion to a specific area demonstrate a dysfunctionDoes a lesion to a specific area demonstrate a dysfunction

++

Lesions to other brain locations Lesions to other brain locations do notdo not cause a similar dysfunction cause a similar dysfunction

DissociationDissociation

Lesion siteLesion site ReadingReading WritingWriting Speaking Speaking

100100 normalnormal normal normal impairedimpaired

102102 impairedimpaired normalnormal normalnormal

104104 normalnormal impairedimpaired normal normal

Allows understanding of specific sites and impairmentsAllows understanding of specific sites and impairments

Hemispherical FunctionHemispherical Function

LeftLeft RightRight

VisionVision linguistic stimulilinguistic stimuli patternspatterns faces facessteropsissteropsis

AuditionAudition language soundslanguage soundsrhythm rhythm

SomatosensationSomatosensation tactile recognitiontactile recognition

MotorMotor complex movementcomplex movement spatial movementspatial movement

MemoryMemory verbal memoryverbal memory non-verbal memorynon-verbal memory

LanguageLanguage speech readingspeech reading prosodyprosodywriting arithmeticwriting arithmetic

EmotionEmotion social emotionssocial emotions primary emotionsprimary emotions

Spatial processesSpatial processes geometrygeometry spatial images orientationspatial images orientation

Split Brain and Commissurotomy Split Brain and Commissurotomy

Corpus Callosum joins hemispheresCorpus Callosum joins hemispheres

Sever corpus callosumSever corpus callosum

Two hemispheres cannot communicateTwo hemispheres cannot communicate

Brain Injury - SummaryBrain Injury - Summary

1. The main cause of secondary damage to the brain is _ _ _ _ _ _ _ ?1. The main cause of secondary damage to the brain is _ _ _ _ _ _ _ ?

2. Head injury alone rarely causes damage. T / F?2. Head injury alone rarely causes damage. T / F?

3. Temporary loss of consciousness or function from a head trauma is a 3. Temporary loss of consciousness or function from a head trauma is a _ _ _ _ _ _ _ _ _ _ ?_ _ _ _ _ _ _ _ _ _ ?

4. Brain injury can occur without any impact trauma. T / F4. Brain injury can occur without any impact trauma. T / F

5. Axons being damaged / shredded is the simple reason for cognitive 5. Axons being damaged / shredded is the simple reason for cognitive problems in head injury patients. T / Fproblems in head injury patients. T / F

Hemispherical testHemispherical test

I always wear a watch

1

Hemispherical test

I keep a journal

2

Hemispherical test

I believe there is a right and wrong way to do everything

3

Hemispherical test

I hate following directions

4

Hemispherical test

The expression "Life is just a bowl of cherries" makes no sense to me

5

Hemispherical test

I find that sticking to a schedule is boring

6

Hemispherical test

I'd rather draw someone a map the tell them how to get somewhere

7

Hemispherical test

If I lost something, I'd try to remember where I saw last

8

Hemispherical test

If I don't know which way to turn, I let my emotions guide me

9

Hemispherical test

I'm pretty good at math

10

Hemispherical test

If I had to assemble something, I'd read the directions first

11

Hemispherical test

I'm always late getting places

12

Hemispherical test

Some people think I'm psychic

13

Hemispherical test

Setting goals for myself helps keep me from slacking off

14

Hemispherical test

When somebody asks me a question, I turn my head to the left

15

Hemispherical test

If I have a tough decision to make, I write down the pros and the cons

16

Hemispherical test

I'd make a good detective

17

Hemispherical test

I am musically inclined

18

Hemispherical test

If I have a problem, I try to work it out by relating it to one I've had in the past

19

Hemispherical test

When I talk, I gesture a lot

20

Hemispherical test

If someone asks me a question, I turn my head to the right

21

Hemispherical test

I believe there are two sides to every story

22

Hemispherical test

I can tell if someone is guilty just by looking at them

23

Hemispherical test

I keep a to do list

24

Hemispherical test

I feel comfortable expressing myself with words

25

Hemispherical test

Before I take a stand on an issue, I get all the facts

26

Hemispherical test

I've considered becoming a poet, a politician, an architect, or a dancer

27

Hemispherical test

I lose track of time easily

28

Hemispherical test

If I forgot someone's name, I'd go through the alphabet until I remembered it

29

Hemispherical test

I like to draw

30

Hemispherical test

When I'm confused, I usually go with my gut instinct

31

Hemispherical test

I have considered becoming a lawyer, journalist, or doctor

32

Hemispherical test

1. L 1. L

2. L2. L

3. L 3. L

4. R 4. R

5. L 5. L

6. R 6. R

7. R 7. R

8. L 8. L

9. R 9. R

10. L 10. L

11. L 11. L

12. R12. R

Hemispherical test

13. R 13. R

14. L 14. L

15. R 15. R

16. L 16. L

17. L 17. L

18. R 18. R

19. R 19. R

20. R 20. R

21. L 21. L

22. R 22. R

23. R 23. R

24. L 24. L

Hemispherical test

25. L 25. L

26. L 26. L

27. R 27. R

28. R 28. R

29. L 29. L

30. R 30. R

31. R 31. R

32. L32. L