Mild Traumatic Brain Injury: Mild Traumatic Brain Injury: Diagnosis and Management Diagnosis and Management Andy Jagoda, MD Andy Jagoda, MD Department of Emergency Medicine Department of Emergency Medicine Mount Sinai School of Medicine Mount Sinai School of Medicine New York, New York New York, New York
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Mild Traumatic Brain Injury: Diagnosis and Management Andy Jagoda, MD Department of Emergency Medicine Mount Sinai School of Medicine New York, New York.
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Mild Traumatic Brain Injury:Mild Traumatic Brain Injury:Diagnosis and ManagementDiagnosis and Management
Andy Jagoda, MDAndy Jagoda, MD
Department of Emergency MedicineDepartment of Emergency MedicineMount Sinai School of MedicineMount Sinai School of Medicine
New York, New YorkNew York, New York
Andy Jagoda, MD
ObjectivesObjectives• Definitions
– Glasgow coma scale score– Amnesia / loss of consciousness
A 50-year-old driver is in a head-on collision at approximately 15 mph. She is not wearing a seat belt and strikes her head on the windshield. The windshield does not break, and though dazed for “several seconds” she does not lose consciousness and has no amnesia. She is taken to the ED where she is alert, oriented times three, and has no complaints. She has no past medical history and is on no medications.
The CaseThe Case
Andy Jagoda, MD
Which of the Following is Not Which of the Following is Not Used to Define Mild TBI?Used to Define Mild TBI?
a. GCS >12
b. Loss of consciousness <1 hr
c. Post-traumatic amnesia <24 hrs
d. Non-focal neurologic exam
e. CT scan
What would the GCS be in the presented What would the GCS be in the presented case If on exam the patient kept her eyes case If on exam the patient kept her eyes closed but opened them to questions; closed but opened them to questions; answered questions with difficulty and was answered questions with difficulty and was confused; moved her extremities confused; moved her extremities appropriately on command?appropriately on command?
a. 15
b. 13
c. 11
d. 09
e. 07
If the presented patient had an occipital If the presented patient had an occipital laceration with no hematoma, which of the laceration with no hematoma, which of the following would be the best initial test?following would be the best initial test?
a. Skull radiographs
b. Non-contrast CT
c. Contrast CT
d. MRI
E. PET
Andy Jagoda, MD
Postconcussive Syndrome (PCS) in Postconcussive Syndrome (PCS) in Mild TBI, which of the following is true?Mild TBI, which of the following is true?
a. Early PCS occurs primarily in patients with psychiatric problems.
b. Early PCS occurs more frequently in patients involved in litigation.
c. Early PCS occurs in up to 20% of patients.
d. Late PCS occurs primarily in men.
e. Late PCS has been linked to anxiety, stress, and depression.
Andy Jagoda, MD
EpidemiologyEpidemiology
• 6 million head injury cases in the USA each year (1 in 45)– Young male predominance
What would the GCS be in the presented What would the GCS be in the presented case If on exam the patient kept her eyes case If on exam the patient kept her eyes
closed but opened them to questions; closed but opened them to questions; answered questions with difficulty and was answered questions with difficulty and was
confused; moved her extremities confused; moved her extremities appropriately on command?appropriately on command?
a. 15
b. 13
c. 11
d. 09
e. 07
Andy Jagoda, MD
Which Of The Following Is Not Which Of The Following Is Not Used To Define Mild TBI?Used To Define Mild TBI?
• a. GCS > 12
• b. Loss of consciousness < 1 hr
• c. Post-traumatic amnesia < 24 hrs
• d. Non-focal neurologic exam
• e. Normal CT scan
Andy Jagoda, MD
Use of CT in Diagnosing MTBIUse of CT in Diagnosing MTBI
• Retrospective study, 215 hospitalized patients– Mild TBI without complications– Mild TBI with complications (positive CT)– Moderate TBI
• Mild TBI patients with positive CT performed on neuropsychiatric testing like moderate TBI
Williams et al. Williams et al. Neurosurgery Neurosurgery 1990;27:422.1990;27:422.
Andy Jagoda, MD
Use of CT in Diagnosing MTBIUse of CT in Diagnosing MTBI
• Moderate group had worse function at 6 months
• Length of LOC or amnesia did not differentiate mild from moderate groups
• Depressed skull fractures without parenchymal lesions did performed as mild TABI
Williams et al. Williams et al. Neurosurgery Neurosurgery 1990;27:422.1990;27:422.
Andy Jagoda, MD
Skull Radiographs and Skull Radiographs and Intracranial LesionsIntracranial Lesions
• Retrospective review
• 207 hospitalized patients with intracranial lesions
• 63% had no skull fracture
• Skull films do not predict intracranial lesion
Cooper P, Ho V. Cooper P, Ho V. Neurosurgery Neurosurgery 1983;13:136.1983;13:136.
Andy Jagoda, MD
• Retrospective review 22,058 cases
• Patients with skull fractures, 91% did not have intracranial injury
• 51% of patients with intracranial injury did not have a skull fracture
Masters et al. NEJM 1987;316:84-91.
Skull Radiographs and Skull Radiographs and Intracranial LesionsIntracranial Lesions
Andy Jagoda, MD
Skull Radiographs and Skull Radiographs and Intracranial LesionsIntracranial Lesions
• Prospective study: 7035 patients – Not all patients received same tests– 48% lost to follow-up
• Skull fracture was associated with an intracranial injury
Masters et al. NEJM 1987;316:84-91.
Andy Jagoda, MD
Skull Radiographs and Intracranial Skull Radiographs and Intracranial LesionsLesions
• Skull fracture did not predict an intracranial injury
• Absence of a skull fracture did not rule out an intracranial injury
• Plain films are neither sensitive nor specific for intracranial injury
Masters et al. NEJM 1987;316:84-91.
Andy Jagoda, MD
Low Risk Group For Low Risk Group For Intracranial InjuryIntracranial Injury
• Asymptomatic• Headache• Dizziness• Scalp hematoma, laceration, contusion• Absence of moderate or high risk criteria,
ie, LOC or amnesia• No patients with neurologic deterioration
identified• No imaging study indicated
Masters et al. NEJM 1987;316:84-91.
Andy Jagoda, MD
Moderate Risk Group For Moderate Risk Group For Intracranial InjuryIntracranial Injury
• Loss of consciousness• Unreliable history• Progressive headache• Alcohol or drug intoxication• Age less than 2 years• Post traumatic seizure• BSF / multiple trauma / possible penetrating
trauma• CT scan recommendedMasters et al. NEJM 1987;316:84-91.
Andy Jagoda, MD
Head CT In Mild TBI Head CT In Mild TBI
• Retrospective review 1538 trauma admissions• GCS > 12; all with history of LOC or amnesia• 265 (17.2%) had intracranial lesion:
– GCS 13: 37.5%– GCS 14: 24.2%– GCS 15: 13.2%
• 58 (3.8% of total 22% of patients with positive CT) required neurosurgery
• No patient with a normal CT deterioratedStein S, Ross S. Stein S, Ross S. Ann Emerg MedAnn Emerg Med 1993;22:1193. 1993;22:1193.
Andy Jagoda, MD
Head CT In Mild TBI Head CT In Mild TBI
• Prospective study: 712 consecutive ED patients• GCS 15; history of LOC or amnesia• Nonfocal neurologic exam
– 4 object recall and digit span testing
• 67 (9.4%) had a positive head CT• 2 (.28%) required emergent neurosurgery• No statistical model could be created to classify
95% of patients into CT normal vs abnormal
Jeret et al. Jeret et al. Neurosurgery Neurosurgery 1993;32:9.1993;32:9.
Andy Jagoda, MD
Head CT In Mild TBI Head CT In Mild TBI
• 10% to 20% have a positive CT
• .2 to 4% have a neurosurgical lesion
• Patients without LOC or amnesia, normal exam, and GCS 15 do not need imaging– Direct trauma to the temporal area– Children <3 years
Andy Jagoda, MD
Head CT in Mild TBIHead CT in Mild TBI
• In patients with LOC or amnesia, there are no combination of findings that identify all patients who have a positive CT
• Patients with a normal CT can be safely discharged home
Andy Jagoda, MD
Magnetic Resonance ImagingMagnetic Resonance Imaging
• Prospective study
• 50 TBI patients; CT, MRI, neuropsych
• 72% had lesions on CT
• 80% had lesions seen on MRI– Scattered punctate lesions; Frontal temporal
regionsLevin et al. J Neurol Neurosurg Psych 1992;55:255.
Andy Jagoda, MD
Magnetic Resonance ImagingMagnetic Resonance Imaging
• MRI identified additional lesions in 52% of patients with lesions on CT
• No correlation with size of lesions and length of LOC: inconsistent relationship between lesions and neuropsych findings
Levin et al. J Neurol Neurosurg Psych 1992;55:255.
Andy Jagoda, MD
Other Diagnostic ModalitiesOther Diagnostic Modalities
If the presented patient had an occipital If the presented patient had an occipital laceration with no hematoma. Which of the laceration with no hematoma. Which of the following is the best initial test?following is the best initial test?
a. Skull radiographs
b. Non-contrast CT
c. Contrast CT
d. MRI
e. PET
Andy Jagoda, MD
PCS: Reading the LiteraturePCS: Reading the Literature• Symptom complex related to TBI
• Incidence in MTBI patients:– 80% at 1 month– 30% at 3 months– 15% at 12 months
Andy Jagoda, MD
PCS: Reading the LiteraturePCS: Reading the Literature
• Lack of uniformity in definitions
• Selection bias
• No controls
• No pre-injury baseline
• Lack of standardization of testing
• Attrition in follow-up
Andy Jagoda, MD
Postconcussive SyndromePostconcussive Syndrome
• Prospective study, 538 patients• MTBI, hospitalized• 3 month follow-up• 79% headaches• 59% memory dysfunction• 33% had not returned to work• Ongoing litigation did not correlate with
complaintsRimel et al. Rimel et al. NeurosurgeryNeurosurgery 1981;9:221. 1981;9:221.
Andy Jagoda, MD
Postconcussive SyndromePostconcussive Syndrome
• 587 hospitalized, uncomplicated MTBI patients• Prospective design over 1 year
– 68% lost to follow-up
• At discharge, 67% had at least one symptom• 38% had symptoms at 3 months• 23% had symptoms at 6 months• 13% had symptoms at 12 months• Presence of symptoms at hospital discharge
were not predictive of symptoms at 3 monthsAlves et al. J Head Trauma Rehab 1993;8:48.
Andy Jagoda, MD
PCS Symptoms and Other InjuriesPCS Symptoms and Other Injuries• 170 patients with chronic pain, with no history of
TBI• All had at least one somatic complaint associated
with PCS• 42% had at least one cognitive complaint
(forgetfulness, problem with attention or concentration)
• Emphasizes importance of assessing patients with PCS for concomitant physical or psychosocial problems