Classification of TBI

Mild TBI
defined as a traumatically induced physiologic disruption of brain function, as
manifested by at least one of the following:
Brief Loss of consciousness (less than 30mins)
Loss of memory for events occurring immediately before or after the accident.
Temporary change in mental state at the time of the accident (e.g. feeling
dazed, disoriented, or confused)
Temporary focal neurologic deficit
Post traumatic amnesia not greater than 24 hrs
An initially Glascow coma scale of 13-15
This definition includes all injuries in which the head is either struck by, or strikes an
object, or in which the brain undergoes acceleration/deceleration movement without
actually striking the head. It excludes trauma resulting from stroke, anoxia, tumor,
encephalitis.
Moderate TBI
results in a loss of consciousness lasting only a few minutes to few hours,
followed by days and or weeks of confusion. People who sustain moderate TBI
usually have physical, cognitive, & behavioral impairments that can last for
many months and may become permanent. Other criteria include the ff:
Glascow Coma scale score 9-12
Abnormal CT scan findings
Operative intracranial lesion
Length of hospital stay is at least 48 hrs.
Long-term physical or cognitive deficits
Severe TBI
usual results in coma, loss of consciousness. When in a coma, the patients eyes
are closed and he or she shows no reaction when spoken to, touched, or
pinched. Some patients demonstrate a reflexive movement, such as hand grip,
when an arm or leg is touched or squeezed. A coma can be brief or can persist
for hours, days, weeks, months, or even years. The longer the person is
unconscious, the more severe the injury & the greater the chance of permanent
neurological damage.
Factors that influence the Outcome of TBI
PREMORBID STATUS
when a brain injury occurs in a person who has already lost a sizeable number of
neurons because of previous brain disease or injury, the result of that brain
injury is usually much worse than it would have been without prior brain
damage.
PRIMARY INJURY

depending on the nature, direction, & magnitude of the forces applied to the
skull, brain & body.

Types of Primary Injury

Local Brain damage

is localized to the area of the brain that is under the site of impact on the skull.
The damage may be in the form of a clot, contusion, or laceration, or a
combination of the three. More severe damage may result in localizing
neurological signs, depending on the location of the injury.
Polar brain damage
occurs when the head is subjected to acceleration-deceleration forces, such as in
a head-on collision. The damage results when the brain moves forward inside the
skull and then suddenly stops due to impact in the skull. Damage to the tips
(poles) & undersurface of the temporal & frontal lobes are the most common.
Damage to the occipital pole can also occur, but is much less common.
Diffuse Axonal Injury (DAI)
refers to widely scattered shearing of subcortical axons within their myelin
sheaths that is not isolated to any one location, but causes a dramatic
cumulative effect. DAI may occur in isolation or in association with local or polar
damage.

SECONDARY INJURY

Hypoxic-ischemic injury (HII)

result in infarction of particular vascular territory in the brain owing to
compromise of circulation secondary to shifting brain structures. A more diffuse
form of HII, resulting in secondary brain injury, is caused by arterial hypoxemia.
The causes of arterial hypoxemia range from obstruction of the airway to
myocardial infarction, pericardial effusion, arrhythmia, CHF, pulmonary embolus,
and pneumothorax. These systemic injuries may result in any number of
respiratory impairments that deprive the brain of nuch-needed oxygen. Arterial
hypotension, often the result of massive blood loss, may also contribute to HII.

Intracranial Hematomas
this complication can transform a seemingly mild injury into life-threatening
situation within hours. Intracranial hematomas are often associated with a patient
who talk and die, that is those who are lucid for a period of time after the initial
injury but who later lapse into coma and die. This late appearing loss of
consciousness is due to compression of the brain by expanding hematoma (mass
effect). This lucid interval occurs only in the portion of patients with TBI. Many are
in coma from the initial injury and the hematoma may go endetected and entreated,
causing an unavoidable death.
Classification of Intracranial Hematoma
Extradural (epidural) hematoma

An extradural (epidural) hematoma consists of an ovoid mass of clotted blood

that lies between the bone of the vault or the base of the skull and the dura. In
two-thirds of cases, the extradural hematoma is caused by a fracture in the
squamous part of the temporal bone; in the remaining cases, the hematoma
may develop in relation to the frontal and parietal parts of the brain or even
within the posterior fossa and, occasionally, they are multiple. Because the
source of the bleeding is usually arterial, the hematoma enlarges fairly rapidly,
gradually stripping the dura from the scalp to form a circumscribed ovoid mass
that progressively indents and flattens the adjacent brain. In many cases, there
is little associated underlying brain damage.

Intradural hematomas
Subarachnoid hematoma. Some degree of subarachnoid hemorrhage occurs in
any serious brain injury. Most occur in association with surface contusions. In
many cases, there is a thin layer of blood clot over the lateral and inferior
aspects of the frontal and temporal lobes, but in approximately 10%15% of
patients, the amounts are larger and may constitute a subarachnoid hematoma.
Under these circumstances, there may be associated constriction (vasospasm) of
the cerebral arteries, and, if large amounts of subarachnoid hemor rhage are
present in the posterior fossa, acute obstructive hydrocephalus may develop.
The entity of traumatic subarachnoid hemorrhage is well recognized as a result
of damage to blood vessels in the posterior fossa often in association with a
fracture of the base of the skull.
Subdural hematomas
A small amount of hemorrhage within the subdural space is common in fatal
brain injury. Because this blood can spread freely throughout the subdural space,
it tends to cover the entire hemisphere, with the result that an SDH is usually
larger than an extradural hematoma. The great majority of SDHs are due to
rupture of veins that bridge the subdural space where they connect the upper
surface of the cerebral hemisphere to the sagittal sinus. Occasionally, they are
arterial in origin
Intracerebral and intracerebellar hematomas.
Intracerebral and intracerebellar hematomas are present in approximately 16%
20% of fatal brain injury cases. They are often multiple and occur most
commonly in the frontal and temporal lobes (Bullock and Teasdale 1990). Less
commonly, they occur in the cerebellum. Sometimes, traumatic intracerebral
hematomas develop several days after the injury, and recognition of this
possibility may have important medicolegal implications if the patient dies.
Burst lobe
The term burst lobe describes an intracerebral or an intracerebellar hematoma
that is continuous with a SDH. It is presumed to be due to damage to or
laceration of superficial brain tissue. It is present in approximately 25% of fatal
cases of brain injury and occurs most commonly in the frontal and temporal
lobes.

OTHER TYPES OF HEAD TRAUMA (TBI)

Concussion (Closed Head Injury)
a blow to the head hard enough to make the brain hit or twist within the skull but
not hard enough to cause cerebral contusion; causes temporary neural
dysfunction by disrupting the reticular activating system (RAS). Recovery is
usually complete within 24 to 48 hours. Repeated injuries exact a cumulative toll
on the brain.
Contusion (bruising of brain tissue; more serious than concussion)
coup-countercoup injuries caused by acceleration-deceleration events disrupt
the normal nerve functions in bruised area. Injury is directly beneath the site on
impact in the brain rebounds against the skull from the force of a blow (a beating
with a blunt instrument, for example), when the force of the blow drives he brain
against the opposite side of the skull, or when the head is hurled forward and
stopped abruptly (as in automobile accident when the drivers head strikes the
windshield). The brain may strike bony prominences inside the skull (especially
the sphenoidal ridges), causing intracranial hemorrhage or hematoma.
Considered to be the hallmark of brain damage due to head injury, they have a
very characteristic distribution generally affecting the frontal poles, the orbital
gyri, and the cortex above and below the sylvian fissures, the temporal poles,
and the lateral and inferior aspects of the temporal lobes. Less frequently, the
inferior surfaces of the cerebellar hemispheres are affected. Contusions are not
usually found in the parietal and occipital lobes unless there is a skull fracture in
these areas
Skull fracture
there are four types of skull fractures, including linear, comminuted, depressed &
basilar. Blow to the head causes one or more of the types. May not be
problematic unless brain is exposed or bone fragments are driven into the neural
tissue. Fractures of anterior or middle fossa are associated with severe head
trauma and are more common than those of posterior fossa.
CATEGORY OF HEAD TRAUMA
Closed Trauma (Blunt Trauma)
is more common. It typically occurs when the head strikes a hard surface or a
rapidly moving object strikes the head. The dura is intact, and no brain tissue is
exposed to the external environment.
Open Trauma
an opening in the scalp, skull, meninges, or brain tissue, including the dura,
exposes the cranial contents to the environment, and the risk of infection is high.
Penetrating head trauma
means that a foreign object has penetrated the skull and the dura; most typically
these are missile (bullet) injuries, but may also include stab wounds.
TYPES OF INJURY

Coup injuries
are more common when the head is accelerated. This causes contusions
beneath the site of impact.
Contrecoup injuries
(across from the blow) are more common with head deceleration. The frequently
occurring contusions of the frontal and temporal poles are almost always
contrecoup, regardless of the site of head impact. Thus, contrecoup lesions by
definition may be those that are not under the point of impact.
Strain
is the proximate cause of tissue injury, whether it is induced by inertia or
contact. Three types of strain affect brain tissue: compression, tension, and
shear. Biological tissues are usually elastic and thus deform slowly rather than
quickly. The three principal tissues affected in a closed-head injury are bone,
blood vessels, and brain, and they vary considerably in their tolerances to
deformation. Brain is virtually incompressible in vivo, but it has a very low
tolerance to tensile or shears strain. The latter two types of strain are the usual
causes of brain damage, as compression injury is rare, and the same holds for
vascular tissue injury as well