Mild Traumatic Brain Injury Issues Related to Evaluation

Mild Traumatic Brain Injury: Issues Related to Evaluation and Diagnosis

Traumatic Brain Injury • Insult to the brain caused by an external physical force • Produces a diminished or altered state of consciousness ▫ Dazed and confused ▫ Loss of consciousness • Post traumatic amnesia (PTA) may be present

Mild/Concuss Severity of ion LOC less then 30 minutes with normal imagining GCS 13 -15 Moderate TBI LOC greater the 30 minutes, less then six hours with abnormal imaging GCS 9 -12 PTA less then 24 PTA less then 7 hours days Severe LOC greater then 6 hours with abnormal imaging GCS<9 PTA greater then 7 days

TBI Prognosis • Injury severity is the strongest predictor of recovery • Recovery after moderate and severe TBI may not be as complete as recovery from mild TBI • Pre and post injury medical and MH issues place people at risk for poorer outcome

Acute Phase • The development of post concussive symptomology (PCS) is normal and expected Alves et al. , 1986) • Initial symptom development is related to organic and neuropathological processes Mc. Crea, 2008 • Symptoms develop within minutes to hours to days after the injury ▫ Delayed symptom development is rare

Post Concussive Symptomology (PCS) ▫ Physical: Headache, dizziness, fatigue, noise/light intolerance, insomnia, sleep disturbances, tinnitus, balance and visual problems ▫ Cognitive: Memory complaints, poor concentration ▫ Emotional: Depression, anxiety, irritability, mood lability

Acute Phase • Research suggests a period of metabolic dysfunction within hours to days of injury • Metabolic disarray explains resulting cognitive impairment and post concussive symptomology • m. TBI subjects show an abnormal profile of cerebral activation in response to cognitive demands • f. MRI shows decreased activation of select neuronal circuits in the frontal lobes • Effect is most evident in m. TBI subjects with LOC Mc. Crea, et al. , 2002

Acute Phase • Cognitive and physical symptoms are most common • Emotional symptoms are difficult to link to concussion verses other stressors in the combat zone • Anxiety, depression, combat stress, PTSD, grief

Recovery • Recovery following m. TBI/concussion is normal and expected • Research has repeatedly demonstrated that in the civilian population, the vast majority of individuals who sustain a concussion completely recover in a matter of days to weeks. ▫ 80 -90% recover in 7 -10 days ▫ 3% experience persistent symptoms beyond one to three months Belanger et al. , 2005; Mc. Crea, 2008; Ivins et al. , 2009

Cognitive Recovery After m. TBI Mc. Crea et al. , 2003

Symptom Recovery After m. TBI Mc. Crea et al. , 2003

Recovery • Return to normal metabolic function is expected within several days • f. MRI studies show no cerebral activation deficits in the injured subjects after a few weeks Mc. Crea, et al. , 2002

Recovery • Recovery follows a progressive course ▫ Symptomology usually improves as time goes on; symptoms usually do not get worse over time ▫ If they do, secondary etiologies should be considered • Delayed symptom onset is rare • Headache is the symptom that tends to linger the longest and to be most problematic in terms for clinical management

“Complicated” verses Uncomplicated • “The unfortunate few”-approximately 3% • m. TBI with structure damage on imaging may have a more complicated recovery course ▫ Outcome may be more consistent with moderate TBI • Individuals with multiple m. TBIs within a short period of time are also at risk for more persistent problems Guskiewicz et al. , 2003

Persistent symptoms • Symptoms persisting beyond the expected recovery course after m. TBI are highly nonspecific to MTBI and are often attributable to non-injury related factors Mittenberg, 1996; Mc. Crea, 2008 • PCS-like symptoms are common in “normal” people

Post Concussive Symptoms Symptom MTBI/PCS General Population Poor Concentration 71% 14% Irritability 66% 16% Fatigue 64% 13% Depression 63% 20% Memory Problems 59% 20% Headaches 59% 13% Anxiety 58% 24% Dizziness 52% 7% Blurry vision 45% 8% Light sensitivity 40% 14% Mittenberg, 1996

Effect Size of m. TBI on Neuropsychological Functioning Iverson, 2005

Effect Size of m. TBI on Memory Functioning Iverson, 2005

Diagnosis Issues • Two questions: ▫ Did the person have a concussion? ▫ Are their current symptoms related to their history of concussion or better explained by other etiologies? • Just because a person has a history of concussion does not mean that they have current brain injury.

Question 1: • Did the patient experience a concussion? ▫ This is the easy question ▫ Assess injury event ▫ Change in consciousness �Alteration in consciousness is different from a posttraumatic stress reaction ▫ Development of post concussive symptomology

Question 2 • Are their current symptoms related to their history of concussion or better explained by other etiologies? ▫ This is the hard question ▫ Emphasis must be on the temporal proximity of symptom development ▫ Must assess other co-morbid medical and MH issues that may explain their current symptomology

VA/DOD Guidelines • Training from central office has stressed the importance of assessing the temporal proximity of symptom development to the injury event ▫ In order for the symptoms to be related to the concussion, they must have developed within hours to days after the injury ▫ Symptoms that develop months to years later are most likely related to other causes

m. TBI Evaluation • Consider other in-theater factors that might explain symptom development ▫ Combat stress, PTSD, sleep deprivation, dehydration • Assess symptoms present prior to the concussion ▫ Complete resolution would not be expected and ongoing problems may not be attributed to concussion ▫ Patient will return to their baseline which is not the same as being symptom free �Patients with headaches before their concussion, will likely continue to experience headaches after

m. TBI evaluation • No symptom checklist can diagnose brain injury • No physical or neurological test can diagnose brain injury • Differential diagnosis relies on an in-depth clinical interview focusing on the temporal development of symptoms ▫ Knowledge and assessment of other conditions that may be contributing is necessary

PTSD Re-experiencing Avoidance Social withdrawal Memory gaps Apathy m. TBI Sequela Difficulty with decisions Mental slowness Concentration Headaches Dizzy Appetite changes Fatigue Sadness Depression Arousal Sensitive to noise Concentration Insomnia Irritability

PTSD Pain Medications Depression Mild TBI Sequela Medical Issues Substance Abuse

Post Traumatic Headaches • Trauma event and headache start must correlate in time ▫ How much time? • International Headache Society (IHS) ▫ Headache must develop within 7 days of the injury • Other standards have been applied ▫ Up to 30 days post injury

Summary • History of concussion does not mean a current diagnosis of brain injury • Most people completely recovery following a concussion • Of the estimated 3% of remain symptomatic a portion of those are symptomatic for reasons other then brain injury

Summary • Other etiologies of their current difficulties must be considered (i. e. , PTSD, depression, medical issues, pain, medications, etc. ) • The timeline of symptom development is very important • Secondary etiologies should be considered symptoms that develop much later

Additional Training Material • VA Polytrauma training ▫ Video with Dr. David Cifu • m. TBI research overview ▫ Video with Dr. Michael Mc. Crea • Readings ▫ Mild Traumatic Brain Injury and Post Concussive Syndrome-Michael Mc. Crea

References • Alves WM, Cohohan AR, O'Leary TJ, Rimel, RW and Jane JA. Understanding post-concussice symptoms after minor head injury. Journal of Head Injury Trauma Rehabilitation, 1986; 1: 1 -12. • Belenger HG, Curtiss G, Demery, JA, Lebowski BK and Vanderploeg RD. Factors moderating neuropsychological outcomes following mild traumatic brain injury: A meta-analysis. Journal of the International Neuropsychological Society; 2005; 11, 215 -227. • Guskiewicz KM, Mc. Crea M, Marshall SW et al. Cumulative effects associated with recurrent concussion in collegiate football players: the NCAA Concussion Study , JAMA, 2003; 290: 2549 -55. • Iverson GL. Outcome from mild brain injury. Curr Opin Psychiatry, 2005; 18: 301 -7.

References continued • Ivins BJ, Kane R and Schwab KA. Performance on the automated neuropsychological assessment metrics in a non-clinical sample of soldiers screened for mild TBI after returning from Iraq and Afghanistan: A descriptive analysis. Journal of Head Trauma Rehabilitation; 2009: 24(1) 24 -31. • Mc. Crea, M. Mild Traumatic Brain Injury and Postconcussion Syndrome: The New Evidence Base for Diagnosis and Treatment. New York: Oxford University Press, 2008. • Mc. Crea M, Kelly JP, Randolph C, Cisler R, Berger L. Immediate neurocognitive effects of concussion. Neurosurgery 2002; 50: 103242. • Mc. Crea M, Guskiewicz KMm Marshall SW, et al. Acute effects and recovery time following concussion in collegiate football players: the NCAA concussion study. JAMA, 2003; 290: 2556 -63. • Mittenberg W, Tremont G, Zielinski R, Fichera S, Rayls, K. Cognitive behavioral prevention of post concussion syndrome. Archive of Clinical Neuropsychology; 1996; 11: 139 -145.