Traumatic Brain Injury (TBI)

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Presentation :

• ==Mild TBI (aka concussion): typically causes temporary neurologic impairment without evidence of structural damage on conventional neuroimaging. ==
  • In most patients, the physical examination is normal and diagnostic investigation is unnecessary
  • Headache is consistently the most common symptom and is among the most disabling sequelae
  • Common TBI symptoms by domain:
• Severe TBI may present with altered consciousness, seizures, repeated vomiting, or focal neurologic deficits.
• Postconcussion syndrome describes the persistence of symptoms of mild TBI beyond a typical recovery period of several weeks.

Pathophysiology :

Diagnostic Testing:

• Patients with mild TBI, a normal neurologic examination, and (when necessary) a normal head CT scan may be safely followed as outpatients.
  • CT in patients with mild TBI should be performed if any of the findings below are positive. This has a nearly 100% sensitivity but low specificity.
    • Age >60 years with loss of consciousness or age ≥65 years with no loss of consciousness
    • Vomiting
    • Severe headache
    • Posttraumatic seizure
    • Drug or alcohol intoxication
    • Persistent drowsiness or short-term memory deficit
    • “Dangerous” mechanisms of injury (fall from height greater than 3 feet or 5 steps, ejection from a vehicle, being struck by a vehicle as a pedestrian)
    • Glasgow Coma Scale score <15
    • Focal neurologic deficit
    • Physical evidence of open, depressed, or basilar skull fracture
    • Coagulopathy

Treatment :

• Athletes suspected of having a mild TBI should be immediately removed from play and should undergo sideline assessment.
  • Return to play may be considered after 1 or 2 days of physical and cognitive rest, resolution of symptoms both at rest and with exertion, and normalization of cognition.
• Postconcussion syndrome: supportive care and rehab.
• NSAIDs and triptans may be useful in treating posttraumatic headache. Tricyclic antidepressants, SSRIs, and SNRIs can also manage posttraumatic headache as well as mood and anxiety disorders.
  • Ppioids and butalbital products should be avoided.
• β-Blockers, antidepressants, and antiepileptic drugs may be useful for headache prevention in patients with persistent posttraumatic headache.
• A seizure occurring within the first week of a traumatic brain event is felt to be symptomatic (closely related to neurologic or systemic insults) and does not warrant antiepileptic therapy

Prognosis:

References:

• MKSAP