Grades of DAI (diffuse axonal injury)
3 grades
Grade 1: microscopic axonal injury only
Grade 2: grade 1 + corpus callosum lesion
Grade 3: grade 2 + brain stem lesion
Norm value of ICP
Norm Value of CPP (central perfusion pressure)
Want it 20 mm Hg or below
About 60 mmH Hg (peds between 40-50)
CPP = MAP - ICP
MAP = 1/3 SBP + 2/3 DBP
GCS - Glasgow Coma Scale
Norm Values
Eye Response: 4- opens spontaneously 3- opens to speech 2- open in response to pain 1- no response
Verbal Response: 5- talking/oriented 4- confused speech but coherent 3- inappropriate words, jumbled phrases 2- incomprehensible sounds 1- no response
Motor Response:
6- Obeys commands fully
5- localizes to pain
4- flexion/withdrawal from noxious stim
3- abnormal flexion/ decorticate posturing
2- extensor response/ decerebrate posturing
1- no response
Mild: 13-15
Moderate: 9- 12
Severe:<9
Ranches Los Amigos Scale (RLA)
Or Level of Cognitive Functioning Scale (LCFS)
Level 1- 8
(9&10)
Level 1- no response
Level 2- generalized response
- responds to external stimuli in non- specific way
Level 3- localized response
- responds specifically and inconsistently with delays , may follow simple commands
Level 4- confused, agitated response
Level 5- confused, inappropriate, non-agitated response
Level 6- confused, appropriate response
Level 7- automatic, appropriate response
Level 8- purposeful, appropriate response
Level 9- purposeful-appropriate
Level 10- purposeful- appropriate (modified independent)
Disorders of Consciousness (DOC)
RLA 1-3 includes:
Brain death
Coma
Vegetative State
Minimally Conscious State
Coma:
Coma:
- state of unarousable responsiveness, eyes remain continuously closed, no understandable response to stimuli
- no sleep/wake cycle
- reflexive activity only
- temporary: becomes vegetative or minimally conscious
- emergence in 2-4 weeks results in favorable outcome
Vegetative State or Unresponsive Wakefulness
No conscious awareness of self or environment, with preserve autonomic or functions
- eyes open
- including sleep/wake cycle
- no purposeful or reproducible responses to stimuli
- no command following
- autonomic system intact for basic functions
- “persistent” defined as 1 month
- “permanent” defined as 12 months
Minimally Conscious State
Severely altered consciousness with minimal behavior evidence of self or environmental awareness
- inconsistent
- may follow commands/ verbalizations, yes/no
- responses/movements in response to environment, not reflexive
Coma Recovery Scale - revised (CRS-R)
0-23
Lower scores= reflexive, brain stem level activity
- oral reflexive movement
- visual pursuits
Higher scores = cortical involvement
- functional object use
- object recognition
- also helps to distinguish MCS or emerging from MCS
- present functional object use and/or functional/accurate communication considered emerging
Auditory Function Scale 4 - consistent movement to command 3- Reproducible movement to command 2- localization to sound 1- auditory startle 0- none
Visual Function Scale: 5- object recognition 4- object localization (reaching) 3- visual pursuit 2- fixation 1- visual startle 0- none
Motor Function scale: 6- functional object use 5- automatic motor response 4- object manipulation 3- localization to noxious stimulation 2- flexion withdrawal 1- abnormal posturing 0- none/flaccid
Oromotor/Verbal Function Scale: 3- intelligible verbalization 2- vocalization/oral movement 1- oral reflexive movement 0- none
Communication Scale: 3- oriented 2- functional, accurate 1- non-functional, intentional 0- none
Arousal Scale: 3 - Attention 2- eye opening without stimulation 1- eye opening with stimulation 0- unarousable
Disability Rating Scale (DRS)
30: dead 29-22: vegetative state 21-8: severe disability 5-3: moderate disability 3-0: good recovery
Modified Ashworth Scale
0- no increase in muscle tone
1- slight increase in muscle tone, catch and release, minimal resistance at end of range of motion
1+ - a catch, followed by minimal resistance throughout the remainder of the range of motion (less than half)
2- more increase in muscle tone through most of the range of motion, affected part is moved easily
3- considerable increase in muscle tone, passive movement is difficult
4- affected part is rigid in flexion or extension
Agitated Behavior Scale (ABS)
14-56
21 or below: normal
22-28: mild agitation
29-35: moderate agitation
> 35: severe agitation
Trunk Impairment Scale (TIS)
- static, dynamic sitting balance and coordination of trunk movement
Diagnoses: stroke, brain injury, MS, CP, PD
0-23 (maximum)
If patient scores 0 on the first item, total score is 0
Dynamic Gait Index (DGI)
Not validated for brain injury
0-24
Functional Gait Assessment (FGA)
Elderly cutoff: < 22
PD cutoff: < 15
Norms: 40s: 28.9 50s: 28.4 60s: 27.1 70s: 80s: Revised version of DGI To reduce ceiling effect
0-30
FIM +FAM
Scale: 7- complete independence 6- modified independence (time, devices) 5- supervision 4- minimal assistance 3- moderate assistance 2- maximum assistance 1- total assist
Predictors of outcomes with disorders of consciousness
At initial hospital admission
AND
Initial acute rehab admission
“Predictors of short term outcome in brain injured patients with disorders of consciousness” article
- Earlier the sign of consciousness after brain injury
- Etiology of injury (traumatic is better than non traumatic) - acute admission
- Younger age - acute admission
- Absence of medical history (alcoholism, drug abuse, mental illness)
- Time between injury and rehab admission - rehab admission
Sharp purser test
How to perform
What it’s testing
Positive/ negative sign
Other symptoms
Next steps
- hand on forehead, finger on spinous process of C2, pt flexes neck while pushing posteriorly
- testing atlantoaxial instability- transverse ligament
- positive with relief of symptoms
- can have leakage of CSF from nose or ears
- notify MD immediately
Normal Pressure Hydrocephalus
Area of brain
Signs and symptoms
- buildup of CSF causes ventriculomegaly
- enlarged temporal and lateral horns of ventricles
- gait ataxia, gait hypometria, incontinence and dementia
(Corticospinal tracts run medially and proximally to ventricles)
Parasympathetic storming symptoms (3)
Bradycardia, posturing, agitation
Stereognosis
- ability to recognize objects by shape (cortical control)
Life expectancy for severe TBI
7 years shorter than general pop
SBP after TBI for pts
50-69
15-49 or >70
>/= 100 >/= 110
Kennard principle
Younger patient may do better than an adult with the same lesion
