1
Q
What is an acquired brain injury?
A
The umbrella term for any brain injury that is not congenital, not progressive and not induced by birth trauma
2
Q
What is a traumatic brain injury?
A
Injury caused by external forces;
- direct impact or indirect/inertial forces (brain moves in the skull)
- can be focal or diffuse
3
Q
What is a non-traumatic brain injury?
A
Caused by something that happens inside the body that affects the brain
- Can be focal or diffuse
4
Q
What is cerebral palsy?
A
A brain injury prior to the first month of life (including in utero)
- After one month, it is an ABI
5
Q
true or false: all Acquired Brain Injuries are Traumatic Brain Injuries but not all Traumatic Brain Injuries are Acquired Brain Injuries
A
false
6
Q
true or false: All Traumatic Brain Injuries are Acquired Brain Injuries but not all Acquired Brain Injuries are Traumatic Brain Injuries
A
true
7
Q
Examples of non-traumatic acquired brain injuries
A
- Aneurysm
- Brain tumour
- Encephalitis, meningitis
- Hydrocephalus
- Hypoxia/anoxia (e.g., near drowning)
- Toxin (e.g., opioid overdose, substance abuse)
- Stroke (Ischemic or Hemorrhagic)
- Post-acute infection conditions (post-covid)
8
Q
Examples of traumatic brain injuries
A
- Assault (e.g., IPV)
- Explosive blasts, combat injuries
- Falls
- Gunshot wounds
- Motor vehicle collisions
- Shaken baby syndrome
- Sports injuries
9
Q
What are the 8 leading causes of TBI in Canada
A
- Motor Vehicle Collisions
- Falls
- Bicycles
- Sports & recreation injuries
- Violence (assault, abuse)
- Gun-shot wounds
- Intentional self-harm
- Work-related injury
10
Q
What is the leading cause of TBIs in 0-1 year olds?
A
Violence
11
Q
What is the leading cause of TBIs in 1-5 year olds?
A
Falls
12
Q
What is the leading cause of TBIs in 5-15 year olds?
A
Bicycle & sports injuries
13
Q
What is the leading cause of TBIs in 15-60 year olds?
A
MVAs, violence
14
Q
What is the leading cause of TBIs in 60+ year olds?
A
Falls
15
Q
True or false: the highest mortality rate amongst those with TBI is in younger patients.
A
false; highest mortality rate is within older adults
16
Q
True or false: 1 in 4 people with TBIs are women
A
false; 1 in 3 people with TBIs are women
17
Q
Which age range is the most common for women with TBIs?
A
15-24 years of age
18
Q
True or false: intimate partner violence and MVCs are a common cause of TBIs
A
true
19
Q
8 Risk factors for TBI:
A
- risk-taking behaviours (e.g., high risk sports, criminal activity)
- low academic or career achievement
- mental health diagnosis
- age (males 18-24; kids <5, adults >65)
- sex: 2:1 male to female
- lower SES
- substance use/misuse
- previous TBI
20
Q
Men aged 18-24 are how many times more likely to get a TBI?
A
3-4 times more likely
21
Q
10 Post-TBI Risks
A
- elevated rates of all-cause mortality
- increased lifetime risk for seizure disorders, neurodegenerative conditions, stroke
- ~2/3 will experience depression in the seven years after TBI
- increased risk of anxiety disorders
- higher incidence and severity of PTSD symptoms
- more likely to experience second brain injury or other injuries
- higher risk of self-medication and substance abuse
- elevated odds of global disability, reduced on measures of participation, social relationships
- connection between homelessness and TBI
- increased risk of being involved with the justice system
22
Q
What percentage of prison population has had at least one TBI?
A
over 60%
23
Q
An Ontario study showed that men and women (18-24) who had sustained a TBI were subsequently about ____ times more likely to be incarcerated than men and women who had not sustained a TBI
A
2.5
24
Q
Indigenous people in Canada have ____ rates of TBI, are ___ likely to receive treatment for TBI and represent a ____ proportion of those incarcerated
A
higher; less; higher
25
Pre-injury factors influencing recovery
S.A.N.K
1. Social adjustment
2. Age
3. Neurological integrity
4. Knowledge base
26
Pre-injury factors influencing recovery: Age
* Younger people recover better
* May precipitate dementia in older adults
* Very young children may have worse prognosis
27
Pre-injury factors influencing recovery: Social adjustment
* Exacerbates pre-injury issues
* Psychiatric or behavioural disorders, substance abuse
28
Pre-injury factors influencing recovery: Neurological integrity
* Prior brain injury → worse outcome
* Learning disability
* Neurological impairments (e.g., in older adults)
29
Pre-injury factors influencing recovery: Knowledge base
* Weak academic, social, vocational knowledge bases (weaker foundation to fall back on)
30
5 Post-injury factors influencing recovery
* Early medical intervention → “Time is Brain”
* Early rehabilitation, availability of rehab in general
* Long-term social supports → family, friends, employers, teachers
* Individual factors: “resilience”, effort, adjustment, beliefs about illness and disability
* Deficit-related factors: Insight into deficits, motivation, behaviour issues
31
True or False: All TBI patients continue to improve long post-injury
False; many people continue to improve long post-injury, but some struggle more over time
32
What factors influence the recovery those TBI patients that struggle more over time? x3 points
* Neurocognitive stall: Children with prefrontal injury may experience growing disability with increasing demands on cognitive domains related to damaged areas
* Experiencing repeated failure may lead to maladaptive behavioural responses
* Overly restrictive, limited environments may lead to behavioural/emotional problems, social isolation
33
TBI is often called an _______ disability
invisible
34
Why is TBI often called an "invisible disability" x6 points
* Much more challenging in some ways than a physical impairment
* Many brain injuries go unreported, left untreated
* Even severe TBI can have no outward signs
* Most of the symptoms tend to be invisible: mood, pain, cognitive and communication problems etc.
* Some of the core impairments interfere with asking for help or advocating for accommodations (reduced insight, initiation, communication, social skills)
* Impairments might present as personality issues, poor choices, bad behaviour
35
Define the multiple ways of classifying TBIs
1. Where/location (focal, diffuse)
2. When/physiological response (primary, secondary)
3. Type (open, closed)
4. How/mechanism of injury (blunt, blast, penetrating)
5. Severity (mild, moderate, severe)
36
WHERE: Focal vs. Diffuse Brain Injury
What is a diffuse brain injury + give examples
An injury that crosses multiple brain regions
* Global ischemic
* Traumatic axonal
* Diffuse vascular
* Brain swelling
37
WHERE: Focal vs. Diffuse Brain Injury
What is a focal brain injury + give examples
An injury that is localized to a specific brain area or region
* Contusion (bruise)
* Laceration (from skull surface/fracture)
* Hematoma
* Intracranial hemorrhage
* Subarachnoid hemorrhage
38
WHEN: Primary vs. Secondary Damage
What is a primary brain injury/primary impact damage? + give examples
Result of initial mechanical forces of the trauma
* Penetrating/Open Head Injuries
* Non-Penetrating/Closed Head Injuries
* Blast
39
WHEN: Primary vs. Secondary Damage
What is a secondary brain injury/secondary damage? + give examples
In the hours and days after the injury, a series of stages of cellular, chemical, tissue, or blood vessel changes in the brain that lead to further destruction of brain tissue.
* Extracranial (e.g. pulmonary, cardiovascular, coagulation, endocrine)
* Intracranial (e.g. elevated ICP, gliosis, metabolic cascade)
40
Two types of primary brain injury/primary impact damage?
* Open head injury
* Closed head injury
41
Types of open head injuries
* Low velocity
* High velocity
42
Types of closed head injuries and their subtypes
1. Acceleration/deceleration (linear velocity and angular deceleration)
2. Shockwave injuries
3. Contact/Non-Acceleration (impression trauma and ellipsoidal deformation)
43
Closed Head Injury
* Definition?
* Focal or Diffuse?
* Definition: Skull stays intact; brain is injured due to a blunt blow or violent shaking.
* Focal or Diffuse: Can be both
44
Acceleration/Deceleration Injury
* Definition?
Definition: Brain hits skull
* Moving object hits moveable head.
* Moving head hits stationary object.
* Head shaken violently
45
Linear Velocity
* Definition?
* Focal or Diffuse?
* Damage?
* Definition: Brain moves in a straight line, hitting front/back of skull.
* Focal or Diffuse: Focal at impact points
* Damage: Coup-contrecoup injury
46
Angular Deceleration
* Definition?
* Focal or Diffuse?
* Damage?
* Definition: Brain rotates inside the skull at an angle.
* Focal or Diffuse: Both?
* Damage: cranial nerve trauma, hemorrhage, diffuse axonal injury: twisting, shearing, abrasions, lacerations
47
Shockwave Injuries
* Definition?
* Focal or Diffuse?
* Damage?
* Definition: From explosions or sports impacts --> pressure wave affects brain without direct hit.
* Focal or Diffuse: Diffuse
* Damage: metabolic cascade
48
Contact/Non-Acceleration
* Definition?
* Focal or Diffuse?
* Damage?
* Definition: Head is still; object hits it, deforming the skull at point of contact.
* Focal or Diffuse: Focal
* Damage: Localized damage at the contact site
49
Impression trauma
* Definition?
* Focal or Diffuse?
* Damage?
* Definition: Rapid blow deforms skull inward + rebound
* Focal or Diffuse: Focal
* Damage: Damage to meninges and cortex at site of impact + pressure from the rebound will cause further damage
50
Ellipsoidal deformation
* Definition?
* Focal or Diffuse?
* Damage?
* Definition: Slow-moving object deforms skull shape (oval to circular), stretching brain tissue outward.
* Focal or Diffuse: Diffuse (central structures)
* Damage: Stretching/tearing of central brain structures
51
Open Head Injury
Definition?
Focal or Diffuse?
Definition: Skull is penetrated by an object.
Focal or Diffuse: Focal
52
Low Velocity
* Definition?
* Focal or Diffuse?
* Damage?
* Definition: Object (e.g., bat) hits skull with enough concentrated force to fracture it.
* Focal or Diffuse: Focal
* Damage: Bone/debris enter brain; possible infection
53
High Velocity
* Definition?
* Focal or Diffuse?
* Damage?
* Definition: Projectile (e.g., bullet) enters skull.
* Focal or Diffuse: Focal
* Damage: Destruction of tissue around projectile path
54
What is a CT scan?
A series of cross-sectional images that reflect the interaction of x-rays with body tissues
55
In a CT scan, higher tissue density has ____ attenuation
higher
56
Pros of a CT scan
* Good availability
* Fast
* Good for identifying acute changes esp. bleeding, fractures
57
What is an MRI scan?
MRI uses a strong magnet and radiofrequency pulses to interact with the hydrogen ions in body tissues; different tissues send signals of different strengths in response
58
Pros of an MRI scan
* Better at detecting soft tissue details; DAI; later changes
59
True or false: closed head injuries are much more common than open head injuries
True
60
Regardless of site of impact, ____ ____ and axonal shearing are often concentrated ____ in ____ and inferior _____ and ______ lobes
focal contusions; bilaterally; anterior; frontal; temporal
61
What impairments are commonly observed in closed head injuries
* Executive control (prefrontal)
* Social perception (prefrontal, fronto-limbic)
* Behavioural self-regulation (prefrontal, fronto-limbic, anterior temporal)
62
Diffuse neuronal shearing may also occur in ____ ____ ____, ____ ____ , and ____ |All this would then result in:
subcortical white matter; corpus callosum; brainstem
* initial coma
* arousal/attention deficits
* reduced speed processing
63
True or false: Perisylvian language centers are surrounded by smooth skull surface.
True
64
What is a coup-contrecoup injury? (closed head)
Hit and then other hit (rebound)
* Head stops, brain continues to move, which leads to contusions, hematomas, SAH at the site of damage
65
What is a hematoma (closed head injury)?
a collection of blood that occurs as a result of head trauma because of injured blood vessels
66
What are the different types of hematomas + their descriptions
**Subdural**:
* Between dura and arachnoid membranes
* Venous blood
* Slower collection
* Crescent-shaped
**Epidural** (extradural);
* Between skull and dura
* Arterial blood
* Collects quickly
* Lens shaped
67
Which type of hematoma is characterized by a brief lucid period following an initial loss of consciousness (LOC)?
Epidural; and the situation is URGENT
68
What's another name for hematomas?
space-occupying lesions
69
What is a contusion? (closed head injury)
bruising of brain parenchyma (functional brain tissue)
70
What is the primary damage that occurs in a contusion?
Tissue absorbs the kinetic energy of impact resulting in micorhemorrhages
71
Where is the location of the damage in a contusion
the outer layers of the brain, especially the gyri -- damage can also extend into deeper brain structures (intracerebal)
72
True or false: usually grey matter is affected by contusions
True; may extend into white matter
73
True or false: Blood is toxic to the brain
duh
74
What follows the primary injury to brain tissue in a contusion?
cascade of secondary effects
75
What is happening in a diffuse axonal injury?
White and grey matter have slightly different mass/volume so with acceleration/deceleration, the shearing caused by change in velocity tends to target axons at grey-white matter junction
76
DAI: What type of damage occurs to neurons due to acceleration/deceleration forces?
Neurons undergo shearing, causing edema
77
True or False: DAI is considered both primary and a secondary brain injury
True; neurons may undergo degeneration in the weeks or months after the trauma
Primary: twisting, stretching, shearing of the axons
78
How does a DAI show up on a MRI scan?
White hyperintensities
*Note*: wouldn’t see it at the time of the impact but will show up later (cascade) also won’t show in a CT only on an MRI
79
True or false: skull is a closed box
true
80
Which 3 components make up the volume of the intracranial compartment? Include their percentages too
* brain parenchyma (83%)
* cerebrospinal fluid (CSF, 11%)
* blood (6%)
81
Each of the 3 contents relies on one another for a _______ environment within the skull
homeostatic
82
An increase in intracranial volume can take place in the traumatized brain via:
mass effect from:
* blood
* both cytotoxic and vasogenic edma
* venous congestion
83
What happens when the intracranial volume exceeds that of its normal constituents? List the steps
A cascade of compensatory mechanisms
* Since the brain tissue is incompressible the edematous brain tissue will initially cause an extrusion of CSF to the spinal cord
* Then, venous blood is also extruded away from the brain
* Eventually, compensatory mechanisms fail which results in pathological brain compression, ensuing death
84
True or false: Conditions that cause secondary damage are largely diffuse in nature
True
85
Which conditions lead to secondary damage
* Hemorrhage
* Cerebral Edema
* Intracranial Pressure
* Hypoxic-Ischemic Damage
* Seizures
86
Secondary Damage: Hemorrhage (types)
* Extracerebral
* Epidural
* Subdural
* Subarachnoid
* Intracerebral
* Bleeding into brain tissue (DAI)
87
Secondary Damage: Cerebral Edema (what is it? locus of damage)
* Fluid between brain and skull, in ventricles, or in brain tissue.
* Around primary site or throughout brain (DAI)
88
Secondary Damage: Intracranial Pressure (what is it? damage?)
* Due to accumulation of blood, CSF, or water.
* Brain tissues compressed, displaced, herniated
89
Secondary Damage: Hypoxic-
Ischemic Damage (what is it? what causes it?)
* Reduced oxygenation and blood supply to brain.
* Due to ICP, cerebral vasospasm, cardiopulmonary
injury.
90
Secondary damage: Seizures (onset)
* Early onset: within 1 week
* Late-onset: after week 1
* >2 seizures = epilepsy
91
A midline shift during secondary damage leads to _____ prognosis (morbidity, mortality)
worse
92
Secondary damage can lead to:
* infection
* gliosis
* metabolic cascade including
- hypotension (low pressure)
- hyponatremia (low sodium)
- hypoglycemia (low sugar)
- hyperthermia (high temperature)
93
Secondary Damage: What is gliosis (+ damage)?
* CNS reaction to injury
* Body creates more/larger glial cells – pro-inflammatory
* Can cause scarring in brain
94
Secondary Damage: What is metabolic cascade? What does it lead to?
* A neurochemical event triggered by injury
* Abrupt neuronal depolarization
* Excitotoxicity –release of excitatory neurotransmitters (e.g., glutamate)
* Hyperglycolysis– increase in glucose metabolism, metabolic stress
* Followed later (5 days) by hypoglycolysis
* Hypoperfusion – altered cerebral blood flow (vasoconstriction)
* Impaired axonal function
95
True or False: Secondary damage can be both focal and diffuse
true
96
Secondary damage affect vulnerable structures such as the _________ (is bilateral or unilateral?)
hippocampus (bilaterally)
97
What factors are considered when determining the severity of a TBI
* Structural imaging
* Loss of consciousness
* Post-traumatic Amnesia (PTA)
* Initial Glasgow Coma Scale (GCS)
98
The "Mild," "Moderate," and "Severe" criteria for structural imagining
* Mild: probably normal
* Moderate: Normal or abnormal
* Severe: Normal or abnormal
99
The "Mild," "Moderate," and "Severe" criteria for LOC
* Mild: 0-30 min
* Moderate: 30 min - 24 hrs
* Severe: >24 hrs
100
The "Mild," "Moderate," and "Severe" criteria for PTA
* Mild: 0-1 day
* Moderate: >1 day <7 days
* Severe: >7 days
101
The "Mild," "Moderate," and "Severe" for initial GCS
* Mild: 13-15
* Moderate: 9-12
* Severe: 3-8
102
The ____ is damaged in the decerebrate posture
midbrain (and downwards)
103
Flexion of hands is associated with the _______ posture
decorticate
104
How do we detect awareness and differentiate among levels of awareness?
Gold standard is to rely on our interpretation of appearance and behaviour to infer self-awareness or “consciousness”
105
Disorders of consciousness (DOCs) taxonomy
Coma → Vegetative State → Minimally Conscious State → Post-Confusional State
106
Why might it be important to accurately assess level of consciousness?
* Prognosis
* Medical decisions
* Family counseling and education
* Interactions and environment
* Placement decisions e.g. long term care vs rehabilitation
107
What is cognitive motor dissociation (CMD)?
patients who lack behavioural signs of awareness (ie, diagnosis of coma, VS, MCS-) but show evidence of command-following on fMRI or EEG assessment -- instruct patient to think about doing a task and record signal from the brain
108
What causes CMD and what does it affect?
Peripheral injury, issues with muscle tone, disconnection of efferent pathways can mask the ability to demonstrate awareness on behavioural assessment
109
What is observed when CMD patients are instructed to think about doing a task?
Volitional brain activity is measured during the task and compared to resting brain activity and/or compared to activity in someone without a TBI
110
True or False: Behaviour is a weak proxy for consciousness
True
111
Prevalence of CMD in in DOCs
* CMD may be present in up to 15-20% of patients with subacute-to chronic DoC
* CMD may be present in as many 15% of patients during the acute period (first 7 days)
112
What is the presence of CMD associated with in relation to recovery?
* associated with recovery of at least partial functional independence at 1-year post injury
* favourable recovery occurs earlier in patients with than without CMD
113
Which domains are affected in a post-traumatic confusional state (PTCS)?
Disturbances in all of the following (F.O.A.M):
* Attention: Reduced ability to focus or sustain attention
* Orientation: Impaired orientation to place, time, and situation
* Memory: Impaired ability to encode and recall new information
* Fluctuation: Nature and severity waxes and wanes during the course of the day
Can also include:
* disturbances in sleep-wake cycles
* delusions
* confabulations
* perceptual disturbances
114
What is retrograde amnesia?
* prevalence?
* prognosis?
* inability to recall things that occurred before the injur
* less common, usually associated only with more severe injuries
* may improve (autobiographical, already stored)
115
What is Anterograde amnesia or post-traumatic amnesia?
* prevalence?
* prognosis?
* impaired recall for events after injury
* much more common
* does not return (information was never “stored”)
116
Someone is in PTA until:
they are storing memories continuously
117
GOAT criteria scale for emergence from PTA
* Normal → 76-100
* Borderline → 66-75
* Impaired → < 66
Score > 75 on 3 consecutive days → emerging from PTA
118
O-log criteria
* Scored out of 30
* Out of PTA: 25 or higher 2 days in a row
119
GOAT and O-log provide comparable estimates of _____ and ____ of the PTA
severity; duration
120
O-Log may be a better predictor of ____ _____ and overall ____ _____
rehab outcomes; mental status
121
Consequences of TBI: Frontal Lobe Dysfunction
* Bony prominences on skull
* Coup-contrecoup injury
* Generalized atrophy
* Prefrontal cortex (PFC) damage
122
Prefrontal Damage Characteristics: **Dorsolateral PFC**
(Brodmann areas: 9, 46) --- x7 points
* Working memory
* Attention (internal)
* Declarative memory
* Rule learning, task switching
* Planning and problem-solving
* Novelty detection and attention (external)
* Motivation → apathy, abulia
123
Dorsolateral PFC damage characteristics are also called ____ characteristics
"cold"; logic/operations
124
Prefrontal Damage Characteristics: **Orbitofrontal Cortex**
(Brodmann areas: 10, 11, 12, 47) --- x5 points
* The famous Phineas Gage
* Inhibitory control and decision-making
* Emotional and social control
* Attention (internal) e.g. to emotional stimuli, memory
* Memory → confabulations
125
Orbitofrontal cortex damage characteristics are also called ____ characteristics
"hot"; emotional
126
Prefrontal Damage Characteristics: **Ventrolateral PFC** (Brodmann areas: 44, 45, 47) --- x3 points
* Spatial attention
* Response inhibition
* Language
127
Medial PFC has ___ subdivisions
2
* Dorsomedial (BA 8, 9, 10, 24, 32)
* Ventromedial (BA 10, 12, 14, 24, 25, 32)
128
Prefrontal Damage Characteristics: **Dorsomedial PFC** --- x6 points
* Inability to detect errors
* Conflict resolution difficulty
* Emotional instability
* Inattention, abulia, akinetic mutism
129
Prefrontal Damage Characteristics: **Ventromedial PFC** --- x2 points
* Disruption of social behaviour
* Difficulty with social, emotional and value-based decision-making
130
Prefrontal Damage Characteristics: **Rostral PFC (BA 10)** → frontal pole --- x8 points
Characteristics
* Traditional neuropsychological testing WNL
* Normal IQ tests
* But: difficulty organizing everyday tasks, impaired
decision-making in real-life contexts
Impaired functions
* Multitasking, prospective memory
* Task-switching
* Creativity
* Theory of Mind
* Metacognition
131
Prefrontal Damage - Lateralization
* **Left PFC Damage** --- x5 points
* Increased personal concern
* Depression
* Decreased initiation
* Decreased verbal fluency
* Reduced language output
132
Prefrontal Damage - Lateralization
* **Right PFC Damage** --- x5 points
* Unawareness
* Inability to read social cues
* Inability to produce appropriate nonverbal communication
* Decreased comprehension of prosody, indirect intents/meanings
* Increased anxiety
133
Consequences of TBI: Physical/Sensory
* Motor → paralysis, hemiparesis, gait disturbance, reduced speed/coordination
* Vision→ blindness, visual field cuts, double vision
* Hearing → deafness, reduced acuity
* Smell → total or partial loss
* Hypersensitivity → total/partial change in tolerance of heat, light, noise
* Seizures → typically early-on in recovery, severity/frequency vary
* Headaches → consistent/occasional pain
* Energy → total loss of energy, increased fatigue, reduced energy at end of day
134
Consequences of TBI: Cognitive
* Attention → altered consciousness, disorientation, hemi-inattention, distractibility
* Memory → global amnesia, PTA of varying degrees, anterograde memory difficulty; can be verbal or nonverbal in nature
* Language/Communication → dysarthria, aphasia, anomia, subtle
communication deficits
* Visuospatial → disorientation, poor spatial mapping, visual processing
* Problem-solving → general intellectual deficits, poor judgment, decreased
abstraction, perseveration, concreteness, difficulty shifting cognitive sets
* Initiation → impulsiveness, indecisiveness, no initiation/anergia
135
Consequences of TBI: Emotional/Psychiatric
* Irritability → agitation, frustration, impatience, anger, overt hostility, argumentativeness
* Emotional Lability → mania, mood swings, alternating optimism/pessimism,
silliness, immaturity
* Depression → suicidal ideation, loss of hope, helplessness, sadness, grief
* “Denial” → anosognosia, impaired insight/understanding of deficits
* Paranoia → loss of trust in others, suspiciousness, overt paranoia
* Anxiety → generalized or episodic, OCD
136
Consequences of TBI: Psychosocial
* Isolation → loss of family, divorce, loss of friends, feelings of alienation
* Dependence → 24 hr supervision, relying on others for assistance with ADLs
* Status Change → loss of identity, job and financial loss, need for state support
* Sexual Adjustment → disinhibition, hypersexuality, insensitivity or indifference to others, decreased libido
* Drug and Alcohol Use → self-medication, decreased tolerance due to TBI/medication
38 D
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