Craniocerebral Trauma

• Lawrence M. Richman, M.D., Neurology• Certified in Neurology, American Board of Psychiatry and Neurology• Certified in Electro-diagnostic Medicine, American Board of Electro-

diagnostic Medicine• Certification, Brain Injury Medicine (ABPN), to be designated 2016• Fellow, American Association of Neuro-muscular and Electro-

diagnostic Medicine• NIH Fellowship, Vestibular (Balance) disorders & Neuro-

ophthalmology • Asst. Clinical Prof., UCLA School of Medicine, 15 years, through

1997, Clinical Instructor Neurology Program, Cedars Sinai-present• Team Physician, U.S. Alpine Olympic Team • Medical Licenses, California & Utah

Post-Concussive Syndrome

• An array of symptoms following head injury with or without loss or alteration of consciousness.

• Approximately 50 % of individuals who sustain blunt head trauma without LOC, go on to develop PCS. Not all patients who sustain a concussion, go on to develop PCS.

• At four years, approximately 15-20% of patients who developed PCS are still symptomatic, i.e. chronic PCS

Symptoms of PCS

• Memory disturbance• Impaired concentration• Easy distractibility, slow reaction time• Irritability, fatigue, diminished appetite• Insomnia• Hyper-somnolence• Tinnitus• Non-vestibular dizziness• Anxiety, Depression• Headaches, Blurring of vision, light/noise

sensitivity

Concussion

• vacant stare (befuddled facial expression) • Delayed verbal and motor responses (slow to answer questions or

follow instructions) • Confusion and inability to focus attention (easily distracted and unable

to follow through with normal activities) • Disorientation (walking in wrong direction, unaware of time, date,

place) • Slurred or incoherent speech (making disjointed or incomprehensible

statements) • Gross observable in-coordination (stumbling, inability to walk

tandem/straight line) • Emotions out of proportion to circumstances (distraught, crying for no

apparent reason) • Memory deficits (exhibited by repeatedly asking the same question

that has already been answered, or inability to recall 3 words at 5 minutes. )

• Any period of loss of consciousness ( coma, unresponsiveness )

Ritchie Russell Scale

• Duration of post-traumatic amnesia may be used to address severity of TBI.

• Less than 5 mts- Very mild• Less than 1 hour-Mild• 1 to 24 hours-Moderate• 1 to 7 days-Severe• More than 7 days-Very Severe• More than 4 weeks- Extremely severe

Shear Injuries

• Also known as Diffuse Axonal Injury (DAI)

• Degeneration of cerebral white matter

• Shearing may not necessarily be realized at the time of injury except when injuries are severe.

• Injury may progress over 24 hours or weeks later; Increased permeability, Ca++ influx, mitochondrial swelling.

Acute Epidural Hematoma

Sub-Acute SDH, Acute ICH

Seizures and Head Trauma

• 1. Traumatic Induced Seizure-blunt trauma triggering a seizure, not a source for future epilepsy. Also referred to as “ Early Seizures,” may occur up to 2 weeks, post injury.

• 2. Seizure after blunt head trauma, LOC of 30’ or <, no skull fracture, no intracranial bleed, NON-statistical for future seizures ( incidence 1.0-2.2 =nl. pop.).

Head Trauma and Seizures

3. Head trauma with LOC of 30” to 24 hours, or associated with skull fracture ( excluding base of skull fracture ), risk of post-traumatic epilepsy: standardized incidence 0.7% @ 1 year, 1.6% 5 years, statistically significant increase for occurrence of epilepsy.

4. Head Trauma, LOC >24 hours, intracranial bleed, incidence 7% @ 1 yr., 11.5 % @ 5 yrs. Mayo Clinic Study, n. 2747.

Compensation Neurosis & Malingering

• 1study in the UK, 200 consecutive mild HT, 47 had psychoneurotic presentation, arrived late, over dramatization, martyrdom appearing but the author did not entirely reject a component of PCS.

• Another study of 398 mild HT patients, found the Dx of Accident Neurosis: bizarre & inconsistent complaints, exaggeration of the initial period of LOC, attention seeking.

Compensation Neurosis

• More common with manual workers than non-manual.

• Psychiatric treatment NOT helpful• Not common found in only 6.8% of the study

group.• Litigants similar to non-litigants showing similar

symptoms and improve over time.• Those applying for compensation have the same

symptoms and those not applying.

Favorable Verdict of Claim

• The end of litigation DOES NOT MEAN the end of symptoms and RTW.

• In one study, 39% of litigants were symptomatic at the time of settlement, 34% symptomatic one year later.

• Older patients and those employed with dangerous work most apt not RTW after settlement per one study.

Treatment mild PTHS/PCS

• Cognitive rehab controversial and costly.• If psych symptoms are prominent, a course of

psychotherapy may be useful• Consider anti-depressants and anti-anxiety

meds in that both these disorders can be a source of cognitive impairment on a neurochemical basis.

• No use for EEG, Dig. EEG, PET, SPECT, fMRI, (the latter 3 affected by depression) and repeat MRIs, CATs, etc.