TRAUMATIC BRAIN INJURY

Traumatic brain injury (TBI),

External force traumatically injures the brain.

Traumatic brain injury is defined as damage to the brain resulting from external mechanical force, such as rapid acceleration or deceleration, impact, blast waves, or penetration by a projectile. Brain function is temporarily or permanently impaired and structural damage may or may not be detectable with current technology

Classification
acquired brain injury (brain damage that occurs after birth) non-traumatic brain injury, which does not involve external mechanical force (examples include stroke and infection).

Classification
based on severity, anatomical features of the injury, and the mechanism (the causative forces)

Classification
Anatomical classification : A closed (nonpenetrating, or blunt) head injury occurs when the brain is not exposed A penetrating, or open, head injury occurs when an object pierces the skull and breaches the dura mater

Severity
level of consciousness (LOC) post-traumatic amnesia (PTA), Glasgow Coma Scale (GCS),

Classification severity
Severity
Severity of traumatic brain injury[13] GCS Mild Moderate Severe 1315 912 38 PTA LOC

<1 day
>1 to <7 days >7 days

030 minutes
>30 min to <24 hours >24 hours

Mechanism Physical forces

Physical forces Forces that may contribute to TBI

angular, rotational, shear, and translational forces type, direction, intensity, and duration of forces

coup and contrecoup injury

When a moving object impacts the stationary head, coup injuries are typical while contrecoup injuries are usually produced when the moving head strikes a stationary object.

Primary brain injury

the damage that occurs at the moment of trauma when tissues and blood vessels are stretched, compressed, and torn people do not die right away but rather days to weeks after the event rather than improving after being hospitalized some 40% of TBI patients deteriorate

Secondary brain injury (cont )

damage to the bloodbrain barrier, release of factors that cause inflammation, free radical overload, excessive release of the neurotransmitter glutamate (excitotoxicity), influx of calcium and sodium ions into neurons, and dysfunction of mitochondria a complex set of cellular processes and biochemical cascades that occur in the minutes to days following the trauma.

Secondary brain injury (cont )

These secondary processes can dramatically worsen the damage caused by primary injury Account for the greatest number of TBI deaths occurring in hospitals.

Secondary brain injury (cont )

changes in the blood flow to the brain; ischemia (insufficient blood flow); cerebral hypoxia (insufficient oxygen in the brain); cerebral edema (swelling of the brain); and raised intracranial pressure (the pressure within the skull).

Secondary brain injury (cont )

Intracranial pressure may rise due to swelling or a mass effect from a lesion, such as a hemorrhage As a result, cerebral perfusion pressure (the pressure of blood flow in the brain) is reduced; ischemia results it can cause brain death or herniation

X-Rays
are still used for head trauma, but evidence suggests they are not useful head injuries are either so mild that they do not need imaging or severe enough to merit the more accurate CT

computed tomography (CT)

The preferred radiologic equipment in the emergency setting It is quick, accurate, and widely available Follow up CT scans may be performed later to determine whether the injury has progressed

Magnetic resonance imaging (MRI)

More detail and more useful than CT for tissue characteristics such as diffuse axonal injury in the longer term MRI is not used in the emergency setting for reasons its relative inefficacy in detecting bleeds and fractures, its lengthy acquisition of images, the inaccessibility of the patient in the machine, and its incompatibility with metal items used in emergency care.

Angiography
may be used to detect blood vessel pathology when risk factors such as penetrating head trauma are involved.

OTHERS
Functional imaging can measure cerebral blood flow or metabolism, inferring neuronal activity in specific regions and potentially helping to predict outcome. Electroencephalography and transcranial doppler may also be used.

HOW THE BRAIN IS HURT

Three separate processes work to injure the brain: bruising (bleeding), tearing, and swelling.

BRUISING (BLEEDING)
The soft tissue of the brain is propelled against the very hard bone of the skull. The brain tissue is "squished" against the skull and blood vessels may tear. When blood vessels tear, they release blood into areas of the brain in an uncontrolled way

Why do medical experts seem so concerned about bleeding in the brain?

 A major problem is that there is no room for this extra blood. The skull, being hard and brittle, does not expand. So the blood begins to press on softer things--like brain tissue. Brain tissue is very delicate and will stop working properly or may even die off.

 With large amounts of bleeding in the brain, the pressure will make critical areas of the brain stop working. Areas that control breathing or heart rate could be affected, and a life or death situation could develop within hours of the accident. Areas that control breathing or heart rate could be affected, and a life or death situation could develop within hours of the accident.

 Some people have sustained a head injury from a car accident and seem "just fine" right after at the accident. Within a short period of time, they began to get more and more confused until they eventually lapse into a coma.

TEARING
the brain is thrown forward, then bounced backward In this forward/backward motion, the brain can be torn The brain can also be torn by the effects of "energy".

 Tearing in the brain "cuts" the wires that make the brain work. One of the problems with tearing is that it happens on a microscopic level

SWELLING
The problem with the brain is that there is no extra room and the pressure begins to build up. This pressure pushes down on the brain and damages structures in the brain If there is too much pressure, this can stop important structures that control breathing or the heart rate.

 Sometimes, doctors will install a "relief valve" (intra-cranial pressure monitor or ICP) to let off the excess pressure.

Cerebral blood flow

is the blood supply to the brain in a given time In an adult, CBF is typically 750 millitres per minute or 15% of the cardiac output This equates to 50 to 54 millilitres of blood per 100 grams of brain tissue per minute

 CBF is tightly regulated to meet the brain's metabolic demands Too much blood (a condition known as hyperemia) can raise intracranial pressure (ICP), which can compress and damage delicate brain tissue. Too little blood flow (ischemia) results if blood flow to the brain is below 18 to 20 ml per 100 g per minute, and tissue death occurs if flow dips below 8 to 10 ml per 100 g per minute.

Cerebral perfusion pressure

is the net pressure gradient causing blood flow to the brain (brain perfusion). It must be maintained within narrow limits because too little pressure could cause brain tissue to become ischemic (having inadequate blood flow), and too much could raise intracranial pressure (ICP).

The pressures that can contribute to the CPP are: Mean Arterial Pressure (MAP) Intra Cranial Pressure (ICP) Jugular Venous Pressure (JVP)

Perfusion scanning
Perfusion is defined as the passage of fluid through the lymphatic system or blood vessels to an organ or a tissue. The practice of perfusion scanning, is the process by which this perfusion can be observed, recorded and quantified.

Methods
CT MRI Nuclear medicine or NM

CT Perfusion
It is most commonly carried out for neuroimaging using dynamic sequential scanning of a pre-selected region of the brain during the injection of a bolus of iodinated contrast material as it travels through the vasculature.

CT Perfusion
Various mathematical models can then be used to process the raw temporal data to ascertain quantitative information such as rate of cerebral blood flow (CBF) following an ischemic stroke or aneurysmal subarachnoid hemorrhage.

MR Perfusion
dynamic susceptibility contrast imaging (DSC-MRI) arterial spin labelling (ASL).

 In DSC-MRI, Gadolinium contrast agent is injected and a time series of fast T2*weighted images is acquired. As Gadolinium passes through the tissues, it produces a reduction of T2* intensity depending on the local concentration.

 The acquired data are then postprocessed to obtain perfusion maps with different parameters, such as BV (blood volume), BF (blood flow), MTT (mean transit time) and TTP (time to peak).

NM Perfusion
Nuclear medicine uses radioactive isotopes for the diagnosis and treatment of patients. Whereas radiology provides data mostly on structure, nuclear medicine provides complementary information about function. However, there are only a few specific scans which are dedicated to looking at only one organ.

NM Perfusion
VQ Scans Ventilation Perfusion Scans, sometimes called a VQ (V=Ventilation, Q=perfusion) scan, is a way of identifying mismatched areas of blood and air supply to the lungs It is primarily used to detect a Pulmonary embolus.

VQ Scans
The perfusion part of the study uses a radioisotope tagged to the blood which shows where in the lungs the blood is perfusing. If the scan shows up any area missing a supply on the scans this means there is a blockage which is not allowing the blood to perfuse that part of the organ.

VQ Scans
If the scan shows up any area missing a supply on the scans this means there is a blockage which is not allowing the blood to perfuse that part of the organ.

NM Perfusion
SPECT
Single photon emission computed tomography

is a branch of Nuclear Medicine and can be used to complement any gamma imaging study, where a true 3D representation can be helpful e.g tumor imaging, infection (leukocyte) imaging, thyroid imaging or bone imaging.

Functional brain imaging

nuclear gamma camera

Usually the gamma-emitting tracer used in functional brain imaging is technetium (99mTc) exametazime (99mTc-HMPAO, hexamethylpropylene amine oxime). Technetium-99m (99mTc) is a metastable nuclear isomer which emits gamma rays which can be detected by a gamma camera.

nuclear gamma camera.

When it is attached to exametazime, this allows 99mTc to be taken up by brain tissue in a manner proportial to brain blood flow, in turn allowing brain blood flow to be assessed with the nuclear gamma camera.

nuclear gamma camera.

Because blood flow in the brain is tightly coupled to local brain metabolism and energy use, 99mTcexametazime (as well as the similar 99mTc-EC tracer) is used to assess brain metabolism regionally, in an attempt to diagnose and differentiate the different causal pathologies of dementia.

PET scanning
fludeoxyglucose (FDG) PET scanning of the brain, which works to assess regional brain glucose metabolism, to provide very similar information about local brain damage from many processes. must be made in an expensive medical cyclotron and "hot-lab" (automated chemistry lab for radiopharmaceutical manufacture), then must be delivered directly to scanning sites, with deliveryfraction for each trip handicapped by its natural short 110 minute half-life.