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cl:tbi [on September 26, 2018]
 cl:tbi [on March 12, 2019]
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 +====== Traumatic Brain Injury ======
 +===== Primer =====
 +**Traumatic Brain Injuries (TBIs)** is an intracranial injury that occurs when an external force injures the brain. When clinically significant,​ the DSM-5 diagnoses are [[cl:​2-major-neurocog-disorder|major neurocognitive disorder]] or [[cl:​3-mild-neurocog-disorder|mild neurocognitive disorder]] Due to Traumatic Brain Injury.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​24820171|Wortzel,​ H. S., & Arciniegas, D. B. (2014). The DSM-5 approach to the evaluation of traumatic brain injury and its neuropsychiatric sequelae. NeuroRehabilitation,​ 34(4), 613-623.]])]
 +
 +==== Prevalence ====
 +About 2% of the population lives with TBI-associated disability. Males account for the majority of TBI cases.
 +
 +== Comorbidity ==
 +Individuals with TBI can also present with [[trauma-and-stressors:​ptsd|]]. Both have common neuropsychiatric symptoms including anxiety, irritability,​ insomnia, personality changes, and memory problems, and this overlap can sometimes complicate the diagnostic picture.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​24568300|Tanev,​ K. S., Pentel, K. Z., Kredlow, M. A., & Charney, M. E. (2014). PTSD and TBI co-morbidity:​ scope, clinical presentation and treatment options. Brain injury, 28(3), 261-270.]])]
 +<WRAP group>
 +<WRAP half column>
 +===== Diagnostic Criteria =====
 +== Criterion A ==
 +The criteria are met for [[cl:​2-major-neurocog-disorder|major]] or [[cl:​3-mild-neurocog-disorder|mild neurocognitive disorder]]
 +
 +== Criterion B ==
 +There is evidence of a traumatic brain injury—that is, an impact to the head or other mechanisms of rapid movement or displacement of the brain within the skull, with one or more of the following:
 +  - Loss of consciousness.
 +  - Posttraumatic amnesia.
 +  - Disorientation and confusion.
 +  - Neurological signs (e.g., neuroimaging demonstrating injury; a new onset of seizures; a marked worsening of a preexisting seizure disorder; visual field cuts; anosmia; hemiparesis).
 +
 +== Criterion C ==
 +The neurocognitive disorder presents immediately after the occurrence of the traumatic brain injury or immediately after recovery of consciousness and persists past the acute post-injury period.
 +
 +</​WRAP>​
 +<WRAP half column>
 +===== Terminology =====
 +==== Concussion ====
 +**Concussions** can be considered a form of mild traumatic brain injury. A regional study of Canadian adolescents found that approximately 20% had sustained a concussion[([[https://​jamanetwork.com/​journals/​jama/​article-abstract/​2654803|Veliz,​ P., McCabe, S. E., Eckner, J. T., & Schulenberg,​ J. E. (2017). Prevalence of Concussion Among US Adolescents and Correlated Factors. Jama, 318(12), 1180-1182.]])]
 +
 +==== Chronic Traumatic Encephalopathy (CTE) ====
 +**Chronic traumatic encephalopathy (CTE)** is a term used to describe brain degeneration likely caused by repeated head trauma. A diagnosis of CTE can only be made during autopsy. CTE is a rare condition and usually found in individuals who play contact sports.
 +
 +</​WRAP>​
 +</​WRAP>​
 +
 +
 +
 +
 +===== Symptoms and Severity =====
 +<WRAP group>
 +<WRAP half column>
 +== Symptoms ==
 +The cognitive presentation and symptoms of a TBI is variable. Difficulties in the domains of complex attention, executive ability, learning, and memory are common as well as slowing in speed of information processing and disturbances in social cognition. In more severe TBI in which there is brain contusion, intracranial hemorrhage, or penetrating injury, there may be additional neurocognitive deficits, such as aphasia, neglect, and constructional dyspraxia. Traumatic brain injuries may also be associated with:
 +  - Disturbances in emotional function (irritability,​ easy frustration,​ tension and anxiety, affective lability)
 +  - Personality changes (disinhibition,​ apathy, suspiciousness,​ aggression)
 +  - Physical disturbances (headache, fatigue, sleep disorders, vertigo or dizziness, tinnitus or hyperacusis,​ photosensitivity,​ anosmia, reduced tolerance to psychotropic medications) ​
 +  - Seizures, hemiparesis,​ visual disturbances,​ cranial nerve deficits (particularly in more severe TBI, neurological symptoms and signs)
 +  - Evidence of orthopedic injuries
 +</​WRAP>​
 +<WRAP half column>
 +== Severity ==
 +
 +<panel type="​info"​ title="​Severity ratings for traumatic brain injury"​ subtitle=""​ no-body="​true">​
 +^ Injury characteristic ​            ^ Mild TBI                            ^ Moderate TBI         ^ Severe TBI  ^
 +| Loss of consciousness ​            | <30 min                             | 30 minutes-24 hours  | >24 hours   |
 +| Posttraumatic amnesia ​            | <24 hours                           | 24 hours-7 days      | 7 days      |
 +| Glasgow Coma Scale on assessment ​ | 13-15 (not below 13 at 30 minutes) ​ | 9-12                 | 3-8         |
 +</​panel>​
 +</​WRAP>​
 +</​WRAP>​
 +
 +
 +===== Investigations =====
 +Biomarkers for acute concussion have been identified, including ubiquitin carboxy-terminal hydrolase L1 (UCH-L1).[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC5494601/​|Mondello,​ S., Palmio, J., Streeter, J., Hayes, R. L., Peltola, J., & Jeromin, A. (2012). Ubiquitin carboxy-terminal hydrolase L1 (UCH-L1) is increased in cerebrospinal fluid and plasma of patients after epileptic seizure. BMC neurology, 12(1), 85.]])] The FDA has recently approved this for clinical use.
 +
 +===== Treatment =====
 +There are no approved pharmacological treatments for TBI, and use is off-label to address neuropsychiatric symptoms related to the injury, including medications such as SSRIs.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC5575613/​|Yue,​ J. K., Burke, J. F., Upadhyayula,​ P. S., Winkler, E. A., Deng, H., Robinson, C. K., ... & Ngwenya, L. B. (2017). Selective serotonin reuptake inhibitors for treating neurocognitive and neuropsychiatric disorders following traumatic brain injury: an evaluation of current evidence. Brain sciences, 7(8), 93.]])]
 + ​[[meds:​dementia:​rivastigmine|]] has been demonstrated to have some benefits in cognitive function for traumatic brain injury patients with moderate to severe memory deficits.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​16966534|Silver,​ J. M., Koumaras, B., Chen, M., Mirski, D., Potkin, S. G., Reyes, P., ... & Gunay, I. (2006). Effects of rivastigmine on cognitive function in patients with traumatic brain injury. Neurology, 67(5), 748-755.]])]
 +
 +===== Recovery =====
 +Neurobehavioral symptoms tend to be most severe in the immediate aftermath of a TBI. Unless there is a severe TBI, the typical course is complete or substantial improvement of neuropsychiatric symptoms. Approximately 80% of all TBIs are of mild severity.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​26269903|Laskowski RA, Creed JA, Raghupathi R. Pathophysiology of Mild TBI: Implications for Altered Signaling Pathways]])]
 +
 +<panel type="​info"​ title="​Prognosis"​ subtitle=""​ no-body="​true">​
 +^ Mild                                                                                                                                                                                                                                                                                                                                                                   ^ Moderate-Severe ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              ^
 +| The symptoms associated with mild TBI tend to resolve within days to weeks after the injury, with complete resolution typical by 3 months. Other symptoms that may potentially co-occur with the neurological symptoms (e.g., depression, irritability,​ fatigue, headache, photosensitivity,​ sleep disturbance) also tend to resolve in the weeks following mild TBI.  | With moderate and severe TBI, in addition to persistence of neurocognitive deficits, there may be associated neurophysiological,​ emotional, and behavioural complications. These include seizures (particularly in the first year), photosensitivity,​ hyperacusis,​ irritability,​ aggression, depression, sleep disturbance,​ fatigue, apathy, inability to resume occupational and social functioning at pre-injury level, and deterioration in interpersonal relationships. Moderate and severe TBI have been associated with increased risk of depression, aggression, and possibly neurodegenerative diseases such as Alzheimer'​s disease. ​ |
 +</​panel>​
 +===== Differential Diagnosis =====
 +In some instances, the severity of neurocognitive symptoms may appear to be inconsistent with the severity of the TBI. After previously undetected neurological complications (e.g., chronic hematoma) are excluded, the possibility of diagnoses such as [[pain-medicine:​dsm-5:​somatic-symptom|somatic symptom disorder]] or [[pain-medicine:​dsm-5:​factitious|factitious disorder]] need to be considered. [[trauma-and-stressors:​ptsd|Posttraumatic stress disorder]] can co-occur with the neurocognitive impairment and have overlapping symptoms (e.g. - difficulty concentrating,​ depressed mood, aggressive behavioural disinhibition).
 +
 +
 +===== Resources =====
 +<WRAP group>
 +<WRAP half column>
 +== For Providers ==
 +  * [[http://​horizon.parachutecanada.org/​wp-content/​uploads/​2014/​10/​Parachute-Concussion-Return_to_Play_Guidelines.pdf|Return To Play Guidelines]]
 +</​WRAP>​
 +<WRAP half column>
 +== Articles ==
 +  * [[https://​www.nytimes.com/​2017/​09/​22/​opinion/​aaron-hernandez-cte.html|NYT:​ Is C.T.E. a Defense for Murder?]]
 +  * [[https://​www.nytimes.com/​2016/​06/​02/​sports/​hockey/​stephen-peat-nhl-enforcer-concussions-cte-health.html|NYT:​ After a Life of Punches, Ex-N.H.L. Enforcer Is a Threat to Himself]]
 +</​WRAP>​
 +</​WRAP>​
 +