Differences

This shows you the differences between two versions of the page.

Link to this comparison view

Both sides previous revision Previous revision
Next revision
Previous revision
cl:tbi [2019/03/12 17:41]
admin ↷ Links adapted because of a move operation
cl:tbi [2020/04/30 22:11] (current)
Line 1: Line 1:
 ====== Traumatic Brain Injury ====== ====== Traumatic Brain Injury ======
 +{{INLINETOC}}
 ===== Primer ===== ===== 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.]])]+**Traumatic Brain Injury ​(TBI)** 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 ==== +== Epidemiology ​== 
-About 2% of the population lives with TBI-associated disability. Males account for the majority of TBI cases.+About 2% of the population lives with TBI-associated disability. Males account for the majority of TBI cases. ​The leading causes of TBI are due to falls, motor vehicle accidents, contact sports, and assaults.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4494623/​|Lauterbach,​ M. D., Notarangelo,​ P. L., Nichols, S. J., Lane, K. S., & Koliatsos, V. E. (2015). Diagnostic and treatment challenges in traumatic brain injury patients with severe neuropsychiatric symptoms: Insights into psychiatric practice. Neuropsychiatric disease and treatment, 11, 1601.]])] There are three peak mean ages of highest TBI incidence, including 0–4 years, 15–19 years, and over 65 years.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4494623/​|Lauterbach,​ M. D., Notarangelo,​ P. L., Nichols, S. J., Lane, K. S., & Koliatsos, V. E. (2015). Diagnostic and treatment challenges in traumatic brain injury patients with severe neuropsychiatric symptoms: Insights into psychiatric practice. Neuropsychiatric disease and treatment, 11, 1601.]])]
  
 == Comorbidity == == 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.]])]+Individuals ​post-TBI have a higher chance of developing [[mood:​1-depression:​|depression]] and [[trauma-and-stressors:​ptsd|posttraumatic stress disorder (PTSD)]].[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​12724117|Rapoport,​ M. J., McCullagh, S., Streiner, D., & Feinstein, A. (2003). Age and major depression after mild traumatic brain injury. The American Journal of Geriatric Psychiatry, 11(3), 365-369.]])] Although substance use is high before the onset of a TBI, it in fact declines after injury.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​29939106|Ponsford,​ J., Alway, Y., & Gould, K. R. (2018). Epidemiology and natural history of psychiatric disorders after TBI. The Journal of neuropsychiatry and clinical neurosciences,​ 30(4), 262-270.]])] PTSD can have symptoms ​such as 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 group>
 <WRAP half column> <WRAP half column>
 +
 ===== Diagnostic Criteria ===== ===== Diagnostic Criteria =====
 == Criterion A == == Criterion A ==
Line 26: Line 28:
 </​WRAP>​ </​WRAP>​
 <WRAP half column> <WRAP half column>
 +
 ===== Terminology ===== ===== Terminology =====
-==== Concussion ​==== +==== Concussions ​==== 
-**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.]])]+**Concussions** can be considered a form of mild traumatic brain injury. A regional study of Canadian adolescents found that approximately 20% of all adolescents have 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) ====
Line 35: Line 38:
 </​WRAP>​ </​WRAP>​
 </​WRAP>​ </​WRAP>​
- 
- 
- 
  
 ===== Symptoms and Severity ===== ===== Symptoms and Severity =====
Line 43: Line 43:
 <WRAP half column> <WRAP half column>
 == Symptoms == == 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:+The cognitive presentation and symptoms ​after a TBI can be 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 ​TBIs that involve ​brain contusion, hemorrhage, or penetrating injury, there can be more neurocognitive deficits, such as aphasia, neglect, and constructional dyspraxia. ​TBIs are also associated with:
   - Disturbances in emotional function (irritability,​ easy frustration,​ tension and anxiety, affective lability)   - Disturbances in emotional function (irritability,​ easy frustration,​ tension and anxiety, affective lability)
   - Personality changes (disinhibition,​ apathy, suspiciousness,​ aggression)   - 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) ​+  - Physical disturbances (headache, fatigue, sleep disorders, vertigo or dizziness, tinnitushyperacusis,​ photosensitivity,​ anosmia, reduced tolerance to psychotropic medications) ​
   - Seizures, hemiparesis,​ visual disturbances,​ cranial nerve deficits (particularly in more severe TBI, neurological symptoms and signs)   - Seizures, hemiparesis,​ visual disturbances,​ cranial nerve deficits (particularly in more severe TBI, neurological symptoms and signs)
-  - Evidence of orthopedic injuries 
 </​WRAP>​ </​WRAP>​
 <WRAP half column> <WRAP half column>
-== Severity == 
  
 +== Severity ==
 <panel type="​info"​ title="​Severity ratings for traumatic brain injury"​ subtitle=""​ no-body="​true">​ <panel type="​info"​ title="​Severity ratings for traumatic brain injury"​ subtitle=""​ no-body="​true">​
 ^ Injury characteristic ​            ^ Mild TBI                            ^ Moderate TBI         ^ Severe TBI  ^ ^ Injury characteristic ​            ^ Mild TBI                            ^ Moderate TBI         ^ Severe TBI  ^
-Loss of consciousness ​            | <​30 ​min                             | 30 minutes-24 hours  | >24 hours   | +Loss of consciousness ​            | <​30 ​minutes ​                            | 30 minutes-24 hours  | >24 hours   | 
-Posttraumatic amnesia ​            | <24 hours                           | 24 hours-7 days      | 7 days      | +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         |+Glasgow Coma Scale on assessment ​ | 13-15 (not below 13 at 30 minutes) ​ | 9-12                 | 3-8         |
 </​panel>​ </​panel>​
 +
 +<callout type="​tip"​ title="​In the First Few Months After a TBI..."​ icon="​true">​
 +It's important to look out for:
 +  * Depression
 +  * Cognitive and memory impairment
 +  * Sleep changes and sleep disorders
 +  * Behavioural changes according to family and collateral report
 +</​callout>​
 </​WRAP>​ </​WRAP>​
 </​WRAP>​ </​WRAP>​
  
 +===== Pathophysiology =====
 +Depending on the neuroanatomical region of the injury, symptoms of TBI can vary as described above. In general, TBIs can cause a variety of cytotoxic processes, including axonal injury, free-radical injuries, changes in Mg<​sup>​+2</​sup>​ and Ca<​sup>​+2</​sup>​ signalling, and neurotransmitter excitotoxicity. These changes contribute to a range of cognitive and neuropsychiatric symptoms.
 +
 +===== 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 [[somatic:​dsm-5:​somatic-symptom|somatic symptom disorder]] or [[somatic:​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).
  
 ===== Investigations ===== ===== Investigations =====
Line 67: Line 79:
  
 ===== Treatment ===== ===== 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.]])] +There are no approved pharmacological treatments for TBI, and use is off-label to address neuropsychiatric symptoms related to the injury.[([[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.]])] ​A variety ​of medications can be used depending ​on the symptom.
- ​[[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 injuryNeurology, 67(5), 748-755.]])]+
  
-===== Recovery ===== +If there is no urgent or acute symptomsdo watchful waiting and assess for spontaneous resolution ​of symptoms ​firstA "start low and go slow” approach is important as those with TBI have increased sensitivity to to cognitive side effects ​of psychotropic and neurological medications.
-Neurobehavioral symptoms tend to be most severe in the immediate aftermath of a TBI. Unless ​there is a severe TBIthe 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">​ +<WRAP group> 
-Mild                                                                                                                                                                                                                                                                                                                                                                   ^ Moderate-Severe ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              ^ +<WRAP half column>​ 
-The symptoms associated with mild TBI tend to resolve within days to weeks after the injurywith complete resolution typical by 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 TBIin addition to persistence of neurocognitive deficitsthere may be associated neurophysiologicalemotional, and behavioural complicationsThese include seizures (particularly in the first year)photosensitivityhyperacusisirritabilityaggressiondepressionsleep disturbancefatigueapathyinability to resume occupational and social functioning at pre-injury leveland deterioration in interpersonal relationshipsModerate and severe TBI have been associated with increased risk of depressionaggressionand possibly neurodegenerative diseases such as Alzheimer'​s disease.  |+<panel type="​info"​ title="​TBI-related Cognitive Deficits" subtitle=""​ no-body="​true" footer="​*Off-label">​ 
 +Dopamine agonists ​               | Amantadine 100 to 300mg daily, [[meds:​dopamine-agonists:​bromocriptine|bromocriptine]] 5 to 45mg daily                                                                                                                                                                                                                                                                         | 
 +^ Acetylcholinesterase inhibitors ​ | [[meds:​dementia:​donepezil|Donepezil]][[meds:​dementia:​rivastigmine|rivastigmine]] ​to 6mg daily[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​16966534|SilverJ. M.KoumarasB., ChenM.MirskiD.PotkinS. G.ReyesP.... & GunayI(2006). Effects ​of rivastigmine on cognitive function in patients with traumatic brain injury. Neurology67(5)748-755.]])]  
 +^ Stimulants ​                      | [[meds:​stimulants:​2-methylphenidate:​|Methylphenidate]] 10 to 15mg BID, [[meds:​stimulants:​modafinil|modafinil]] 100 to 400mg daily                                                                                                                                                                                                                                             |
 </​panel>​ </​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 [[somatic:​dsm-5:​somatic-symptom|somatic symptom disorder]] or [[somatic:​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). 
  
 +<panel type="​info"​ title="​Depression"​ subtitle=""​ no-body="​true"​ footer="​*Off-label">​
 +^ SSRIs  | [[meds:​antidepressants:​ssri:​fluoxetine|Fluoxetine]] 60mg daily, [[meds:​antidepressants:​ssri:​sertraline|sertraline]] 100mg daily  |
 +</​panel>​
 +</​WRAP>​
 +<WRAP half column>
 +<panel type="​info"​ title="​Aggression/​Agitation"​ subtitle=""​ no-body="​true"​ footer="​*Off-label">​
 +^ Anticonvulsants ​                  | [[meds:​mood-stabilizers-anticonvulsants:​1-valproic-divalproex|Valproic acid]] 600 to 2250mg daily, carbamazepine 400 to 800mg daily                       |
 +^ Beta-blockers ​                    | [[meds:​non-benzo-anxiolytics:​propranolol|Propranolol]] up to 420mg/​daily,​[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​17054165/​|Fleminger,​ S., Greenwood, R. R., & Oliver, D. L. (2003). Pharmacological management for agitation and aggression in people with acquired brain injury. Cochrane Database of Systematic Reviews, (1).]])] pindolol 60 to 100mg daily                                 |
 +^ Mood stabilizers ​                 | [[meds:​mood-stabilizers-anticonvulsants:​1-lithium|Lithium]] 900mg daily                                                                       |
 +^ Second generation antipsychotics ​ | [[meds:​antipsychotics:​second-gen-atypical:​7-clozapine|Clozapine]] 300 to 500mg daily, [[meds:​antipsychotics:​second-gen-atypical:​6-quetiapine|quetiapine]] 25 to 300mg daily, [[meds:​antipsychotics:​second-gen-atypical:​4-ziprasidone|ziprasidone]] 20 to 80mg daily  |
 +</​panel>​
 +
 +
 +<panel type="​info"​ title="​Somnolence"​ subtitle=""​ no-body="​true"​ footer="​*Off-label">​
 +^ Stimulants ​ | [[meds:​stimulants:​2-methylphenidate:​|Methylphenidate]] 10 to 15mg BID, [[meds:​stimulants:​modafinil|modafinil]] 100 to 400mg daily  |
 +</​panel>​
 +</​WRAP>​
 +</​WRAP>​
 +
 +===== Prognosis =====
 +Neuropsychiatric symptoms tend to be most severe in the first few months following a TBI. In mild-moderate 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]])] The symptoms associated with mild TBI resolve within days to weeks after the injury, with complete resolution typical by 3 months. Neuropsychiatric symptoms such as depression, irritability,​ fatigue, headache, photosensitivity,​ sleep disturbance also tend to resolve in the weeks following mild TBI. 
 +
 +In moderate to severe TBI, seizures (particularly in the first year), photosensitivity,​ and hyperacusis can remain. Neuropsychiatric symptoms such as irritability,​ aggression, depression, sleep disturbance,​ fatigue, and apathy can occur. These changes can lead to significant psychosocial impairment compared to the pre-injury level, and deterioration in interpersonal relationships. Moderate and severe TBI are associated with increased risk of depression, PTSD, aggression, and possibly neurodegenerative diseases such as Alzheimer'​s disease.
 +
 +==== Older Adults ====
 +Those aged >75 years have the highest incidence of TBI of any group.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​17038079|Thompson,​ H. J., McCormick, W. C., & Kagan, S. H. (2006). Traumatic brain injury in older adults: epidemiology,​ outcomes, and future implications. Journal of the American Geriatrics Society, 54(10), 1590-1595.]])] The most common mechanism of injuries are falls from standing height and motor vehicle accidents. In this older cohort, women are affected more than men. There is an increased risk of intracranial bleeding (even in those with mild TBIs). ​
  
 +Older adults generally also have higher morbidity and mortality, slower recovery, and worse functional outcomes.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​17038079|Thompson,​ H. J., McCormick, W. C., & Kagan, S. H. (2006). Traumatic brain injury in older adults: epidemiology,​ outcomes, and future implications. Journal of the American Geriatrics Society, 54(10), 1590-1595.]])] The impairment in cognitive domains post-TBI may improve within the first 6 to 12 months, but keeping an age-related [[geri:​dementia:​|dementia]] on the differential diagnosis is important. Additionally,​ the increased frequency of pre-existing and co-morbid medical conditions make TBI outcome assessments challenging,​ and it can be hard to isolate the effect of the TBI alone. Though age is an important prognostic factor for recovery in TBI, it is not the sole determining factor. Older adults with TBI can have similar outcomes as their younger cohorts.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​10969893|Rapoport,​ M. J., & Feinstein, A. (2000). Outcome following traumatic brain injury in the elderly: a critical review. Brain injury, 14(8), 749-761.]])]
 ===== Resources ===== ===== Resources =====
 <WRAP group> <WRAP group>
 <WRAP half column> <WRAP half column>
 == For Providers == == For Providers ==
 +  * [[https://​www.psychiatrictimes.com/​special-reports/​pharmacological-management-psychiatric-aspects-traumatic-brain-injury|PsychiatricTimes:​ Pharmacological Management of the Psychiatric Aspects of Traumatic Brain Injury]]
 +  * [[https://​www.bcmj.org/​articles/​pharmacological-interventions-traumatic-brain-injury|Talsky,​ A., Pacione, L. R., Shaw, T., Wasserman, L., Lenny, A., Verma, A., ... & Bhalerao, S. (2010). Pharmacological interventions for traumatic brain injury. BC Med J, 53(1), 26-31.]]
   * [[http://​horizon.parachutecanada.org/​wp-content/​uploads/​2014/​10/​Parachute-Concussion-Return_to_Play_Guidelines.pdf|Return To Play Guidelines]]   * [[http://​horizon.parachutecanada.org/​wp-content/​uploads/​2014/​10/​Parachute-Concussion-Return_to_Play_Guidelines.pdf|Return To Play Guidelines]]
 </​WRAP>​ </​WRAP>​