AZ ÉLETTUDOMÁNYI- KLINIKAI FELSŐOKTATÁS GYAKORLATORIENTÁLT ÉS HALLGATÓBARÁT

KORSZERŰSÍTÉSE A VIDÉKI KÉPZŐHELYEK NEMZETKÖZI VERSENYKÉPESSÉGÉNEK ERŐSÍTÉSÉRE

TÁMOP-4.1.1.C-13/1/KONV-2014-0001

Andras Buki M.D., Ph.D.,D.Sc.Department of Neurosurgery, Medical Faculty of Pecs University, Pecs, Hungary, H-7624

Identification andClassification of TBI

• epidemiology

• classification – injury

• classification – injured: triage

• no injury to the skull can be as trivial or so

severe to deny treatment

Hippocrates of Kos (460–377 BC)

MOTTO

TBI Definition VA/DoD

• VA/DoD “Clinical Practice Guideline For Management of Concussion/ Mild Traumatic

Brain Injury” (V1.0 2009) and Brain Trauma Foundation, AANS and ANC joint

“Guidelines for the management of the Severe Traumatic Brain Injury” (3rd edition,

2007) has defined traumatic brain injury as a

traumatically induced structural injury and/or physiological

disruption of brain function as a result of an external force that

is indicated by new onset or worsening of at least one of the

following clinical signs, immediately following the event:

4

TBI Definition VA/DoD II

• loss of or a decreased level of consciousness (LOC)

• loss of memory for events immediately before or after the injury

(post-traumatic amnesia [PTA])

• alteration in mental state (confusion, disorientation, slowed thinking

etc.) (Alteration of consciousness/mental state [AOC])

• Neurological deficits (weakness, loss of balance, change in vision,

praxis, paresis/plegia, sensory loss, aphasia, etc.) that may or may

not be transient

• Intracranial lesion

• A computed tomography scan (CT or CAT scan) is the gold

standard for the radiological assessment of a TBI patient.

5

• epidemiology

• classification – injury

• classification – injured: triage

Traumatic brain injury…

• …the silent epidemic

• …the disease of unmet medical need

• …leading cause of mortality in the active

population

• 2.1 million TBI cases per year causing

100,000 deaths and

500,000 hospitalizations

• TBI-related death rate of the population under 35 years of age is3.5 times as many as that of cancer and heart disease together

• 90,000 survivors will endure life-long debilitating loss of function

• 5,000 new cases of epilepsy

• 2,000 permanent vegetative state

• The cumulative societal cost per year for TBI is $48 billion

(Lewin I. C. F: Head injuries: costs and consequences. J.Head.Trauma.Rehabil. 67:76-91, 1991.)

The significance of severe TBI

TBI in the Military

• penetrating brain injuries

claim 25% of soldiers killed

in battle

• 2/3 of casualties have brain

injuries and concussion is

growing military medical

problem

http://www.brainandspinalcord.org/brain-injury/statistics.html

Mild Traumatic Brain Injury (MTBI) in Sports• 1.6 - 3.8 million sports related

concussions occur each year

• N.F.L. found that dementia-related

diseases are much higher in former

players than the national population

• Sports incidence of TBI (5-18 yrs of

age)

– Cycling: 64,993

– Football: 36,412

– Baseball and Softball: 25,079

– Basketball: 24,701

– Powered RV: 24,090

– Skateboards/Scooters w/power:

18,542

– Soccer: 17,108

– Skateboards/Scooters: 16,477

http://educationalissues.suite101.com/article.cfm/tbi_statistics

http://www.cdc.gov/NCIPC/tbi/FactSheets/Concussion_in_Sports_factsheet.pdf

September 26, 2009 Florida vs Kentucky, Tim Tebow

from Univ. of Florida suffered a mild concussion

Emerging (but debated…)

• Mild traumatic brain injury

• CT negative, MRI positive

• SWI negative, MRI positive

• Post-concussive syndrome

• PTSD

The burden of traumatic brain injury

• Traumatic brain injury is the primary cause

of death under 40

• WHO estimates that until 2020 TBI will be

the third most frequent cause of death in

the Earth(Langlois et al., J. Head Trauma Rehabil. 2006, 21, 375-378

Murray et al. Lancet 1997, 349, 1436-1442)

Intervention GBP

Se cholesterol check-up (age40-69) 220

Neurosurgical care for TBI 240

Neurosurgical care for SAH 490

Stroke prevention with anti-hypertensive medication (age40-64) 940

pm implantation 1100

Kidney transplantation 4710

Neurosurgical care for brain tumors 107780

GBP/QALY by the NHS:

• epidemiology

• classification – injury

• classification – injured: triage

PRIMARY BRAIN INJURY

SECONDARY BRAIN INJURYhypoxiahypoperfusion

ASSOCIATED CNS INJURYassociated C-spine (CO-II) injurytandem injury

ASSOCIATED INJURYassociated multiorgan injury/failure (MOF)

General classification

PRIMARY BRAIN INJURY

• occurs at the time of impact

• almost immediate clinical effects

• refractory to most treatment

• can be influenced by preventive measures

SECONDARY BRAIN INJURY

• occurs at some time after the impact

• characterized by hypoperfusion/hypoxia

• propagates gradually

• preventable and treatable

PRIMARY BRAIN INJURY

SECONDARY BRAIN INJURY

ASSOCIATED CNS INJURYassociated C-spine (CO-II) injurytandem injury

ASSOCIATED INJURYmultiple/polytraumaassociated multiorgan injury/failure (MOF)

General classification

CLOSED – PENETRATINGsimple open skull fracture depressed „compound fracture”

skull-base fracture

Classic „anatomical”: on the basis of skull injury (reflects the probability of intracranial infection)

Advanced Trauma Life Support®-ATLS ®

• circumstances of injury + energy/forces + type of impact

• potential structural damage, pathobiological processes evoked

Potential forces

• STATIC

• DYNAMIC– impact

– acceleration-deceleration

Focal Diffuse

• contusioncoup - contrecoup

• epidural hemorrhage• subdural hemorrhage

Patho-morphology

Diffuse Axonal Injury (DAI)Hypoxic Brain DamageBrain SwellingDiffuse Vascular InjuryDiffuse Neuronal Somatic Injury

IMPACT-TYPE, dynamic forcesAcceleration-deceleration-type,dynamic forces

Focal Diffuse

• contusioncoup - contrecoup

• epidural hemorrhage• subdural hemorrhage

Patho-morphology

Diffuse Axonal Injury (DAI)Hypoxic Brain DamageBrain SwellingDiffuse Vascular InjuryDiffuse Neuronal Somatic Injury

IMPACT-TYPE, dynamic forcesAcceleration-deceleration-type,dynamic forces

• epidemiology

• classification – injury

• classification – injured: triage

Triage

• pre-CT- classification

• classification upon the severity of brain injury

Classification of TBI Severity adopted

from 2009 VA/DOD Guideline

Neurosurgery. 2009 Apr;64(4):690-6; discussion 696-7. doi: 10.1227/01.NEU.0000340796.18738.F7.

Patients with moderate head injury: a prospective multicenter study of 315 patients.

Compagnone C, d'Avella D, Servadei F, Angileri FF, Brambilla G, Conti C, Cristofori L, Delfini R, Denaro L, Ducati A, Gaini SM,

Stefini R, Tomei G, Tagliaferri F, Trincia G, Tomasello F.

• Moderate head injury: GCS 9-12 is NOT a homogenious group

• Neuroworsening, seizures, and medical complications as outcome predictors with a GCS of 11 to 13

• Low motor GCS score ismore outcome-related in patients with GCS of 9 and 10.

Saatman KE, Duhaime AC, Bullock R, Maas AI, Valadka A, Manley GT; Workshop Scientific Team and Advisory Panel Members. Classification of traumatic brain injury for targeted therapies. J Neurotrauma. 2008;25(7):719-38.

• Current classifications of TBI are outdated

• Classifications that describe the whole injury spectrum are needed

Triage

• Probability of intracranial hemorrhage following traumatic brain injury:

LOW:

lack of factors indicating medium and high probability

patients are discharged with warning notices

• Probability of intracranial hemorrhage following traumatic brain injury:

Medium:

1., LOC2., Progressive headache3., Alcohol/drug intoxication4., Seizure 5., Unreliable history6., Age under 2y7., Repeated vomiting8., Amnesia9., Physical signs of skull fracture10.,Repeated trauma11.,Severe maxillo-facial trauma12.,Child abuse13.,Significant subgaleal swelling/collection14.,Coagulopathy15.,Diabetes

CT scan followed by discharge or observation

diagnostic measures:

• ultrasound

• transillumination

• CT

• MRI

• X-Ray NOOOOOOO!!!!!!!!

• Probability of intracranial hemorrhage following traumatic brain injury:

HIGH:

1., GCS 12 or less2., Focal neurological signs3., Decrease in GCS value4., Open/penetrating skull injury5., On the basis of injury-mechanism intracranial injury is suspected.

Immediate transfer to a neurosurgical department

Head injured patients (outpatient/emergency)

room)

Low risk

- initial GCS over 14

- from “medium risk”-categories only the

following:

- sober responsible adult supervision - immediate access to transportation

- repeated injury can be excluded

informed discharge with

warning notices

All other cases:

observation on the floor

Medium risk

Observation on the floor/CT

Normal CT

risk Pathological CT

Consult a neurosurgeon

Deterioration amnesia

loss of consciousness

No deterioration

• Adverse outcome of an intracranial hematoma is so costly that it more than balances the expense of CT scans.

• In cost-effectiveness models the liberal use of CT scanning in mild TBI appears justified.

• Stein SC J Trauma. 2007 May;62(5):1309.

• Geijerstam et al. Emerg Med J. 2004 Jan;21(1):54-8.

Undén J, Ingebrigtsen T, Romner B; Scandinavian Neurotrauma Committee (SNC) Scandinavian guidelines for

initial management of minimal, mild and moderate head injuries in adults: an evidence and consensus-based

update. BMC Med. 2013 Feb 25;11:50.

J Neurotrauma. 2013 Mar 14. [Epub ahead of print]

GFAP-BDP as an Acute Diagnostic Marker in Traumatic Brain Injury: Results from the

prospective TRACK-TBI Study.

Okonkwo DO, Yue JK, Puccio AM, Panczykowski D, Inoue T, McMahon PJ, Sorani MD, Yuh EL,

Lingsma H, Maas A, Valadka A, Manley GT M D Ph D.

Source

University of Pittsburgh, Dept of Neurological Surgery, Pittsburgh, Pennsylvania, United States;

okonkwodo@upmc.edu.

Abstract

Reliable diagnosis of traumatic brain injury (TBI) is a major public health need. Glial fibrillary acidic

protein (GFAP) is expressed in the central nervous system and breakdown products (GFAP-BDP) are

released following parenchymal brain injury. Here we evaluate the diagnostic accuracy of elevated

levels of plasma GFAP-BDP in TBI. Participants were identified as part of the prospective

Transforming Research And Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) Study. Acute

plasma samples (<24 hours) were collected from patients presenting with head injury who had CT

imaging. The ability of GFAP-BDP level to discriminate patients with demonstrable traumatic lesions

on CT and with failure to return to pre-injury baseline at 6 months was evaluated by the area under the

receiver operating characteristic curve (AUC). Of the 215 patients included for analysis, 83% suffered

mild, 4% moderate, and 13% severe TBI; 54% had acute traumatic lesions on CT. The ability of

GFAP-BDP level to discriminate patients with traumatic lesions on CT as evaluated by AUC was 0.88

(95%CI, 0.84-0.93). The optimal cutoff of 0.68ng/ml for plasma GFAP-BDP level was associated with

a 21.61 Odds Ratio for traumatic findings on head CT. Discriminatory ability of unfavorable 6-month

outcome was lower, AUC 0.65 (95% CI, 0.55-0.74), with a 2.07 Odds Ratio. GFAP-BDP levels reliably

distinguish the presence and severity of CT scan findings in TBI patients. While these findings confirm

and extend prior studies, a larger prospective trial is still needed to validate the use of GFAP-BDP as a

routine diagnostic biomarker for patient care and clinical research. (ClinicalTrials.gov number

NCT01565551;NIH Grant 1RC2NS069409).

Summary

• Current characterization of TBI is outdated

• Emphasise should be on timely recognition of patients at risk

• Novel classification/characterization is needed to describe the entire injury-spectrum

Childhood:1 no response2 unrecognizable voices (sounds but no crying)3 unproper words (crying)4 non comprehensive talk (agitated)5 oriented (smiles, follows objects, finger)

•DEFINITIONS AND CLASSIFICATION

•SYMPTOMS AND SIGNS OF RAISED ICP

•PRIMARY ASSESSMENT OF THE HEAD INJURED

/PRIMARY ASSESSMENT IN LOC

•GENERAL PRINCIPLES OF THE TREATMENT OF THESEVERELY HEAD INJURED

•EPIDEMIOLOGY OF TRAUMATIC BRAIN INJURY

• ☺** Poor outcome under systolic

pressure of:

• 65 Hgmm 0-1 y;

• <75 Hgmm 2-5 y;

• <80 Hgmm 6-12 y;

• <90 Hgmm 13-16 y.

60

60

60

Thank You!