Mild Traumatic Brain Injury

Definitions:
Mild Traumatic Brain Injury
• Controversial
• NSW Head Injury Guidelines1:
o GCS 14-15 is deemed mild (80%)
o GCS 9-13 is deemed moderate (10%) because GCS 13 is similar in
prognosis and intracranial abnormalities to (9-12)2-5
o GCS 3-8 is deemed severe (10%)
• Characterised by: transient LOC, amnesia, confusion, rare for neurosurgical
intervention, common to have post-concussion symptoms, and good long
term outcomes1.
Concussion
• American Academy of Neurology: trauma-induced altered mental status with
or without LOC6.
Epidemiology:
• Most head injury is mild 75-95%7-8.
Aetiology
• Common causes are MVA (45%), falls (30%), occupational accidents (10%),
recreational accidents 10%) and assaults (5%)9.
Pathophysiology
• Coup (moving object vs stationary head) or contrecoup (moving head vs
stationary object) injuries
• Axonal injury, swelling followed by the release of acetcylcholine, glutamate,
aspartate and free radicals10.
• Complications: contusion and oedema, bleeding, fracture, space-occupying
lesions, seizures
Clinical Features11
Symptoms:
• Early symptoms: headache, dizziness, vertigo or imbalance, lack of
awareness of surroundings, nausea and vomiting.
• Late symptoms: mood and cognitive disturbance, photophobia and
phonophobia and sleep disturbances.
Signs:
• Confusion: Vacant stare, inattention, disorientation, slurred or incoherent
speech, uncoordination, emotionality
• Amnesia: memory deficits
• LOC.
• Seizures (mostly in the first hour, then 24 hours, then up to a week after
head injury). Increases the risk of post-traumatic epilepsy to 25%.
Sequelae:
• Second impact syndrome: diffuse cerebral swelling, due to disorder cerebral
autoregulation causing cerebrovascular congestion and malignant cerebral
oedema with increased ICP. It is rare.
• Postconcussion syndrome: headache, dizziness, neuropsychiatric symptoms,
cognitive impairment (few days to few months)
• Post-traumatic headache (25-75%)
• Post-traumatic epilepsy: 2 fold increase (not including the week after the
injury), most occur in the first 2 years).
• Post traumatic vertigo: damage to the cochlear and vestibular structures in
transverse fracture of temporal bone, BPPV as otoliths are displaced, rupture
of the oval or round window
• Cranial nerve injuries: anosmia, facial nerve pain
 • Neuropsychological impairment
Investigations
• CT pros1:
o Identify those who require acute neurosurgical intervention
o Identify those who are more likely to need admission for monitoring
o Identify those at low risk of deterioration and expedite discharge.
• CT Cons1:
o Yield- >90% are negative, <1% of scans require neurosurgical
intervention
o Costs
o Limited resource
o Radiation risks
o Early CTs have some potential to miss small (?clinically significant)
lesions such as subdurals and contusions.
Scan Criteria
New Orleans Criteria (2000)12
• Used by: Endorsed by American College of Emergency Physicians
• Method:
o 2 phases
o Phase 1- 520 pts with minor head injury (GCS 15) AND LOC (all
underwent CT) and positive findings noted, and used to develop
criteria
o Phase 2- 909 pts in predictive and prospective study to validate criteria
• Criteria: HEADS MT
o Headache
o Emesis
o Age over 60
o Drug and alcohol intoxication
o Seizures
o Memory deficit
o Trauma above the clavicles
• Sensitivity: 100%
• Specificity: 25%
• Negative predictive value: 100%
• Cons: when validated in Australian population, it is still 100% sensitive but
only reduce the proportion of CT scans by 3.8% 13.
Canadian Head CT Criteria (2001)14
• Used by: National Institute of Clinical Excellence UK
• Method:
o Inclusion:
 Blunt trauma  LOC, amnesia or disorientation
 Excluded depressed fracture and acute focal neurological deficit,
seizure, or bleeding disorder
 GCS 13-15
o CT:
 Based on clinician discretion
 Those without CT had a day 14 telephone outcome check
o Criteria:
 Developed 5 high risk and 2 medium risk factors
• Sensitivity:
o High risk factors: 100% for neurosurgical intervention and 32% would
require CT
 o Medium risk factors 98.4% for clinically important brain injury, 54%
undergo CT
o Does not include CT abnormalities not deemed “clinically important” or
requiring craniotomy elevation of skull fracture, ICP monitoring or
intubation. Eg. It missed pts with small contusions not requiring
intervention
• Specificity
o High risk: 68.7%
o Medium risk: 49.6%
• Cons:
o Low sensitivity: When applied to an Australian population, it reduced
the number of 46.7% without missing any patient requiring
neurological intervention but would not have detected 2/10 patients
with clinically significant CT abnormalities. (A small fracture and
subdural, 0.5cm left frontal contusion and fracture)12
NEXUS II (2005)15 (National Emergency X-radiography Utilisation Study II)
• Method:
o Prospective multi-centre study including 13728 enrolled patients who
had a head CT ordered in nth American Eds.
o Clinicians chose to make imaging decisions on clinical judgment
o Submit information on clinical variables
o CT evaluated for injuries requiring neurosurgical intervention
(craniotomy, ICP monitoring, ventilation) or lead to rapid deterioration.
o Instrument developed based on clinical variables
o However, methodology may miss patients who don’t have a CT and
have an adverse outcome
• Criteria:
o BEAN BASH
o Behavioural abnormality, Emesis intractable, Age >65, Neurological
deficit, Bleeding disorder, Altered mental status, Skull fracture,
Haematoma
• Sensitivity 95.2%
• Specificity 17.4%,
• Negative predictive value 99.1%
• Cons: Yet to be validated in an Australian population
NSW Health Guidelines1:
 • Cons: high number of CT scans
Management1
• Resuscitation if necessary
• Monitor serial GCS
• Consideration of CT scan
• Admit if:
o Requiring neurosurgery: mass effect, herniation, substantial
haematomas, haemorrhages and contusions, depressed skull fracture,
pneumocephalus, diffuse cerebral oedema
o CT positive but non-urgent neurosurgical patients (small haematomas,
contusions)
 Increased risk of delayed haematomas, raised ICP, post-
traumatic seizures and SIADH, and disabling post-concussive
symptoms.
 Should be admitted for prolonged observation
o Clinically abnormal and not showing clinical improvement in 4 hours
• Discharge if:
o Clinically improving
o No risk factors
o Normal CT
o Meeting social criteria for discharge: responsible person to take patient
home, to observe at home, patient able to return easily, written and
verbal discharge advice.
• Provide discharge advice regarding possible sequelae to expect and when to
return if complications occur.
References
1. NSW Health and Institute of Trauma and Injury Management (2007) Initial
Management of Closed Head Injury In Adults as accessed from
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resonance imaging of mild head injury--is it appropriate to classify patients
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11. Evans RW (2010) Concussion and Mild Traumatic Brain Injury accessed from
www.uptodate.com on 17/8/10
12. Haydel MJ et al. (2000) Indications for computed tomography in patients with
minor head injury NEJM 343: 100-5
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injury Lancet 357: 1391-96
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