NCD due to TBI

Table of Contents

1. Overview

  • mild TBI or concussion are not "mild" or "benign"

2. Diagnosis

  1. NCD criteria are met
  2. evidence of TBI - impact to head with
    1. loss of consciousness
    2. post-traumatic amnesia
    3. disorientation and confusion
    4. neuro signs
  3. NCD starts immediately after the TBI

3. Severity rating

Criteria mild moderate severe
neuroimaging normal normal or abnormal normal or abnormal
LOC <30min 0.5-24h >24h
Altered consciousness <=24h >24h  
Post-traumatic amnesia <24h 24h-7d >7d
GCS 13-15 9-12 3-8
  • major NCD due to TBI corresponds to moderate and severe TBI; mild NCD corresponds to mild TBI/concussion

4. Epidemiology

  • TBI contributes to 30% of all injury related deaths
  • highest prevalence in <4yo, late adolescence, >65yo
  • men > women
  • no numbers: research accounts for ED visits only

5. Etiology

  • brain collides with inside of skull causing cerebral contusions and axonal injury either at external site of impact or at opposite pole
  • direct blow, head striking an object, acceleration/deceleration, explosions/blasts, penetration of the brain
  • concurrent subdural or epidural hematoma or hemorrhagecan cause compression of surrounding brain tissue
  • leading cause: falls 40%, accidental blunt trauma 15%, MVA 14%, assault 10%

6. Clinical features

  • Common somatic symptoms include headaches (typically migraine, occipital neuralgia, or cervicogenic), cognitive fatigue, physical fatigue, sensitivity to light/noise, insomnia and other sleep disturbances, drowsiness, dizziness, nausea and vomiting, vision problems, transient neurological abnormalities, seizures, and balance problems.
  • psychological symptoms following a TBI can include personality change (e.g., disinhibition, apathy, suspiciousness, aggression) as well as disturbances in emotional function (e.g., irritability, easy frustration, tension and anxiety, affective lability).

7. Investigations

  • CT scan: petechial hemorrhage, subarachnoid hemorrhage
  • MRI hyperintenssities suggestive of hemorrhage
  • neuropsych testing

8. DDx

  • r/o neurological complications (e.g. hematoma)
  • if symptoms aren't accounted for
    • somatic symptom disorder or factitious disorder
    • PTSTD
    • depressive symptoms

9. Course and prognosis

  • severity not predictive
    • cofactors - age, prior injuries, substance use, etc
  • mild TBI
    • complete or substantial improvement in cognitive, neuro, and psych symptoms
    • cognitive: typically resolve by 3 months
    • psych (depression, irritability, sleep dis): within weeks
    • neuro (headache, photosensitivity): within weeks
    • dizziness post-trauma and cognitive fog 3 days post - longer recovery
  • moderate/sever
    • persistence of neurocog deficits and neuro (seizures, photosensitivity, hyperacusis) and psych (irritability, aggression, depression, sleep, apathy)
    • long-term or permanent disability
    • worse outcome: older >40yo, low GCS, worse motor function, pupillary nonreactivity, CT brain injury
    • mod/severe - increased risk of neurodegen diseases
  • older individuals with depleted cog reserve may experience incomplete recoveries after mild TBI

10. Treatment

  • acute
    • no safe pharm treatment
    • insufficient evidence for cooling, hyperventilation, hyperbaric O2
  • chronic
    • cog impairment
      • cog rehabilitation: strategies to minimize impact
      • progressive physical exercise
      • stimulants (methylphenidate) to improve processing speed, arousal, attention, memory
      • donepezil: memory impairment post mod/severe TBI
    • other associated symptoms
      • depression, sleep, etc

Author: Armin

Created: 2022-07-25 Mon 01:38