NorthBay Center for Neuroscience “Focus on TBI and Concussion” Essential Elements in the Evaluation and Care of the TBI and Concussion Patient May 3, 2019 Edie E. Zusman, MD, MBA Medical Director NorthBay Center for Neuroscience Chief of Neurosurgery Disclosure • Partner – Benzil Zusman, LLC – Neuroscience Strategy Consulting • World Neurosurgery Editorial Board- Section Editor • Neurosurgery – Editorial Board • Board of Directors – Epilepsy Foundation of Northern CA and Head Royce • NorthBay – Foundation Board • International Advisor, RISE Clinic Anambra , Nigeria NorthBay Neurosurgery Team • Corey Beausoleil • Kawanaa Carter • Bita Joobbani • Patrick Maloney • Saint-Aaron Morris • Phillip Parry • Atul Patel • Sherry Taylor • Edie Zusman NorthBay State of the Art Neurosurgery OR Intraoperative CT/O ARM with Computer Guidance Zeiss Pantera Microscope NorthBay Hospital – Top Technology Wellness Center – HealthSpring Fitness o State of the art Operating Rooms o NorthBay is completiing 200 million dollar expansion o Zeiss Microscopes and Endoscopes o Minimally Invasive technology o Stealth Computer Navigation o State of the art Health Fitness Center o 50,000 square foot wellness center o 4 swimming pools and jogging track o Mayo Clinic Model – One Stop Shop o Concussion Patients Seen within Days o Multidisciplinary TBI and Concussion Clinic IRB Approved Clinical Trial for Chronic TBI NorthBay Center for Neuroscience “Focus on TBI and Concussion” Welcome Honored Guests • Diana Lopez Lomeli, MA • Joanne Jacob, RN • Richard Riemer, DO • Mary Mancini, MD Thank you to our NorthBay Center for Neuroscience Team • Kelly Rhoads-Poston • Shauna Bishop • Sarah Jewel • Mechelle Levingston • Justine Zilliken • Wayne Geitz • Elnora Cameron • Aimee Brewer High Functioning Trauma Team: Peter Zopfi and Heather Venezio Neurotrauma – Current Capabilities TBI and Concussion o ACS Certified Level II Trauma Center o Helipad o Multidisciplinary TBI and ConcussionClini o Discharge Pathway/Continuum of Care o Trauma Quality and Program Meetings o Trauma CME and Educational Events o Evidence Based Best Practices o Clearance of C Spine o TBI Order Set and Pathways of Care o Building National Reputation o Tracking Metrics and Outomes Neurotrauma TBI and Concussion o TBI and Concussion Clinic to Primary Care and ED – Dr. Joshua Kuluva o Link with schools, teams broadly to extend brand/familiarity – Dr. Neil Pathare o Pediatric concussion collaborations with Oakland Children’s and NorthBay’s Dr. Michael Ginsberg o IRB Approved Clinical Trial Dr. Zusman/Omalu o Grant Opportunities – Collaboration with David Grant Military Neurosurgeons Dr. Morris and Dr. Maloney Concussion – Sports Remember the Good Old Days? Vanderbilt Sports Concussion Center 2016 Topics • Focal and Diffuse TBI • Traumatic Brain Injury Basics – Scalp/Skull • Glasgow Coma Scale • Concussion and Mild TBI • Post-Concussive Syndrome • Post -Concussive Seizures • Severe Traumatic Brain Injury – COMA • Epidural Hematoma • Subdural Hematoma – acute and chronic Traumatic Brain Injury Generalized Concussion SDH Diffuse Axonal Injury Focal EDH Contusion Skull and Scalp - Basics • Skull Fractures occur when the elastic tolerance of the bone has been exceeded (temporal areas, thinner bone) • Intracranial lesions are evident in 2/3 of skull fracture patients.. • Clean Staple actively bleeding scalp lacerations vs. pack/local dressing for delayed formal washout in ED – OK for simple non displaced skull fractures • Subgaleal Hematoma may help understand the mechanism of impact • Air Sinuses protect the brain – Think Mercedes • About 15% of skull fracture pts have a cervical spine fracture Skull Fractures – DIAGNOSE by CT HEAD Categorized by: Location: basilar skull fracture v. convexity Pattern: linear, depresssed or comminuted Infection Risk: open or closed Is there pneumocephalus? Is there a CSF leak (nose or ear)? NOTE: No role for skull xrays – go straight to CT (CT Scout is old fashioned lateral skull xray) Linear Skull Fractures • Most have minimal clinical significance • EXCEPTIONS – C rosses the Temporal Bone – Laceration of Middle Meningial Artery Associated with Epidural Hematoma – Crosses Venous Sinus - Risk of Bleeding - Risk of Thrombosis • OK for antibiotic washout and primary closure/staple in the ED Depressed Skull Fractures • Trauma was of significant force to drive a segment of skull below the level of adjacent skull. • May be open or closed • Greater than a bone thickness or 1 cm depression associated with dural laceration • Cortical lacerations higher association with post traumatic seizures • Elevate and washout open depressed skull fractures greater than 1 cm depression/skull thickiness in the OR Evaluation for Basilar Skull Fracture • Otorrhea or Rhinorrhea • Hemotympanum – decreased hearing • Bruising around the eyes – Racoon Eyes • Bruising over the mastoids – Battle Sign • Facial Nerve - flattening of face • Meningitis - Delayed NO Role for Skull XRAYS in 2017 Obtain CT HEAD for any of the above Battle Sign Raccoon Eyes Hemotympanum Basilar Skull Fractures – Management • Patients diagnosed with a basilar fracture should be admitted for observation • If bloody drainage, check for a ‘halo sign’ Most leaks resolve spontaneously within a few days • RISK of MENINGITIS– but routine treatment with antibiotics leads to superinfection/resistance – moved away from prophylactic abx • RISK of DELAYED Cranial Nerve VII palsy - due to swelling from compression, starting 2-3 days after the injury. May use steroids, obtain ENT consult ‘Halo Sign – Catch on Sterile Gauze • Collect drops of bloody drainage from the nose (rhinorrhea), or ear (otorrhea) is placed on a white tissue or cloth. Cerebrospinal fluid, if present, will separate beyond the blood. • Beta 2 Transferrin Traumatic Brain Injury • In Football alone, an estimated 10% of US college and 20% of US high school players sustain brain injuries each season. • The prevalence of long-term disability related to TBI in the U.S. is estimated at between 3 to 5 million, or approximately 1 – 2% of the population. The Glasgow Coma Scale • A neurological scale which is aimed at giving a reliable, objective way of recording the conscious state of a person for initial as well as subsequent assessment. • Was initially only used to evaluate trauma, but is now used for grading and monitoring most neurologically compromised patients. • The range of scoring is from 3 (deeply unconscious) to 15. What does it mean when you are called for a GCS of 1? GCS = Glasgow Coma Score Interpretation of GCS level Mild Brain Injury … GCS 13 - 15 Moderate … GCS 9 – 12 Severe … GCS 8 and below Expressed in the form… “GCS 9 = E2 V4 M3 in the field at 0730 and currently GCS 12 improving” PUPIL REACTIVITY – Flashlight or Pupillometer with Speed of Contraction. Mild Traumatic Brain Injury - Often benign, but carries a high risk of serious short and long-term sequela - Occurs with a head injury due to contact and/or acceleration/deceleration forces - Typically defined as ‘mild’ by a Glasgow Coma Scale (GCS) score of 13 to 15 - Concussion – neurologically normal by 24 hours Mild TBI • Because of a wide variation in outcomes in the ‘mild’ group (which includes most TBI patients), this group is further divided into “low risk”, “medium risk” and “high risk” sub-groups. • ‘Low risk’ = GCS 15 and NO Hx of LOC, amnesia, vomiting or diffuse headache. • ‘Medium risk’ = GCS 15, but with a + hx of LOC, amnesia, vomiting or diffuse headache. These pts have a 1-3% risk of having an intracranial hematoma requiring surgical evacuation. Option to CT or observe. Check TOX • The ‘high risk’ mild head-injury patients are those with a GCS of 14 or 15 with neurological deficits. • About 10% of these ‘high risk group’ patients will require surgical evacuation of intracranial hematomas. • Patients with a coagulopathy, drug or alcohol consumption, previous neurosurgical procedures, epilepsy, or age greater than 60 years are included in the high-risk group. • CT IF ON BLOOD THINNERS Mild Traumatic Brain Injury • ‘Concussion’ is a term commonly used for what in the medical literature is now termed ‘mild traumatic brain injury’ (MTBI) • The American Academy of Neurology defines concussion as “a trauma-induced alteration in mental status that may or may not involve loss of consciousness” • Length of Anterograde Amnesia – acquisition of new memories Mechanism • The CSF cushions the brain from light trauma • In times of more severe impact, the forces on the brain may be linear, angular, or rotational • In rotational movement, the head turns around its center of gravity – this is the primary mechanism causing concussion • There is a transient electro-physiologic dysfunction of the reticular activating system in the upper midbrain caused by rotation of the cerebral hemispheres on the fixed brainstem Symptoms of Mild TBI • Feeling dazed or star struck, often after a blunt forward impact that caused sudden deceleration of the cranium and a movement of the brain within the skull. • Retrograde Amnesia - if only a few moments of unresponsiveness is reported, then the amnesia will only last for a brief time. It will respond quickly once the patient is alert. • The memory loss can vary from only moments before the injury, to even several weeks prior to the trauma (retrograde amnesia). Again, this lasts longer, the more severe the injury. • Anterograde amnesia - This is the inability to form new memories. Ask do you remember the injury and what is the first thing you remember after the injury? Symptoms: • Dizziness