TBI and Stroke:
What is the Same? What is
Different?
Carol Ann Smith, RN, CNRNProgram Coordinator - Traumatic Brain Injury Center
Donna Lindsay, MN, RN, SCRNProgram Coordinator - Hennepin Stroke Center
Objectives
At the end of this presentation the learner will be able to: Define traumatic brain injury (TBI) and
stroke Describe similarities in TBI and stroke
neurological & functional impairments Identify differences in TBI and stroke
prevention
Definition
TBI and Stroke are both types of acquired brain
injury
Acquired brain injury is damage to the brain that occurs after birth
The two main types of acquired brain injury are: Traumatic brain injury▪ Direct or indirect trauma to the brain
Non-traumatic brain injury▪ Includes brain damage from stroke, brain tumors, infection, hypoxia or substance abuse
Definition
In both TBI and Stroke, brain injury is often categorized as primary or secondary
Primary brain injury occurs at the time of the initial insult to the brain (trauma, hemorrhage or infarct)
Secondary injury occurs over hours to days and involves an array of cellular processes that may be the result or independent of the primary insult Common causes of secondary brain injury are impaired
cerebral perfusion, altered brain metabolism & oxygen utilization, increased intracranial pressure, cerebral edema, seizure activity, electrolyte abnormalities and hypoxemia
Stroke Definitions
The rapid loss of brain function due to disturbance in the blood supply to the brain
Stoppage of blood flow to brain: a sudden blockage or rupture of a blood vessel in the brain
A stroke or "brain attack" occurs when a blood clot blocks an artery or a blood vessel breaks, interrupting blood flow to an area of the brain
Traumatic Brain Injury Definitions
Traumatic Brain Injury (TBI) is caused by a blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain Mild TBI ▪ a pathophysiological process affecting the brain induced by
direct or indirect biomechanical forces
▪ GCS 14-15
Severe TBI ▪ CT scan shows bleeding, bruising, shear injury, swelling
▪ Major changes in blood flow & how the brain uses oxygen
▪ Unconscious, GCS score 3-8
Stroke Statistics
Approximately 795,000 Americans suffer a stroke each year
Stroke is the 4th leading cause of death and the leading cause of serious, long-term disability in the US.
The cost of stroke in the US is approximately $28.6 billion annually.
On average in the US, every 40 seconds someonehas a stroke and every 4 minutes someone dies.
87 % of all strokes are ischemic, 10 % areintracerebral hemorrhage, and 3 % aresubarachnoid hemorrhage.
Stroke Statistics in Minnesota
Over 97,000 Minnesotans have had a stroke
Approximately 11,500 new strokes occur each year
Stroke is the 5th leading cause of death and the leading cause of long-term disability
In 2011, $414 million was spent on hospital care for stroke
TBI Statistics
According to research from CDC, approximately 3.5 million persons have a TBI in the United States each year. 2.1 million receive care in emergency departments, 300,000 are hospitalized, 84,000 are seen in outpatient departments, 1.1 million receive care from office-based
physicians, 53,000 die▪ TBI is a contributing factor to a third (30.5%) of all injury-
related deaths
An Estimated $76.5 billion in direct medical costs and indirect costs such as lost productivity due to TBI each year
5.3 million Americans living with long term disability
TBI Statistics in Minnesota 14,548 Minnesotans sustained traumatic brain
injury in 2012: (MDH - MIDAS)
10,310 were discharged from the emergency department 3.960 were hospitalized 278 died 58% male and 42% female This only counts people who present to the ED
Over 100,000 Minnesotans live with a disability as a result of a brain injury
83% of offenders entering the Minnesota prison system have a history of TBI
Non-fatal TBI in Minnesota
Types of Stroke
Ischemic Atherothrombotic Embolic Transient Ischemic
Attack
Hemorrhagic Intracerebral
Hemorrhage Subarachnoid
Hemorrhage
Types of Traumatic Brain Injury Brain injuries can be classified as:
Mild, moderate or severe▪ As determined by the Glasgow Coma Scale
Open or Closed▪ Skull fracture or no skull fracture▪ Linear, depressed, basilar▪ Penetrating wound (knife, bullet or other object)
Focal or diffuse▪ The injury is localized to one area (focal)▪ Hematoma, contusion
▪ The injury is throughout the entire brain (diffuse)▪ Concussion, shear injury
Types of TBI
ConcussionContusionEpidural HematomaSubdural Hematoma Intraparenchymal BleedSubarachnoid Hemorrhage Intraventricular HemorrhageDiffuse Axonal Injury (Shear)
What Causes Stroke?
Controllable Risk Factors High blood pressure (> 140/85 or if diabetic >
130/80)*
High cholesterol (LDL > 130 if no other risk factors, > 100 if other risk factors present)
Smoking* Atrial Fibrillation Heart Disease ( dilated cardiomyopathy, heart valve
disease, artificial heart valve, heart failure)
Carotid Artery Disease Diabetes*
What Causes Stroke?
Controllable Risk Factors (cont.) Alcohol and Substance Abuse* Physical Inactivity Sleep Apnea Clotting Disorders*
Vasculitis*
Uncontrollable Risk Factors Age (every decade over age 55 the risk of ischemic stroke doubles)
Gender (men are at slightly higher risk) Race/Ethnicity* Family History* Vascular Abnormality*
* Risk factor for both hemorrhagic and ischemic stroke
How Do You Prevent Stroke? It is believed that 80 – 85% of ischemic
strokes could be prevented if risk factors were identified and controlled
Challenges to stroke prevention Lack of healthcare screening (risk factors
not identified) Failure of patients to adhere to risk
reduction measures Failure of healthcare providers to
implement aggressive risk reduction measures
How Do You Get a TBI?
Etiologies: Falls (35.2%)▪ Leading cause of TBI▪ Rates highest in children 0-4 & elderly > 75
Motor Vehicle Collision (17.3%) ▪ Results in greatest # of hospitalizations▪ Rate highest in 15-19 age group
Struck by/fell against (16.5%)
How Do You Get a TBI?
Assault (10%)▪ Firearm use leading cause of death related to
TBI▪ Blasts leading cause of TBI for active duty
military personnel in a war zone
Unknown (0%) Other (7%) Bicycle/non-MV (3%) Suicide (1%
(Source CDC)
How Do You Prevent a TBI? The only known cure for brain injury is
prevention!!
Protect your brain - always wear a helmet for sports and recreational activities Purchase only consumer product safety commission (CPSC)
certified helmets Concentrate on driving - never talk on a cell phone or text while
driving Everyone buckle up every time – infant car seats, booster seats for
children under 8 or under 40 lbs, then seat belts Stay focused & have a clear mind, do not drive impaired by drugs or
alcohol Stay steady - prevent falls from ladders and steps. Never shake a baby, never Keep small children away from open/screened windows and stairs Prevent falls in the elderly
Home safety evaluations, medication & vision checks
How Do You Manage Ischemic Stroke?
Recanalization Therapy 0 – 4.5 hours after last known well
▪ IV rtPA
0 – 6 hours after last known well
▪ Mechanical Thrombectomy
▪ Intra-arterial Thrombolysis
IV rtPA 0–3 hours – Outcome Data
Favorable outcome (complete or nearly complete recovery 3 months after stroke): 50% in treated group
38% in placebo group For a favorable outcome, NNT = 8.3 For an improved outcome, NNT = 3.1
National Institute of Neurologic Disorders and Stroke (NINDS) Acute Stroke Trial - December 1995
IV rtPA 0-3 hours – Outcome Data
Symptomatic intracerebral hemorrhage▪ 6.4% in treated group
▪ 0.6% in placebo group
Mortality rate at 3 months and 1 year▪ 17% and 24% in treatment group
▪ 20% and 28% in placebo group
National Institute of Neurologic Disorders and Stroke (NINDS) Acute Stroke Trial - December 1995
IV rtPA 3-4.5 hours – Outcome Data
Favorable outcome (complete or nearly complete recovery 3 months after stroke):▪ 52.4% in treated group▪ 45.2% in placebo group▪ This is a modest but statistically
significant difference For a favorable outcome, NNT = 14 For an improved outcome, NNT = 8
European Cooperative Acute Stroke Study (ECASS - 3) - 2008
IV rtPA 3-4.5 hours – Outcome Data
Symptomatic intracerebral hemorrhage 7.9% in treated group 3.5% in placebo group
Mortality rate at 3 months 7.7% in treatment group 8.4% in placebo group
European Cooperative Acute Stroke Study (ECASS - 3) - 2008
IV rtPA – Timing of Treatment
Odds ratios for favorable outcome by time of drug initiation from onset of symptoms: 0 – 90 minutes 2.81†
91 – 180 minutes 1.55 †
181 – 270 minutes 1.3
†Alteplase Thrombolysis for Acute Non-interventional Treatment of Stroke (ATLANTIS) - IV rtPA 0.9 mg/Kg 0–5 hours from stroke onset. U.S. based, industry funded trial
Pooled data from ECASS-1, ECASS-2, ECASS-3 and ATLANTIS
Solitaire revascularization device
Image courtesy of ev3.
Mechanical Thrombectomy
Mechanical Thrombectomy
Mechanical Thrombectomy
How Do You Manage Ischemic Stroke?
Acute Stroke Treatment Minimize secondary brain injury
▪ Allow “permissive hypertension” for first 24-48 hours
▪ Maintain Normothermia
▪ Decompressive craniotomy/ICP management if edema is severe
Avoid complications (swallow screening and if needed modified diet, VTE prophylaxis, early mobilization, fall prevention)
Initiate rehabilitation therapies
Diagnostic work-up to identify cause of stroke and stroke risk factors
Implement stroke risk factor reduction measures
How Do You Manage Hemorrhagic Strokes?
Intracerebral Hemorrhage Most common type of hemorrhagic
stroke Mortality rate is 35 – 55% Emergent reversal of INR if
anticoagulated Decompressive craniotomy, hematoma
evacuation Minimize secondary brain injury (similar
to TBI) Avoid complications Initiate rehabilitation therapies
How Do You Manage Hemorrhagic Strokes?
Subarachnoid Hemorrhage (non-traumatic) Mortality rate is approximately 50% (15% die prior
to reaching medical attention)
Treat the underlying cause▪ 80% of SAH is caused by ruptured aneurysm▪ Surgical clipping or endovascular therapy
▪ 5% is caused by arteriovenous malformation▪ Endovascular therapy, radiosurgery and/or craniotomy
Prevent/manage secondary brain injury (vasospasm, hyponatremia)
Avoid complications Initiate rehabilitation therapies
How Do You Manage Hemorrhagic Strokes?
Treatment of Aneurysm - Clipping
Treatment of Aneurysm - Coiling
How Do You Manage Hemorrhagic Strokes?
Treatment of Aneurysm – Pipeline Stent
How Do You Manage Hemorrhagic Strokes?
Treatment of AVM – embolization/surgery
How Do You Manage Hemorrhagic Strokes?
Stroke Rehabilitation/Post-Acute Management
Physical and Occupational Therapy to maximize functional independence▪ Body Weight Supported Treadmill Training▪ Constraint Induced Movement Therapy▪ Functional Electrical Stimulation▪ Mirror Therapy▪ Robotic Aided Systems▪ Virtual Reality
Cognitive Therapy▪ Cognitive Re-training▪ Provide memory tools to aid in maintaining safety
Stroke Rehabilitation/Post-Acute Management
Speech Therapy for communication disorders
Dysphagia Management▪ May require long-term or permanent feeding
tube and enteral nutrition Depression Management Promote Socialization (social-isolation is
common)
Seizure Management ▪ prophylactic anticonvulsants are not
recommended
How Do You Manage Severe TBI?- For people who have a severe TBI:
Intracranial hypertension 40-50% Multiple injuries 50% Surgical mass lesion 40-50%
Mortality 30-35%
Favorable Outcome 40-45%
Transfer to Level 1 Trauma Center CDC research shows patient outcomes 25% better when
sent to a Level 1 Trauma Center
For individuals hospitalized after a TBI, almost half (43%) have a related disability one year after the injury
Management of Severe TBI(minimizing secondary injury)
Dark, quiet, low stimulus environment HOB elevated Neck midline 3% saline infusion ICP & PbtO2 monitor CSF drainage Sedation & Pain Mgmt: Propofol, Fentanyl, Ativan 23% saline bolus Normothermia Selective hypothermia Decompressive craniectomy Paralyze with Vecuronium Osmotic therapy Hyperventilation rescue therapy for acute herniation
How Do You Manage Mild TBI?
At least 75% of TBI are mild CT usually “negative” Patient usually alert and oriented Range of symptoms that may or
may not involve LOC Manage the symptoms
Definition of Mild TBI
A patient with mild traumatic brain injury is a person who has had a traumatically induced physiological disruption of brain function, as manifested by a least one of the following:
any period of loss of consciousness; Only 10% lose
consciousness any loss of memory for
events immediately before or after the accident; ▪ Anterograde and/or▪ Retrograde
focal neurological deficit(s) that may or may not be transient;
any alteration in mental state at the time of the accident (eg, feeling dazed, disoriented or confused);
but where the severity of the injury does not exceed the following: Post-traumatic amnesia (PTA)
not greater than 24 hours.
after 30 minutes, an initial Glasgow Coma Scale (GCS) of 13-15; and
loss of consciousness of approximately 30 minutes or less;
Mild TBI Symptoms
Cognitive Feeling confused Dazed, foggy Amnesia Memory impairment Trouble concentrating Trouble with math Trouble finding the right
word to say
Affective Irritability Emotionally labile Feeling anxious Feeling depressed
Somatic Headache Dizziness, vertigo Nausea Tinnitus Double or blurry vision Insomnia/sleep
disturbances, fatigue Sensory disturbances,
phono &/or photophobia
Mild TBI Management
Initial Treatment is Symptomatic: Time & Rest Treat headache Treat nausea & vomiting Dark room/sunglasses for photophobia Quiet for phonophobia and headache No sleep medication (especially Ambien) No video games, excessive TV watching, texting If it causes symptoms, don’t do it
Mild TBI Management – Sent Home from ED
Rest, especially if you have any of the symptoms listed
Do not do any physical work or exercise until your symptoms go away. Anything that causes you to sweat is too much activity.
It is recommended that you see your family doctor within 2 weeks. Do not drive until your family doctor has told you it is okay to drive.
You should not work until you have not had any symptoms for 1 week.
Mild TBI Management – Sent Home from ED
If you go back to work and your symptoms come back and don’t go away for more than a week:▪ Stop working ▪ Go home▪ Call the HCMC TBI clinic for an appointment ▪ Do not go back to work until you have seen a
TBI clinic doctor Do not use alcohol (beer, wine, hard liquor) for
at least 2 months after your TBI. Do not play any sports until you have not had
any symptoms for at least 1 month.
Mild TBI - When do you need a Comprehensive TBI Clinic?
The natural evolution of concussion is that 80% of the people will be back to their usual baseline within a month
Someone still experiencing symptoms after 4 weeks should be evaluated at a comprehensive TBI Clinic
Students should be seen at 2-3 weeks if having problems in school
Evaluation at a Comprehensive TBI Clinic
Management based on history, social situation and physical examination: Patient history & subjective complaints Review of medical records from TBI Patient Education▪ Natural History of TBI & Expectations for Recovery
Potential Referrals:▪ Neuropsychological testing▪ Speech Language Pathology▪ Occupational Therapy
▪ Vision Therapy
▪ Physical Therapy▪ Clinical Psychology▪ Therapeutic Recreation▪ Vestibular clinic
Medications for headache, nausea, sleep
TBI Rehabilitation/Post-Acute Management
Severe TBI rehab similar to stroke
Mild TBI rehab focuses on treating the symptoms. Examples include: Energy Management and Relaxation Vestibular Management▪ Balance & Coordination▪ Epley Maneuver
Neuro Visual Rehab Cognitive & Linguistic Rehab Management of headache & other somatic symptoms Working with employers & schools on accommodations
What Functional Changes Do You See After Stroke?
Physical/Somatic Hemiparesis/plegia (occasionally bilateral) Facial droop Hemi-sensory loss/alteration (numbness, paresthesia)
Visual Changes (visual field cuts, monocular blindness)
Dizziness, loss of balance Altered Gait Photo/phono sensitivity (common with SAH)*
Headache (often resolves after acute phase)
Cranial Nerve Dysfunction (with brainstem involvement)
What Functional Changes Do You See After Stroke?
Communication Disorders Dysarthria (ranges from mild to severe) Expressive Aphasia▪ Word-finding difficulty▪ Hesitant or stuttering speech pattern▪ Fluent aphasia (word salad)
Agraphia (inability to communicate in writing)
Receptive Aphasia Alexia (inability to understand written information)
What Functional Changes Do You See After Stroke?
Cognitive Altered memory (especially short-term) Slowed cognitive processing Impaired judgment Impulsivity Disinhibition/boundary issues
Affective Depression Emotional lability Sleep disorders
What Other Changes Do You See After Stroke?
Post-Stroke Seizures Approximately 12% of stroke survivors
will develop seizures within 5 years Stroke is the most common cause of
seizures in the elderlySocial Isolation
What Type of Functional Changes Do You See After TBI?
Physical/Somatic Headache Dizziness/Vertigo Weakness or paralysis Swallowing problems Visual changes Occulomotor dysfunction Tinnitus Photo/phonosensitivity Balance/coordination Sleep impairments/extreme fatigue Seizure disorder
What Type of Functional Changes Do You See After TBI?
Communication Disorders Similar to stroke, especially the expressive
aphasia and word finding difficulties
Affective/Emotional Personality changes Emotional lability/quick mood changes Disinhibition Irritability Anxiety Depression
What Type of Functional Changes Do You See After TBI?
Cognitive Amnesia Short term memory Insight Judgment Confusion Attention Concentration Processing speed
Where Do People Go After a Stroke or TBI?
Stroke TBIHome or home with assistance 51% 73%
Acute Rehabilitation 18% 11%
Long Term Acute Hospital (e.g. Bethesda) 1% 7%
Subacute Rehabilitation (SNF) 24% 6%
Questions??Contact Information
Donna Lindsay, MN, RN, CNS-BC, SCRN
Program CoordinatorHennepin Stroke Center(612) [email protected]
Carol Ann Smith, BAN, RN, CNRNProgram CoordinatorTraumatic Brain Injury Center(612) [email protected]
Hennepin County Medical Center701 Park Avenue SouthMinneapolis, MN 55415
Hennepin County Medical Center Hennepin Stroke Center
A comprehensive center of excellence providing care to patients and families who have been affected by stroke, including early treatments, acute care management, rehabilitation and research. The Stroke Center is also dedicated to increasing public awareness and education regarding stroke.
▪ www.hcmc.org/stroke▪ Joint Commission Certified Primary Stroke Center
The Traumatic Brain Injury Center - A comprehensive, multidisciplinary center of excellence for
patient care, education and research to serve people who have sustained a traumatic brain injury ▪ www.hcmc.org/braininjury▪ www.hcmc.org/prevention▪ www.savethisbrain.org
Resources
The Minnesota Stroke Association www.strokemn.org
National Stroke Association www.stroke.org
American Stroke Association www.strokeassocation.org
National Aphasia Association www.aphasia.org
Minnesota Stroke Partnership www.mnstrokepartnership.org
Resources
The MN Brain Injury Alliance www.braininjurymn.org
Brain Trauma Foundation (www.braintrauma.org) Guidelines for the Management of Severe TBI in the
Adult- 3rd Edition – Brain Trauma Foundation – May 2007
Traumatic Brain Injury: The Journey Home www.traumaticbraininjuryatoz.org
TBI Model Systems www.tbindsc.org
Resources
American Association of Neuroscience Nurses (www.aann.org)
AANN Core Curriculum for Neuroscience Nursing – 5th Edition
Clinical Practice Guidelines
▪ Care of the Patient with Mild TBI+
▪ Guide to the Care of Hospitalized Patients with Ischemic Stroke
▪ Care of the Patient with Aneurysmal Subarachnoid Hemorrhage
▪ Nursing Management of Adults with Severe Traumatic Brain Injury
▪ Care of the Patient Undergoing Intracranial Pressure Monitoring/External Ventricular Drainage or Lumbar Drainage
Webinars
Resources – MN Concussion Law Legislation on Concussion & Youth Sports signed into law June
2010 and took effect September 2011 Most comprehensive legislation in the nation
The goal of this new law is to improve the recognition and response of youth concussion injuries within all statewide youth athletic activities. This is the most comprehensive legislation in the country.
The Minnesota law applies to all players under the age of 18 and applies to ALL youth sports organizations both PUBLIC and PRIVATE. The law requires that parents have access to information on the risks and symptoms of concussions and coaches must have training on concussions once every 3 years.
The entire text of law can be seen online at the MN Legislature website https://www.revisor.mn.gov/laws Chapter 90, Senate File 612.
Resources
BrainLineMilitary.org a new online service to help service members — Army, Navy, Air Force,
Marines, National Guard, and Reserve —and veterans with brain injury and their families.
The Clinical Practice of Neurological and Neurosurgical Nursing – Joanne Hickey
Consensus Statement on Concussion in Sport 3rd International Conference on Concussion in Sport – Zurich – November 2008 – McCory P., et al. Clin J Sport Med 2009;19:185-200
“Guidelines for the Acute Medical Management of Severe TBI in Infants, Children and Adolescents”, a supplement to Pediatric Critical Care Medicine - July 2003
Resources
MN State Law Concussion Training for Coaches: Information on the education for coaches can be found at
the Centers for Disease Control and Prevention http://www.cdc.gov/concussion/HeadsUp/high_school.html
and their new National Center for Injury Prevention and Control website http://www.nfhslearn.com/electiveDetail.aspx?courseID=15000
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