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) 873-8712Donna.Lindsay@hcmed.org

Carol Ann Smith, BAN, RN, CNRNProgram CoordinatorTraumatic Brain Injury Center(612) 873-3284Carolann.smith@hcmed.org

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