Congenital and acquired brain injury
Congenital and Acquired Brain Injury. 1. Epidemiology, Pathophysiology, Prognostication, Innovative Treatments, and Prevention

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Abstract

Brown AW, Elovic EP, Kothari S, Flanagan SR. Kwasnica C. Congenital and acquired brain injury. 1. Epidemiology, pathophysiology, prognostication, innovative treatments, and prevention.

This self-directed learning module reviews the current epidemiology of traumatic brain injury (TBI), its pathophysiology, prognostication after injury, currently available innovative early approaches to diagnosis and treatment, and effective methods of prevention. It is intended to provide the rehabilitation clinician with current knowledge to accurately inform patients, families, significant others, referring physicians, and payers and to aid in clinical decision making while caring for patients after TBI.

Overall Article Objective

To describe current knowledge in traumatic brain injury epidemiology, pathophysiology, prognostication, acute treatment, and prevention.

Section snippets

1.1 Educational Activity: To discuss the public health implications of traumatic brain injury epidemiology and its effect on the local community

BRAIN TRAUMA HAS A dramatic social and economic impact on our society. This review provides the context to inform clinical discussions with patients, families, significant others, health care providers, and payers regarding the current epidemiology of traumatic brain injury (TBI) in the United States.

Incidence

The most recent estimates indicate that 1,565,000 people experienced TBI in 2003 in the United States, a rate of 538.2 per 100,000 population.1 Of these injuries, approximately 78% were treated in an emergency department and not hospitalized, 19% were hospitalized, and for 3% the injury was fatal. The overall incidence rate has been stable since 1998,1 although reported rates underestimate incidence because the reporting of mild injury is incomplete. The estimates reported below are based on

Prevalence

Although the majority of injuries are mild and cause no lasting impairment, TBI of any severity can lead to significant long-term disability. It is estimated that as many as 5.3 million people are living in the United States with disability related to TBI, approximately 2% of the population.4 This compares with the estimated United States breast cancer prevalence of 2.3 million and multiple sclerosis prevalence of 400,000.

Severity

Among persons surviving TBI, the vast majority will experience a mild injury, with almost 90% of all injuries categorized as mild in population-based estimates.3 Even for those hospitalized after TBI, state surveillance reports have estimated 75% of hospital discharges were mild based on the Glasgow Coma Scale (GCS) score (initial GCS score of ≥13).5

Age

In 2003, overall rates of TBI were highest in the very young (age group of 0−4y, 1188.5/100,000) followed by adolescents (age group of 15−24y, 917.5/100,000) and the elderly (age group >65y, 524.3/100,000). Injury rates were lowest for the age group 45 to 64 years (327.3/100,000).

Survival

For people surviving TBI for 6 months, 10-year life span does not appear to be shortened compared with the general population, indicating that these people will age with any acquired activity-limiting impairment along with their noninjured peers.3 However, additional long-term mortality has been shown in a subpopulation of persons who survive moderate to severe injury and receive inpatient rehabilitation.6

Mechanism of Injury

Injury related to falls has been the leading cause of medically attended TBI for over a decade, with estimated average annual incidence rates greatest for 2 groups: those aged 0 to 4 years (594.2/100,000) and those older than 75 years (359.8/100,000).7 Incidence rates for injuries related to motor vehicles and traffic (273.1/100,000) and assaults (125.9/100,000) are highest among adolescents age 15 to 19 years. In the United States in 2003, 32% of TBIs were caused by falls, 19% by motor vehicle

Other Demographic Factors

The risk of TBI for men is still almost twice that for women. American Indian, Alaskan Native, and black men are at highest risk, whereas female members of those same ethnic groups are at the lowest risk. Alcohol intoxication is estimated to be associated with TBI-related hospitalizations greater than 12% of the time, and an estimated 40% to 50% of transportation-related TBIs occur in the absence of personal protective equipment.5

Economic Impact

The total economic impact of TBI in the United States in 2000 was estimated to be $60.434 billion: $9.222 billion in lifetime medical costs and $51.212 billion in productivity losses. Although TBI ranked eighth out of 9 body regions in injury incidence rate, the estimated medical costs per injury were $14,809, second only to spinal cord injury ($56,080 per injury) and far greater than the next most costly body region (lower limb, $2085 per injury).8

Among injuries, it is clear that brain trauma

1.2 Clinical Activity: To counsel the family members of your 17-year-old male patient who has sustained TBI about the need for preventing reinjury and to develop prevention strategies for the entire family

Prevention efforts can be classified into 1 of 4 areas: passive, active, educational, and legislative.9 Passive activities include those in which no direct action is required by the potentially injured host. These include areas such as road safety engineering and airbags. It is in the area of active strategies (eg, using seatbelts and motorcycle helmets, not driving while intoxicated) where family members may most benefit from clinician input.

Transportation-Related Injury Prevention

The majority of hospitalizations resulting from TBI are caused by transportation-related events.4, 9, 10 Prevention efforts contributed to a reduction in the incidence of TBI-related motor vehicle crash (MVC) deaths by 38% between 1980 and 1994, and fatality rates per 100 million passenger miles traveled dropped from 4.6 in 1970 to 2.3 by 1989.10 Both active and passive strategies played a role in this decline. These strategies include airbags, the use of seatbelts, raising the legal drinking

Drugs and Alcohol

Alcohol is perhaps the most important risk factor for sustaining a TBI. More than 50% of people sustaining TBI are intoxicated at the time of injury. A person has twice the risk of a repeat trauma admission within 2 years if he/she is intoxicated at the time of the initial injury. Raising the legal drinking age and lowering the acceptable blood alcohol level for driving have led to a reduction in alcohol-related MVCs.9 One third of all teenagers report they would drive with a friend who had

Falls

Falls are the second most common cause of TBI requiring hospitalization.9 In the pediatric population, falls account for 9% of the total trauma related deaths,13 and 41% of hospital admissions.14 For persons over 75 years of age, falls are the most common cause of trauma-related death. Fall-prevention efforts can be very effective in reducing risk. Installation of window guards resulted in a 96% decrease in falls from windows.13 Playground-related falls can also be effectively reduced by

1.3 Educational Activity: To discuss the approach to prognosis for a patient recently admitted to inpatient rehabilitation 1 month after a severe TBI

Information about prognosis has been identified by families as one of their most important needs after a TBI. Unfortunately, it is a need that often goes unmet. One reason for this is the difficulties that TBI clinicians encounter in trying to extract useful guidelines from the extensive scientific literature published on this topic. Recently, a comprehensive, evidence-based review16 was performed with the aim of deriving empirically supported, clinically useful guidelines for prognostication

1.4 Educational Activity: To discuss the potential pathophysiologic features that explain why an 18-year-old patient remains unresponsive 1 week after TBI in the presence of a normal CT

Pathologic changes after TBI can be divided into broad categories: focal versus diffuse and primary versus secondary. Focal injuries involve an injury to a localized region of the brain, whereas diffuse injuries are more widely dispersed. Primary injuries occur at the time of impact, whereas secondary injuries occur at some time after the initial blow to the head and may possibly be avoided or minimized by treatment.

Focal injuries include cerebral contusions, localized hemorrhages, and focal

1.5 Educational Activity: To participate in developing the guidelines and options for using innovative treatments in the early management of TBI for your local city health department

The early management of TBI begins at the scene of the injury. First responders must understand the signs of TBI so patients can be transported to appropriate centers to receive state-of-the-art care. In a recent study22 of an organized state trauma system, direct transport to a trauma center resulted in significantly lower mortality than indirect transport. Transport mode, air versus ground, and time to admission were not related to mortality, a finding that supports current management

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