1. Traumatic Brain Injuries: Pathophysiology, Treatment and Prevention

4. Mechanisms of Injury Traumatic Brain Injury Blunt(Closed) Penetrating Explosion Fall GSW Stab Blast Fragment Motor vehicle crashes (MVC)

5. Traumatic Brain Injury Description GCS = Glasgow Coma Scale LOC = Loss of consciousness PTA = Posttraumatic amnesia >7 days >24 hrs. 3 – 8 Severe > 24 hrs. - <7days 1 – 24 hrs. 9 – 12 Moderate <24 hr <20 min-1 hr 13 – 15 Mild PTA LOC GCS Severity

7. Relative Proportion of Levels of Care for TBI Source: CDC: Traumatic Brain Injury in the United States, October 2004 50,000 Deaths 235,000 Hospitalizations 1,111,000 Emergency Department Visits ??? Other Medical Care or No Care

8. Head Injury in the U.S. Military Ommaya AK, Ommaya AK, Dannenberg AL, Salazar AM. Causation, incidence, and costs of traumatic brain injury in the U.S. Military Medical System. J Trauma . 1996

9. Traumatic Brain Injury (TBI) Epidemiology: Incidence From D. Hovda, UCLA BIRC Program (modified from Kraus JF, et. al. 1996 and Durkin MS, et. al. 1998) Age (years) Incidence (cases/100,000)

10. Incidence of TBI-Related Hospitalizations Among Active Duty US Army Personnel ( Ivins, et al, Neuroepidemiology, 2006)

11. Mechanisms of Injury Diffuse Axonal Contra coup Penetrating Gun Shot Wound From the Centre for Neuro Skills

19. Brain-Behavior Relationships and Regional Cortical Vulnerability to TBI Figure adapted from Arciniegas and Beresford 2001) Dorsolateral prefrontal cortex (executive function, including sustained and complex attention, memory retrieval, abstraction, judgement, insight, problem solving) Amygdala (emotional learning and conditioning, including fear/anxiety) Anterior temporal cortex (memory retrieval, sensory-limbic integration) Ventral brainstem (arousal, ascending activation of diencephalic, subcortical, and cortical structures) Hippocampal-Entorhinal Complex (declarative memory) Viewed on coronal MRI Orbitofrontal cortex (emotional and social responding) (

23. fMRI study of MTBI and Memory (McAllister, et al, 2000)

24. Neurometabolic Changes and Concussion (Hovda et al, 1998)

25. Simple Reaction Time Warden D, Bleiberg J, Cameron K, et al, Neurology , 2001 Baseline 1 hour post 4 days post p < 0.05

26. Concussion:Time to Recovery Bleiberg J., et al. Neurosurgery, 2004.

29. WRAMC TBI Screening Flow Chart Involved in/exposed to/experienced: Blast, vehicular crash, fall, GSW to head/face and/or neck, (including superficial wounds): Yes TBI Symptom Screening/Interview: Any LOC, AOC, PTA and symptoms endorsed on the Post Concussive Symptom Checklist Cognitive, physical, and/or emotional symptoms or findings thought to be due to TBI Cognitive, physical, and/or emotional symtoms or findings thought to be due to PTSD or other psychiatric disorder Medical Evaluation Yes Note: Both may be present at this level

32. Military Context

33. Blast Wave Physics Courtesy of Keith Prusaczyk, Ph.D.

40. Questions?