Neuropsychological Disorders & Traumatic Brain Injury: Causes, Symptoms & Consequences, Exams of Nursing

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• Glasgow Coma Scale (GCS) 3- Severe TBI; normal or abnormal structural imaging. LOC over 24 hours, post traumatic amnesia over 7 days -
• Glasgow Coma Scale 9 Moderate TBI; LOC over 30 minutes but less than 24 hours; alteration of consciousness over 24 hours, post traumatic amnesia more than 1 day but less than 7 days
• Glasgow Coma Scale 13- Mild TBI; normal imaging; LOC 0-30 minutes, alteration of consciousness up to 24 hours, post traumatic amnesia up to 1 day
• 3 parts of neuron Cell body Axon Dendrites
• 2.5 million TBIs 53,000 deaths (2%) 284,000 hospitalizations (11%) 2,214,000 ED visits (87%)
• Coup-contrecoup When the brain accelerates in one directions, it rebounds in the opposite direction * Acquired Brain Injury An injury to the brain that is not hereditary, congenital, degenerative or induced by birth trauma
• Traumatic Brain Injury An alteration of brain function or other evidence of brain pathology caused by an external force
• Incidence Rate or range of occurrence
• Prevalence Number of people with a given condition at a specific point in time * What determines the effects of brain injury?

Injury severity Age at injury Alcohol misuse Domestic violence Service in military Participation in sports

• Concussion Mild TBI caused by bump, blow or jolt to head that can change the way the brain works (or a fall) Can occur in any sport or recreation activity Memory loss May or may not lose consciousness 00:0201:
• 2.5 million people sustained TBI in 2010 ...
• Brain Stem Top of spinal column Central point for all incoming and outgoing information and basic life functions
• Limbic System Emotions and basic feelings
• Frontal Lobe Damage Executive function/personality Lack of control of behaviors, poor short term memory and working memory
• Broca's Area Located in lower portion of motor cortex (left frontal-temporal lobe) Expression- production of speech
• Wernicke's Area Located in left temporal parietal area Receptive- understanding of speech
• Risk of TBI after first injury 3x greater for 2nd injury
• Risk of TBI after second injury 8x greater for 3rd injury
• Alcohol and TBI 37%-51% of brain injuries 22% of drivers aged 15-20 involved in fatal MVAs had been drinking 56% not wearing seat belts
• Neurons Communicating cells
• Frontal Lobe Primary motor cortex and prefrontal cortex Planning, organizing, problem solving, judgment, impulse control, decision

making, working memory, emotional control, motivation, verbal expression * Occipital Lobe Visual stimuli processing Brain Injury in Prisons 2 million people in prisons have a brain injury not recognized, diagnosed or treated Female inmates convicted of violent crime are more likely to have sustained a pre crime TBI or other form of physical abuse Lost Productivity Loss of earning potential, payment of taxes and the re-investment of earnings into the economy Neurogenic Bladder Affected cerebral structures that control bladder storage and emptying functions Incontinence Spasticity Increase in muscle tone resulting in abnormal motor patterns Faster stretch = stronger spasm Monitor for sedating effects of meds Dura Mater Outer layer of meninges; heavy covering Bleed in this area: subdural hematoma Arachnoid Layer 2nd layer of meninges; similar to spider web Bleed in this area: subdural hematoma Pia Mater 3rd layer of meninges; molds around sulci and gyri of brain Synapse Junction between cells Action Potential Electrical impulse fired Brain stem areas Medulla Pons Midbrain Cerebellum Lower back section of brain Coordinates, modulates and stores all body movement Occipital Lobes Primary visual center Visual cortex connected to eyes by optic nerves Interprets visual info (recognize size, color, light, motion, dimensions) Occipital Lobe Damage

Visual-pereptual-motoric distortions Neuroplasticity Brain can adapt and reorganize due to environment around it or due to cell death Nervous system changes itself, forms new connections and creates new neurons to compensate for injury or adapt to changes in environment Restorative approach Polytherapies The use of more than one treatment method in a combined therapeutic approach; may provide better results Plasticity A change in the expression of genes or proteins related to neuroplasticity Constraint Induced Movement Therapy Contrain unaffected limb for first 2 weeks post injury, plasticity in cortex opposite stroke is eliminated Encourages greater use of impaired limb Axonal Shearing Axons are twisted and disconnected; functional abilities diminished Tension type Headache

Bilateral head pain; tight hat or vice clamping around head Tx with NSAIDs and low load craniocervical mobilization Cervicogenic Headache Head pain generated from cervical spine Can provoke headache through movement or manipulation of neck Tx with manual therapies or nerve injections Post-traumatic Migraine Episodes of headaches with different phases Prodrome-> aura -> headache -> post drome Typically unilateral, throbbing, stabbing or sharp pain Tx with triptans, NSAIDs, dark room, quiet environment Neuralgia Pain caused by damage to nerve or structural change in nerve Standard Precautions Hand hygiene, PPE, respiratory hygiene, safe injection and disposal of sharps, cleansing of equipment, isiolation Awareness An individual's ability to receive and process information and use that information to relate to an intentional way to the outside world Regulated by higher cortical areas in cerebrum Costs of Brain Injury Lost productivity Insufficient or inappropriate diagnosis, treatment and care CDC Centers for Disease Control Carries out projects to reduce the incidence of TBI Brain Injury is a silent epidemic Person looks normal Under diagnoses, unreported Problems at work/school, changes in personal relationships, legal problems, homelessness Public Funding of TBI Medicaid Medicare Patient Protection and Affordable Care Act 2010 Axon Transmits signals electrochemically from one cell body to another Dendrite Receives information at the synapse from other neurons Synaptic Gap Between axon and other neuron's dendrite (neurotransmitters come here)

2 parts of diencephalon Thalamus Hypothalamus Excitotoxicity Neuron is no longer able to maintain resting potential as a result of impairment of sodium and potassium pump in combination with large scale increases in extracellular excitatory neurotransmitters Neurons fire repeatedly Apoptosis Programmed cell death; increases of free radical production mTBI (mild) 75% of TBIs (1.1 million persons) Traumatically induced physiologic disruption of brain function.. any period of loss of consciousness, any loss of memory, any alteration in mental state at time of incident Normal brain structure on CT or MRI GCS 13- Anticoagulants Clotting, stroke risk Coumadin, heparin, lovenox Fall risk and skin integrity issues Coma No arousal/eye opening No behavioral signs of awareness Impaired spontaneous breathing Impaired brainstem reflexes No vocalizations > 1 hour 2-4 weeks Vegetative State Months to years long Arousal/spontaneous or stimulus induced eye opening No behavioral signs of awareness Preserved spontaneous breathing Preserved brainstem reflexes No purposeful behaviors No language production/comprehension Preservation (partial or complete) of hypothalamic and brainstem autonomic functions May grimace to pain, localize to sounds inconsistently Disinhibition Engaging in behaviors on impulse without reflecting on potential future consequences

Increased lability, social inappropriateness, depression, apathy Fatigue mTBI Common symptom Mental exertion not physical Altered sleep pattern Limit overall activity for 2-4 weeks Vision Changes mTBI Impaired motor control-> blurred vision Convergence insufficiency -> cannot focus Orthostatic Hypotension Drop in blood pressure upon standing Change in balance Benign Paroxysmal Positional Vertigo (BPPV) Vestibular disorder Inner ear and visual/spatial and proprioceptive centers Nystagmus Epley maneuver to correct Sleep Disturbance Management Sleep hygiene education: proper sleep ritual, bedroom environment, diet Neuropsychologists Assess cognitive and psychological functioning EI: education and reassurance Make recommendations for therapies for improved tx Monitor return to work or school Treat emotional problems The management and treatment of mTBI is a serious matter that requires a well rounded diagnostic and treatment approach. A concussion creates changes to the chemical and physical structures of brain which should be monitored to ensure full recovery. Review any lingering symptoms. ... Intrathecal Baclofen (ITB) Severe spasticity Used only when there is a poor response to oral meds Works at level of spine to inhibit excitatory activity at spinal reflexes Pump considered after 1 year Botox Injected into muscles and used to treat increased muscle stiffness (elbow, wrist, fingers typically) Contractures

Fixed loss of PROM of joint due to pathology of connective tissue, tendons, ligaments, muscles, joint capsules and cartilage Early mobilization, ROM, positioning, orthotics Heterotopic Ossification Formation of new bone around joints Decreased ROM, increased spasticity, increased pain Commonly occurs on side where spasticity is worse Obesity following TBI During initial recovery and poor nutritional state weight gain is the goal Decreased mobility; unable to burn off calories Weight gain can cause poor fitting equipment Atrophy Due to time without use Decrease in muscle bulk

Ataxia Caused by injury to cerebellum Lack of muscle coordination during voluntary movements Movement Dysfunction Bed mobility Transfers Gait Balance Athetoid Writhing movements Dystonia Extreme tone or stiffness limiting movement Repetitive movements or abnormal posture Tremors Unpredictable movements with motion or at rest Visual Acuity Clarity of vision Test with Snellen eye chart Eye Movements Tracking for ROM-> follow moving object Saccades -> fast eye movements from one object to another Smooth pursuits -> follow slow moving target Fixation -> hold gaze steady on target Visual Fields Zone of vision forward, central and peripheral visual fields Binocular Vision How eyes are working together Deficits can cause double vision Vergence Pulling eyes in close for near work Unilateral Neglect Not integrating or registering stimuli from one side of body or environment Anosognosia Inability to recognize deficits or problem circumstances caused by neurological injury Somatoagnosia Lack of awareness of body structure and body part relationships Ideomotor Apraxia Inability to perform a task on command or imitate gestures Unable to blow out candle on command, can blow out when presented with lit candle Ideational Apraxia Inability to perform tasks automatically and on command Vestibular Dysfunction

Dizziness, loss of balance Rarely exists in isolation: visual, perceptual, vestibular, and somatosensory symptoms combined Concomitant SCI Cooccurring SCI with brain injury 60% Complete SCI No motor or sensory function below level of injury Incomplete SCI Functioning of sensory and possibly some or much motor sensation below level of injury Pressure Sores Impaired sensation Decreased ability to reposition Perform skin checks frequently-especially bony prominences Hyperreflexia Involuntary increase in muscle tone and exaggerated deep tendon reflexes Osteoporosis Diminished levels of estrogen and testosterone Vulnerable to falls and injuries Incontinence Presence of bilateral central lesions Damage to pedundal nerve and sacral nerve roots UTI Occur early and late post injury Cognitive or behavioral changes Maintain hydration, timed voiding Dysphagia Impaired motor control, weakness of facial, masticatory, pharyngeal or laryngoesphogeal muscles, dyscoordination with breathing and muscle function and changes in sensation MBS ordered Frazier Free Water Protocol Dysphagia patients Use of water with minimal risk of aspiration Requires stringent oral care and oral suction Dysphagia Food Levels Pureed Mechanically altered Advanced Regular diet Dysphagia Liquid Levels Thin Nectar

Honey Spoon/pudding Complications of Reproductive System Changes in libido, arousal and sexual performance Hormonal changes Limited ability to utilize oral contraceptives Reasons for Skin Breakdown Dependence for repositioning Physical restlessness and associated shearing Bowel and bladder incontinence Splint pressure Bowel/Bladder Dysfunction Incontinence Constipation Bowel irregularities Discomfort Infections with stool or UTIs Hygiene and skin issues Goal Setting of Persons with Disorders of Consciousness Based on responses to stimuli, tolerance for stimuli/activity, risk management, caregiver development Person unable to participate in goal setting and passive participate in therapeutic activity Person does not have volitional control over responses or functioning Goals for Physical Management ROM Orthotics Upright positioning: maintain bone density, normalize body function, increase alertness Bed positioning Fatigue The awareness of a decreased capacity for physical and/or mental activity due to an imbalance in the availability, utilization, and/or restoration of resources needed to perform activity Physical: muscle weakness or other changes or injuries in peripheral nervous system Physiological: depletion of energy, hormones, neurotransmitters or a reduced number of neural connections Anxiety, depression, pain Sleep Disturbance Following TBI 30-80% of individuals with TBI Changes in REM sleep Excessive day time sleepiness

Circadian rhythm disorders Treatment of Sleep Disturbances Regulate lifestyle (decreased work, modify demands, rest breaks) Physical conditioning programs Sleep hygiene techniques Pharmacological interventions (not longterm tx) Narcolepsy Repeated episodes of naps or lapses into sleep of short duration usually less than one hour Post-traumatic Hypersomnia Excessive sleepiness that occurs as a result of a traumatic event involving CNS

Insomnia Difficulty falling asleep, frequent awakenings with difficulty falling back to sleep (> minutes) and a feeling of daytime fatigue or difficulty getting through day Selective Attention Maintain attention in presence of competing distractors Alternating Attention Shift focus between tasks Divided Attention Respond simultaneously to multiple task demands while maintaining speed and accurracy Short term Memory Immediate recall of info lasting a few seconds or minutes Long term Memory Permanent consolidation and storage of info lasting a lifetime Processing Speed Speed at which info is processed Metacognition Self awareness and knowledge of one's strengths and weaknesses Apraxia of Speech Oral motor speech disorder in which a person cannot translate what they want to say into motor plans to initiate speech Dysarthria Speech disorder in which muscle weakness affects speech production Private funding of Treatment for TBI Auto insurance Worker's compensation Commercial health insurance Funding of TBI Private Public (medicaid) Home and community based waiver program Employment support Alzheimer's Disease Any history of head injury doubles chances of developing dementia Psychiatric Disease and TBI OCD Anxiety disorder Psychotic disorder Mood disorder Major depression

Private funding of TBI Auto insurance Workers compensation Commercial health insurance Meninges Membranes covering the brain Dura mater Arachnoid layer Pia mater Neurotransmitters Chemical messengers Interconnections of the brain Every behavior depends on the interconnectedness Related to memories (sights, sound, smell) Central Cord Syndrome Caused by neck hyperextension Weakness and numbness in UEs vs LEs Frequently includes bowel and bladder incontinence Neuroprotective Compound or Strategy Limits neuronal death following injury and enhances recovery of function Drug therapies, nutritional supplements, hypothermia, cellular transplants, gene therapies Experience Dependent Learning Behavior (Experience) -> Synaptic Change -> Motor map (reorganization) Neurogenesis Formation of new neurons Intracortical Microstimulation Electrodes placed on motor cortex, stimulate, examine behavioral responses Transcranial Magnetic Stimulation Noninvasive method of stimulating brain using electromagnetic induction Depression, CVAs, migraines, dystonia, tinnitus, Parkinson's Metabolic Alterations Adverse chemical changes in brain Second Impact Syndrome Return to play while neurologically at risk/symptoms haven't resolved Possibly fatal or result in severe disability Under age 24 more at risk

Headache Post traumatic headache: within 14 days of loss of consciousness Primary headache: no specific cause Secondary headache: identifiable cause Chronic headache: occurs at least 14 days/month for at least 3 months Craniomandibular Headache Subtype of tension headache Difficulty eating/talking Tx with bite blocks, dietary changes, surgery Neuroma Nerve becomes entrapped in scar tissue CNS Stimulants Attention Ritalin, adderall, provigil Irritability, mania, agitation, seizures, weight loss SSRIs, SNRIs, Tricyclics Depression Zoloft, paxil, prozac, cymabital, elavil, wellbutrin Headache, altered mental state, sweating, fever Anti-cholingerics and Cholingerics Bladder Enablex, ditripan, urecholine Increased urgency, falls, confusion, constipation Alpha blockers, Infection suppressant, laxatives, stool softeners, suppositories and enemas UTI prevention and bowel Flomax, cranberry tablets, miralax, colace Fall risk, constipation, bowel obstruction GI meds (motility) Promotes motility, slows motility Reglan, lomodil, pepito bismol Tardive dyskinesia, movement disorders GI meds (appetite stimulant/acid production) GI Nexium, pepcid, prilosec, marinol, megace Tardive dyskinsia, movement disorder Behavioral/Emotional Symptoms mTBI Depression, anxiety, agitation, irritability, aggression, impulsivity Headaches mTBI Typically worsen with increased physical and mental exertion

Meds commonly used are avoided secondary to restricting blood flow (prevents healing) Chronic Traumatic Encephalopathy (CTE) Rare, progressive, degenerative condition of CNS Seen in repetitive brain trauma (multiple concussions) Can develop ALS Diffuse axonal injury-relase of Tau proteins creating a chronic inflammatory statue Deterioration in concentration, attention, memory, judgment, insight Dizziness and headaches Apathy, impulsiveness, suicidal thoughts Cardiopulmonary and Vascular Complications of Brain Injury Direct damage to organ, complications from trauma or trauma care, damage to parts of brain that control function Tracheostomy, risk of aspiration, BP issues Cranial Nerve Dysfunction

Visual disturbances Facial drooping Postural instability Dysphagia Autonomic dysregulation Neuropathy Weakness resulting from injury to peripheral nerve Nutritional Management of TBI Metabolic needs increase as body works to heal brain At least 40% more calories Infections Invasion of body tissues by disease causing microorganisms Open wounds, indwelling devices, immuno-suppressed Meningitis, respiratory infections, UTIs, surgical sites, cellulitis Periodic Limb Movement Disorder Periodic episodes of repetitive and highly stereotyped limb movements that occur during sleep (usually leg) Minimally Conscious State Months to years long Arousal/spontaneous eye opening Fluctuating but re-produceable behavioral signs of awareness Response to verbal directive Environmentally contingent smiling or crying Object localization/manipulation Sustained visual function and pursuit Verbalization Intentional but unreliable communication Emergence: functional communication, functional object use Respiratory Concerns Tracheostomy tube Sleep apnea (decreased muscle tone or nervous system injury) Tracheal aspiration Neurobehavioral Assessment Designed to capture a broad range of responses to sensory input and to provide rater with quantifiable findings (establish level of consciousness, caregiver education, outcome prediction, identify most effective targets for treatment) Measurement of Fatigue Quantify fatigue levels, assess subjective distress and measure impact on performance of daily activities Primary fatigue Results directly from injury or disease Secondary Fatigue Factors that exacerbate fatigue (pain, sleep disturbance, stress)

Sleep Apnea Syndromes Repetitive episodes of upper airway obstruction that occur during sleep (obstructive) or characterized by the decreasing or stopping of breaths during sleep (central) Sustained Attention Maintain attention to complete a task accurately and efficiently over a period of time Object/Experience Categorization Identifying objects or experiences based on prior experiences and perceptual features Working Memory Temporary storage and manipulation of info Procedural Memory Allows people to remember how to tie shoes (muscle memory) Long term implicit memory Negative Punishment Removal of stimulus Decreased likelihood that the response will occur again Positive Punishment Addition of a stimulus Decreases likelihood that the response will occur again Reinforcement Any process that increases likelihood that will occur again in future Negative Reinforcement Removal of stimulus Increased likelihood of response Positive Reinforcement Addition of stimulus Increases likelihood of response Focus with this approach Extinction A particular response never produces a reinforcer Disappearance of a previously learned behavior when the behavior is no longer reinforced Task Analysis List of very specific steps involved in completing a task Prompting and Cueing A process by which an individual is supported to display a correct response Visual, audible, tactile, environmental Fading Process by which one learns to produce the same response under gradually changing conditions Provide gradually less support from environment or another individual Generalization When an organism responds similarly to different/untrained stimuli or situations Restraint and Seclusion

Last resort Only when individual or others are in imminent danger Highly regulated Risk of injury Person performing can be held accountable Always followed by medical attention, debriefing and formal documentation Neuropsychology Focus on how behaviors and the nervous system interact Neuropsychology Assessment Detailed description of abilities, strengths/weakness in areas of functioning Determine cognitive deficits Establish baseline Assist in treatment planning and make recommendations in community Record review, clinical interview, standardized tests, report and feedback Adaptability Individuals capacity to change behaviors in order to adapt to changes in internal or external environment Compensatory approach Dual Diagnosis The relationship of a set of symptoms including behaviors which are or resemble symptoms of a known psychiatric disorder and TBI Comborbidity creates additional stressors, affects long term recovery and quality of life Bipolar Affective Disorder Mood disorder Bipolar I: manic Bipolar II: depressive Cyclothymia Bipolar disorder Risk factors: behavioral swings, medication compliance, substance use Generalized Anxiety Disorder Factors: loss of independence, cognitive deficits, fear of making mistakes Feeling of fear, worry, fatigue, irritability, muscle tension, restlessness Worry about mistakes, finances, loss of control etc. Panic Attack Anxiety occurs suddenly and intensely Intense fear, pounding heart, sweating, SOB, abdominal symptoms etc. Premorbid tendency to worry leads to higher risk of anxiety disorder Those with anxiety or depression perceive their illness as far more severe Obsessive Compulsive Disorder Repetitive, ritualistic behavior so severe it becomes time consuming

Not common post TBI Cognitive Behavior Therapy may be useful Post traumatic Stress Disorder A group of symptoms following a traumatic event that may include re-experiencing the traumatic event, avoidance of stimuli, increased arousal, flashbacks Reduced awareness/amnesia following event may decrease risk of development Can be incapacitating

Substance Misuse Consumption of alcohol and illegal drugs and use of prescription drugs exceeding the prescribed amount or the use of another's prescription Substance Use Disorder Involves continued use despite health, psychological or social consequences * TBI is a contributing factor to 1/3 of all injury related deaths ...

• 75% of TBIs are concussions or other forms of mild TBI ...
• Domestic Violence and TBI 67% of women victims of domestic violence had symptoms associated with brain injury
• 5% of persons with severe brain injuries have adequate funding for long term treatment and supports ... The Olmstead Decision Supreme Court States must administer services, programs, and activities in the most integrated setting appropriate to the needs of qualified individuals with disabilities * TBI Act of 1996 To expand efforts to identify methods of preventing TBI, to expand biomedical research efforts or minimize the severity of dysfunction as a result of such an injury HRSA TBI state grant program Improve integration of services Establishment of policy Procurement of financial support TBI and Mortality 2x likely to die Life expectancy reduction of 7 years 37x more likely to die from seizures 12x from septicemia 4x from pneumonia 3x from respiratory conditions Traumatic Impact Contact Injury Closed Focal or diffuse Brain contusions, brain lacerations, intracerebral hemorrhage, diffuse axonal injury Blast related, assaults, vehicular accidents, sports accidents Traumatic Impact Contact Injury Open

Primarily focal Epidural hematomas, subdural hematoma, intracerebral hemorrhage, infections Gun shot, stabbing falls, vehicular accidents, sports accidents Skull fracture Traumatic Inertial Noncontact Injury Rotational/Angular Forces Primarily diffuse (multifocal) Diffuse axonal injury, white matter lesions, hemorrhage Falls, vehicular accidents, sports accidents Non traumatic internal insult Severe reduction in blood flow or hemorrhage due to clotting Focal or diffuse White matter lesions, hemorrhage CVA, neurotoxic poisoning, hypoxia/anoxia, ischemia, infection, tumors The Rehabilitation Act of 1973 A federal/state supported system of services which assists persons with disabilities who are pursuing meaningful careers Prohibits discrimination on disabilities in programs run by government agencies Evaluation services Job development, job placement, job coaching Glial Cells Non communicating cells which support and nourish neurons Vesicles Sacs filled with neurotransmitters Medulla Brainstem base Reflex center controlling breathing, heart rate, blood pressure, swallowing, vomiting, sneezing Injury here is life threatening Pons Brainstem Facial movements, facial sensation, hearing, coordinating eye movements Connects cerebellum and cerebral cortex Midbrain Brainstem Seeing, hearing, alertness, arousal Smallest part of brainstem

• Thalamus Diencephalon Relay station for incoming and outgoing sensory information Taste, touch, sight, hearing
• Hypothalamus Diencephalon Control center for hunger, thirst, sexual response, endocrine levels and temperature regulation Fight or flight (ANS) Sleep wake cycle, emotional responses, behavior Limbic System Components Hippocampus Amygdala Basal ganglia Hippocampus Memory functioning Limbic system Susceptible to anoxia, hypoxia Amygdala Emotional memories and reactions Aggressive responses (fight or flight) Limbic System Basal Ganglia 4 nerve cell clusters Physical movements, relays information from cerebral cortex to brainstem and cerebellum Limbic system Information Processing Right Hemisphere Holistic Visual spatial Intuitive Controls left side of body Music, art, shapes Information Processing Left Hemisphere Linear Verbal-analytic Logical Controls right side of body Speaking, reading, writing

Cerebral Cortex Right and Left Hemisphere 4 lobes: frontal, parietal, temporal, occipital lobes Highest levels of thinking, moving, acting Primary Motor Cortex Frontal lobe Curves over top of head like headband Controls voluntary movement Prefrontal Cortex Frontal lobe Executive functions Short term memory, working memory

Temporal Lobe Functions Memory Language Hearing Parietal Lobes Primary sensory cortex (somatosensory cortex) Sensation, perception (touch, temp, pain) Damage to Parietal Lobe Lack of awareness of impairment of body on affected side Difficulty identifying sensation (location, type) Anterior Cord Syndrome Loss of muscle control, pain + temp, sensation Maintain proprioception and touch sensation Posterior Cord Syndrome Maintain strength, loss of proprioception Intraoperative complications, cell death Brown Squared Syndrome One side of spinal cord is damaged Ipsilateral paralysis, loss of light touch sensation on side of lesion, loss of pain + temp on contralateral side Magnesium Trial of neuroprotective agent for TBI Involved in cellular processes (cellular respiration, protein synthesis, membrane stability, regulation of vascular tone) Progesterone Trial of neuroprotective agent for TBI Decreased cerebral edema Lower dose Nicotinomide Trial of neuroprotective agent for TBI Soluble B group vitamin Reduced injury volume, decreased glial activation, reduced blood brain barrier breach, improved motor performance, reduced behavioral impairments 6-24 hours post TBI Axonal Sprouting and Synaptogenesis When a subset of neural projections to a brain region is lost, remaining ones sprout and form new synaptic connections onto partially denervated neurons Osmolarity Edema caused with imbalances Contributes to intracranial pressures and apoptosis Implications of Seizure Increased mortality Increased morbidity