Severe TBI Symptoms

Brain injuries can range in scope from mild to severe. Traumatic brain injuries (TBI) result in
permanent neurobiological damage that can produce lifelong deficits to varying degrees. Moderate
to severe brain injuries typically refer to injuries that have the following characteristics:

 Moderate brain injury is defined as a brain injury resulting in a loss of consciousness from 20
minutes to 6 hours and a Glasgow Coma Scale of 9 to 12
 Severe brain injury is defined as a brain injury resulting in a loss of consciousness of greater than
6 hours and a Glasgow Coma Scale of 3 to 8

The impact of a moderate to severe brain injury depends on the following:

 Severity of initial injury

 Rate/completeness of physiological recovery
 Functions affected
 Meaning of dysfunction to the individual
 Resources available to aid recovery
 Areas of function not affected by TBI

The impact of a moderate to severe brain injury can include:

Cognitive deficits including difficulties with:

 Attention
 Concentration
 Distractibility
 Memory
 Speed of Processing
 Confusion
 Perseveration
 Impulsiveness
 Language Processing
 “Executive functions”

Speech and Language

 not understanding the spoken word (receptive aphasia)

 difficulty speaking and being understood (expressive aphasia)
 slurred speech
 speaking very fast or very slow
 problems reading
 problems writing

Sensory

 difficulties with interpretation of touch, temperature, movement, limb position and

fine discrimination

Perceptual

 the integration or patterning of sensory impressions into psychologically meaningful data

Vision

 partial or total loss of vision

 weakness of eye muscles and double vision (diplopia)
 blurred vision
 problems judging distance
 involuntary eye movements (nystagmus)
 intolerance of light (photophobia)

Hearing

 decrease or loss of hearing

 ringing in the ears (tinnitus)
 increased sensitivity to sounds

Smell

 loss or diminished sense of smell (anosmia)

Taste

 loss or diminished sense of taste

Seizures

 the convulsions associated with epilepsy that can be several types and can involve disruption
in consciousness, sensory perception, or motor movements

Physical Changes

 Physical paralysis/spasticity
 Chronic pain
 Control of bowel and bladder
 Sleep disorders
 Loss of stamina
 Appetite changes
 Regulation of body temperature
 Menstrual difficulties

Social-Emotional

 Dependent behaviors
 Emotional ability
 Lack of motivation
 Irritability
 Aggression
 Depression
 Disinhibition
 Denial/lack of awareness

Click below to go to the other Symptoms of TBI sections:

 Symptoms of Traumatic Brain Injury Homepage

Symptoms of TBI

The broad spectrum of Traumatic Brain Injury (TBI) symptoms and disabilities contribute to the
complexity of any TBI. The purpose of this section is to educate and empower caregivers and
survivors of traumatic brain injuries and help understand the symptoms and the symptom-grading
systems of TBI.
 Bookmark this site for the symptoms of brain injuries, the latest medical breakthroughs and brain
research, the highest quality treatment for brain damage and the nation’s best traumatic brain
injury rehabilitation centers and resource information.

This section explains:

Glasgow Coma Scale

There are a few different systems that medical practioners use to diagnose the symptoms of
Traumatic Brain Injury. This section discusses the Glasgow Coma Scale. Click on the link to find
out more information about the Ranchos Los Amigos Scale.

The Glasgow Coma Scale is based on a 15 point scale for estimating and categorizing the
outcomes of brain injury on the basis of overall social capability or dependence on others.

The test measures the motor response, verbal response and eye opening response with these
values:

I. Motor Response
6 – Obeys commands fully
5 – Localizes to noxious stimuli
4 – Withdraws from noxious stimuli
3 – Abnormal flexion, i.e. decorticate posturing
2 – Extensor response, i.e. decerebrate posturing
1 – No response

II. Verbal Response

5 – Alert and Oriented
4 – Confused, yet coherent, speech
3 – Inappropriate words and jumbled phrases consisting of words
2 – Incomprehensible sounds
1 – No sounds

III. Eye Opening

4 – Spontaneous eye opening
3 – Eyes open to speech
2 – Eyes open to pain
1 – No eye opening

The final score is determined by adding the values of I+II+III.

This number helps medical practioners categorize the four possible levels for survival, with a lower
number indicating a more severe injury and a poorer prognosis:

Mild (13-15):

 More in-depth discussion on the Mild TBI Symptoms page.

Moderate Disability (9-12):

 Loss of consciousness greater than 30 minutes

 Physical or cognitive impairments which may or may resolve
 Benefit from Rehabilitation

Severe Disability (3-8):

 Coma: unconscious state. No meaningful response, no voluntary activities

Vegetative State (Less Than 3):

 Sleep wake cycles

 Aruosal, but no interaction with environment
 No localized response to pain

Persistent Vegetative State:

 Vegetative state lasting longer than one month

Brain Death:

 No brain function
 Specific criteria needed for making this diagnosis

Information about the other tests as well as symptoms and diagnosis can be found in the following
sections:

Ranchos Los Amigos Scale

There are a few different systems that medical practitioners use to diagnose the symptoms of
Traumatic Brain Injury. This section discusses the Ranchos Los Amigos Scale. Click on the link to
find out more information about the Glasgow Coma Scale.

The Ranchos Los Amigos Scale measures the levels of awareness, cognition, behavior and
interaction with the environment.

Ranchos Los Amigos Scale

Level I: No Response
Level II: Generalized Response
Level III: Localized Response
Level IV: Confused-agitated
Level V: Confused-inappropriate
Level VI: Confused-appropriate
Level VII: Automatic-appropriate
Level VIII: Purposeful-appropriate

The following sections explain:

Mild TBI Symptoms

A traumatic brain injury (TBI) can be classified as mild if loss of consciousness and/or confusion
and disorientation is shorter than 30 minutes. While MRI and CAT scans are often normal, the
individual has cognitive problems such as headache, difficulty thinking, memory problems,
attention deficits, mood swings and frustration. These injuries are commonly overlooked. Even
though this type of TBI is called “mild”, the effect on the family and the injured person can be
devastating.

Other Names For Mild TBI

 Concussion
 Minor head trauma
 Minor TBI
 Minor brain injury
 Minor head injury

Mild Traumatic Brain Injury is:

 Most prevalent TBI

 Often missed at time of initial injury
 15% of people with mild TBI have symptoms that last one year or more.
 Defined as the result of the forceful motion of the head or impact causing a brief change in mental
status (confusion, disorientation or loss of memory) or loss of consciousness for less than 30
minutes.
 Post injury symptoms are often referred to as post concussive syndrome.

Common Symptoms of Mild TBI

 Fatigue
 Headaches
 Visual disturbances
 Memory loss
 Poor attention/concentration
 Sleep disturbances
 Dizziness/loss of balance
 Irritability-emotional disturbances
 Feelings of depression
 Seizures

Other Symptoms Associated with Mild TBI

 Nausea
 Loss of smell
 Sensitivity to light and sounds
 Mood changes
 Getting lost or confused
 Slowness in thinking

These symptoms may not be present or noticed at the time of injury. They may be delayed days
or weeks before they appear. The symptoms are often subtle and are often missed by the injured
person, family and doctors.

The person looks normal and often moves normal in spite of not feeling or thinking normal. This
makes the diagnosis easy to miss. Family and friends often notice changes in behavior before the
injured person realizes there is a problem. Frustration at work or when performing household
tasks may bring the person to seek medical care.

Diagnosis

With moderate or severe traumatic brain injury (TBI), the diagnosis is often self evident. In the
presence of other life threatening injuries, which is often the case with motor vehicle accidents,
closed head injury can be missed. The focus is on lifesaving measures.

The patient may be on a ventilator (breathing machine) and sedated and the evaluation for brain
injury will be limited until the patient is allowed to emerge from medications and mechanical
ventilation. Mild traumatic brain injury may not be diagnosed until the individual begins to have
problems in what were once easy tasks or social situations.
 Injury to specific areas of the brain will cause certain symptoms. For example, injury to the frontal
lobes will cause loss of higher cognitive functions, such as loss of inhibitions leading to
inappropriate social behavior. Injury to the cerebellum will cause loss of coordination and balance.
The brainstem controls things like breathing and heart rate, as well as arousal. An injury to this
area could inhibit any of these processes.

Methods of Diagnosis

A detailed neurological examination is important and will bring out evidence of brain injury.
Brain imaging with CAT scan, MRI, SPECT and PET scan may be useful.
Cognitive evaluation by a Neuropsychologist with formal neuropsychological testing.
Evaluations by physical, occupational and speech therapists help clarify the specific deficits of an
individual.

Click on the links below to go to other sections:

Traumatic brain injury, often referred to as TBI, is most often an acute event similar to other
injuries. That is where the similarity between traumatic brain injury and other injuries ends. One
moment the person is normal and the next moment life has abruptly changed.

In most other aspects, a traumatic brain injury is very different. Since our brain defines who we
are, the consequences of a brain injury can affect all aspects of our lives, including our personality.
A brain injury is different from a broken limb or punctured lung. An injury in these areas limit the
use of a specific part of your body, but your personality and mental abilities remain unchanged.
Most often, these body structures heal and regain their previous function.

Brain injuries do not heal like other injuries. Recovery is a functional recovery, based on
mechanisms that remain uncertain. No two brain injuries are alike and the consequence of two
similar injuries may be very different. Symptoms may appear right away or may not be present for
days or weeks after the injury.

One of the consequences of brain injury is that the person often does not realize that a brain injury
has occurred.

This section explains:

 Understanding TBI Home

On this Page

 TBI Classification Systems

 Potential Affects of Severe TBI
 Meeting the Challenge of Severe TBI
 References

Each year, TBIs contribute to a substantial number of deaths and cases of permanent disability.
In fact, TBI is a contributing factor to a third (30%) of all injury-related deaths in the United
States.1 In 2010, approximately 2.5 million people sustained a traumatic brain injury.2 Individuals
with more severe injuries are more likely to require hospitalization.
Changes in the rates of TBI-related hospitalizations vary depending on age. For persons 44
years of age and younger, TBI-related hospitalizations decreased between the periods of 2001–
2002 and 2009–2010. However, rates for age groups 45–64 years of age and 65 years and
older increased between these time periods. Rates in persons 45–64 years of age increased
almost 25% from 60.1 to 79.4 per 100,000. Rates of TBI-related hospitalizations in persons 65
years of age and older increased more than 50%, from 191.5 to 294.0 per 100,000 during the
same period, largely due to a substantial increase (39%) between 2007–2008 and 2009–
2010. In contrast, rates of TBI-related hospitalizations in youth 5–14 years of age fell from 54.5
to 23.1 per 100,000, decreasing by more than 50% during this period.1,2

A severe TBI not only impacts the life of an individual and their family, but it also has a large
societal and economic toll. The estimated economic cost of TBI in 2010, including direct and
indirect medical costs, is estimated to be approximately $76.5 billion. Additionally, the cost of
fatal TBIs and TBIs requiring hospitalization, many of which are severe, account for
approximately 90% of the total TBI medical costs.3,4

Lt. Col. Tim Maxwell’s Story

They train together. They fight together. So if wounded, why shouldn’t they go through recovery
together? This was the question that Lt. Col. Tim Maxwell asked about his fellow marines being
discharged from the hospital and left alone to recover from injuries of war.

Read more of this story

TBI Classification Systems

TBI injury severity can be described using several different tools.

The Glasgow Coma Scale (GCS),5 a clinical tool designed to assess coma and impaired
consciousness, is one of the most commonly used severity scoring systems. Persons with GCS
scores of 3 to 8 are classified with a severe TBI, those with scores of 9 to 12 are classified with a
moderate TBI, and those with scores of 13 to 15 are classified with a mild TBI.

Other classification systems include the Abbreviated Injury Scale (AIS), the Trauma Score, and
the Abbreviated Trauma Score. Despite their limitations,6 these systems are crucial to
 understanding the clinical management and the likely outcomes of this injury as the prognosis for
milder forms of TBIs is better than for moderate or severe TBIs.7-9

Potential Affects of Severe TBI

A non-fatal severe TBI may result in an extended period of unconsciousness (coma) or amnesia
after the injury. For individuals hospitalized after a TBI, almost half (43%) have a related disability
one year after the injury.10 A TBI may lead to a wide range of short- or long-term issues affecting:

 Cognitive Function (e.g., attention and memory)

 Motor function (e.g., extremity weakness, impaired coordination and balance)
 Sensation (e.g., hearing, vision, impaired perception and touch)
 Emotion (e.g., depression, anxiety, aggression, impulse control, personality changes)

Approximately 5.3 million Americans are living with a TBI-related disability and the consequences
of severe TBI an affect all aspects of an individual’s life.11 This can include relationships with
family and friends, as well as their ability to work or be employed, do household tasks, drive,
and/or participate in other activities of daily living.

Fast Facts

 Falls are the leading cause of TBI and recent data shows that the number of fall-related TBIs
among children aged 0-4 years and in older adults aged 75 years or older is increasing.
 Among all age groups, motor vehicle crashes and traffic-related incidents result in the largest
percentage of TBI-related deaths (31.8%).12
 People aged 65 years old and older have the highest rates of TBI-related hospitalizations and
death.13
 Shaken Baby Syndrome (SBS), a form of abusive head trauma (AHT) and inflicted traumatic
brain injury (ITBI), is a leading cause of child maltreatment deaths in the United States.

Meeting the Challenge of Severe TBI

While there is no one size fits all solution, there are interventions that can be effective to help
limit the impact of this injury. These measures include primary prevention, early management,
and treatment of severe TBI.

CDC’s research and programs work to reduce severe TBI and its consequences by developing
and evaluating clinical guidelines, conducting surveillance, implementing primary prevention and
education strategies, and developing evidence-based interventions to save lives and reduce
morbidity from this injury.
Developing and Evaluating Clinical Guidelines
CDC researchers conducted a study to assess the effectiveness of adopting the Brain Trauma
Foundation (BTF) in-hospital guidelines for the treatment of adults with severe traumatic brain
injury (TBI). This research indicated that widespread adoption of these guidelines could result in:

 a 50% decrease in deaths;

 a savings of approximately $288 million in medical and rehabilitation costs; and
 a savings of approximately $3.8 billion—the estimated lifelong savings in annual societal
costs for severely injured TBI patients.14

TBIs in the Military

Blasts are a leading cause of TBI for active duty military personnel in war zones.15 CDC
estimates of TBI do not include injuries seen at U.S. Department of Defense or U.S. Veterans
Health Administration Hospitals. For more information about TBI in the military including an
interactive website for service members, veterans, and families and caregivers, please
visit: www.dvbic.org.
CDC, in collaboration with 17 organizations, published the Field Triage Guidelines for the Injured
Patient.16 These guidelines include criteria on severe head trauma and can help provide uniform
standards to emergency medical service (EMS) providers and first responders, to ensure that
patients with TBI are taken to hospitals that are best suited to address their particular injuries.

Conducting Surveillance
Data are critical to help inform TBI prevention strategies, identify research and education
priorities, and support the need for services among those living with a TBI. CDC collects and
reports both national and state-based TBI surveillance data:

 CDC presents data on the incidence of TBI nationwide in its report: Traumatic Brain Injury in
the United States: Emergency Department Visits, Hospitalizations, and Deaths, 2002-2006.
This current report presents data on emergency department visits, hospitalizations, and
deaths for the years 2002 through 2006 and includes TBI numbers by age, gender, race, and
external cause.
 CDC currently funds 30 states to conduct basic TBI surveillance through the CORE state
Injury Program. (Note: While some un-funded states do participate in the submission of TBI-
and other injury-related data compiled in this report, the report does not include data from all
50 states
CDC currently funds 30 states to conduct basic TBI surveillance through the CORE state
Injury Program ( Note: while