TRAUMATIC BRAIN INJURY Traumatic brain injury is physical injury to brain tissue that temporarily or permanently impairs brain

function. Diagnosis is suspected clinically and confirmed by imaging (primarily CT). Initial treatment consists of ensuring a reliable airway and maintaining adequate ventilation, oxygenation, and blood pressure. Surgery is often needed in patients with more severe injury to place monitors to track and treat intracranial pressure, decompress the brain if intracranial pressure is increased, or remove intracranial hematomas. In the first few days after the injury, maintaining adequate brain perfusion and oxygenation and preventing complications of altered sensorium are important. Subsequently, many patients require rehabilitation. In the US, as in much of the world, traumatic brain injury (TBI) is a common cause of death and disability. Causes include motor vehicle crashes and other transportation-related causes (eg, bicycle crashes, collisions with pedestrians), falls (especially in older adults and young children), assaults, and sports activities.

Pathology
Structural changes from head injury may be gross or microscopic, depending on the mechanism and forces involved. Patients with less severe injuries may have no gross structural damage. Clinical manifestations vary markedly in severity and consequences. Injuries are commonly categorized as open or closed. Open injuries involve penetration of the scalp and skull (and usually the meninges and underlying brain tissue). They typically involve bullets or sharp objects, but a skull fracture with overlying laceration due to severe blunt force is also considered an open injury. Closed injuries typically occur when the head is struck, strikes an object, or is shaken violently, causing rapid brain acceleration and deceleration. Acceleration or deceleration can injure tissue at the point of impact (coup), at its opposite pole (contrecoup), or diffusely; the frontal and temporal lobes are particularly vulnerable. Axons, blood vessels, or both can be sheared or torn. Disrupted blood vessels leak, producing contusions, intracerebral or subarachnoid hemorrhage, and epidural or subdural hematomas (see Table 1: Traumatic Brain Injury (TBI): Common Types of Traumatic Brain Injury ).

Table 1

Common Types of Traumatic Brain Injury

Disorder Clinical Findings Diagnosis

Acute subdural hematoma

Typically, acute neurologic dysfunction, which may be focal, nonfocal, or both Patients with small hematomas may have normal function

CT: Hyperdensity in subdural space, classically crescentshaped Degree of midline shift important

Basilar skull fracture

Leakage of CSF from the nose or ear Blood behind the tympanic membrane (hemotympanum) or in the external ear Ecchymosis behind the ear (Battle's sign) or around the eye (raccoon eyes)

CT: Usually visible

Brain contusion

Widely variable degrees of neurologic dysfunction or normal function

CT: Hyperdensities resulting from punctate hemorrhages of varied sizes Based on clinical findings CT or MRI: Clinical abnormalities not explained by lesions in brain parenchyma

Concussion

Transient mental status alteration (eg, loss of consciousness or memory) lasting < 6 h

Chronic subdural hematoma

Gradual headache, somnolence, confusion, sometimes with focal deficits or seizures

CT: Hypodensity in subdural space (abnormality is isodense during subacute transition from hyperdense to hypodense)

Diffuse axonal injury

Loss of consciousness lasting > 6 h but may not have focal deficits or motor posturing

Based on clinical findings CT: At first, may be normal or show small hyperdensities (microhemorrhages) in corpus callosum, centrum semiovale, basal ganglia, or brain stem MRI: Often abnormal

Epidural hematoma

Headache, impaired consciousness within hours,

CT: Hyperdensity in epidural space, classically lenticular-

sometimes with a lucid interval Herniation typically causing contralateral hemiparesis and ipsilateral pupillary dilation Subarachnoid hemorrhage Typically, normal function Occasionally, acute neurologic dysfunction

shaped and located over the middle meningeal artery (temporal fossa) due to a temporal bone fracture

CT: Hyperdensity within subarachnoid space on the surface of the brain; often outlining sulci