Head Injury

Kuah Yan Xin, Nurfarahin Hamizah, Wafa

Nabilah

Outline
Define and classify head injury
Relevant signs and symptoms of head injury
Obtain history on patients presented with head
injury
Give differential diagnosis of head injury
Perform examination of the head injury
Identified the initial investigation and management
To know when and how to refer the patient to
surgical for head injury

Definition
Head injury is a broad term that describes a
vast array of injuries that occur to the scalp,
skull, brain, and underlying tissue and blood
vessels in the head.

(The University of Chicago Medical Center)

Anatomy

Head Injury

Skull

Brain
Traumatic
Brain Injury
(TBI)
Traumatic
Parenchym
al Injury
Concussion

Contusion

Acquired
Brain Injury
(ABI)
Traumatic
Vascular
Injury

Diffuse
Axonal
Injury

Epidural
Hematoma

Coup

Subdural
Hematoma

Contrecoup

Subarachno
id
Hematoma

Coupcontrecoup

Levels of
Brain Injury

Linear

Scalp

Depressed

Anoxia

Mild

Vault

Open

Hypoxic

Moderate

Basilar

Closed

Severe

Traumatic Brain Injury

1) Traumatic Parenchymal Injury

Concussion (most common type)

Reversible altered consciousness from head injury in

the absence of contusion

Brain receives trauma from an impact or a sudden

momentum or movement change

May remain conscious, but feel dazed

Caused by direct blows to the head, gunshot

wounds, violent shaking of the head or force from
whiplash type injury

Skull fracture, brain bleeding, or swelling may or

may not be present

Defined by exclusion, considered as a complex

neurobehavioural syndrome

Traumatic Brain Injury

Contusion
Bruise on the brain
Wedge-shaped, with the widest aspect closest to the
point of impact
Further divided into coup, contrecoup and coupcontrecoup according to the site of bruise
Coup - at the site of the impact
Contrecoup - opposite the site of the impact on the
other side of the brain
o The force moves the brain and cause it to slam into
the opposite inner skull table
Coup-contrecoup - both at the site of the impact and on
the complete opposite site of the brain

Traumatic Brain Injury

Diffuse Axonal Injury

Caused by shaking or strong rotation of head, as with
Shaken Baby Syndrome
Or by rotational forces, such as with car accident
Rapid displacement of the head and brain can tear axons
Disrupt axonal integrity and function, causing immediate
severe, irreversible neurologic deficits
Lesions are asymmetric, most commonly found near the
angles of the lateral ventricles and in the brain stem
Axonal swelling appears within hours of injury
Temporary or permanent widespread brain damage,
coma, or death

Traumatic Brain Injury

2) Traumatic Vascular Injury
Directly disrupt vessel walls, leading to haemorrhage
The accumulated blood volume causes increased
intracranial pressure, which in turn damages the brain
and can lead to permanent neurologic deficit or death
Depending on the location of affected vessels, can be
divided into epidural, subdural and subarachnoid

Traumatic Brain Injury

Epidural hematoma
Accumulation of blood between skull and dura mater
Most are frontal and temporal, associated with rupture
of the meningeal arteries, most commonly the middle
meningeal artery
In infants, traumatic displacement of the easily
deformable skull may tear a vessel, even in the absence
of a skull fracture
In children and adults, by contrast, typically associated
with skull fractures
Lucid for several hours between the moment of trauma
and the development of neurologic signs
May expand rapidly and constitutes a neurosurgical
emergency

Traumatic Brain Injury

Subdural Hematoma
Accumulation of blood between dura mater and
arachnoid mater
More common than epidural hematoma
Result from tearing of bridging veins which extend from
the cerebral hemispheres through the subarachnoid and
subdural space to the dural sinuses
Sometimes, but not always, associated with a skull
fracture
Most common over the lateral aspects of the cerebral
hemispheres and may be bilateral
Can grow fairly slowly due to low-pressure venous
bleeding and the presentation can be delayed by days to
weeks

Traumatic Brain Injury

Subarachnoid haemorrhage
Spontaneous arterial bleeding in the subarachnoid
space which is in between arachnoid mater and pia
mater
Often associated with a cerebral aneurysm (stroke)
Can also caused by a skull fracture
Endure some degree of life-long impairment or
chronic headache

Acquired Brain Injury

Damage to the brain not necessarily caused by an external
force
Examples :
- strokes
- tumors
- anoxia
- hypoxia
- toxins
- degenerative neurological diseases
- near drowning

Acquired Brain Injury

1) Anoxia when brain does not receive any oxygen
a) Anoxic anoxia
no oxygen supplied to brain
b) Anemic anoxia
blood does not carry enough oxygen
c) Toxic anoxia
toxins or metabolites that block oxygen in the blood from
being used

2) Hypoxic when brain receives some, but not enough oxygen

a) Hypoxic ischemic brain injury
Stagnant hypoxia or ischemic insult
Lack of blood flow to brain because of a critical reduction in

Levels of Brain Injury

Mild
Glasgow Coma Scale (GCS) score 13-15
Stunned or dazed for a few seconds or minutes
Remains alert without post-traumatic amnesia
(PTA)
Headache can follow
Complete recovery is usual

Levels of Brain Injury

Moderate
GCS score 9-12
Usually result from a non-penetrating blow to the head, and/or
a violent shaking of the head
A loss of consciousness lasts from a few minutes to a few hours
Confusion lasts from days to weeks
Physical, cognitive, and/or behavioral impairments last for
months or are permanent
Good recovery with treatment or successfully learn to
compensate for their deficits

Levels of Brain Injury

Severe
GCS score 3-8
Usually result from crushing blows or
penetrating wounds to the head
PTA of more than 24 hours
Coma with no meaningful response and no
voluntary activities lasts days, weeks, or
months

Skull Fractures
Any break in the skull
Type of skull fracture depends on :
- the force of the blow
- the location on the skull at which the impact
occurs
- the shape of the object making impact with the
head
Only one cause: an impact or a blow to the head that
is strong enough to break the bone
Two major types of skull fractures :
- Linear

Linear Skull Fractures

The most common type of skull fracture
Result from low-energy blunt trauma over a wide surface
area of the skull
Run through the entire thickness of the bone
Can be further divided into vault and basilar skull
fractures
Basilar skull fracture
Linear fracture at the base of the skull
It is usually associated with a dural tear
Found at specific points on the skull base
Temporal, sphenoid and occipital condylar fractures

Depressed Skull Fractures

Result from a high-energy direct blow to a small surface area of
the skull with a blunt object such as a baseball bat
Part of the skull is actually sunken in from the trauma
Most common in the frontal and parietal region
May be open or closed
Open fractures
have either a skin laceration over the fracture
or the fracture runs through the paranasal sinuses and the middle
ear structures, resulting in communication between the external
environment and the cranial cavity

Closed fractures
Simple fractures
Skin is not broken or cut

Scalp Injury
Scalp is the highly vascular skin that cover and
protect the skull
may manifest as abrasion, bruising, laceration, or a
burn
may lead to bleeding or tissue damage

Signs of Head Injury

Dilation of one or both pupils of the eyes
Leakage of clear fluid which is cerebrospinal fluid
(CSF) into the ear (otorrhea) or nose (rhinorrhea)
Ecchymosis over the mastoid process (Battle's
sign)
Bruising around the tissue of periorbital area
(Raccoon eyes)

Symptoms of Head Injury (Mild)

Physical symptoms
Loss of consciousness for a few
seconds to a few minutes
No loss of consciousness, but a
state of being dazed, confused
or disoriented
Headache
Nausea or vomiting
Fatigue or drowsiness
Difficulty sleeping
Sleeping more than usual
Dizziness or loss of balance

Sensory symptoms

Blurred vision
Ringing in the ears
A bad taste in the mouth or
changes in the ability to smell
Sensitivity to light or sound

Cognitive or mental
symptoms
Memory or concentration
problems
Mood changes or mood
swings
Feeling depressed or anxious

Symptoms of Head Injury (Moderate

to Severe)
Physical symptoms

Cognitive or mental

Loss of consciousness from

several minutes to hours

symptoms

Persistent headache or
headache that worsens
Repeated vomiting or
nausea
Convulsions or seizures
Inability to awaken from
sleep
Weakness or numbness in
fingers and toes

Profound confusion
Agitation, combativeness or
other
unusual behavior
Slurred speech
Coma and other disorders of
consciousness

DIFFERENTIA
L DIAGNOSIS

DIFFERENTIAL DIAGNOSIS
Stroke
Cardiac Arrest
Hypertensive Encephalopathy
Basilar Artery Thrombosis
Cerebral Venous Thrombosis
Seizure

HISTORY
TAKING

HISTORY TAKING
After initial resuscitation and management of ABCDs,
a focused history should be performed on every
patient with a TBI or unknown cause of altered
mental status.
A detailed description of the traumatic event should
be solicited from the patient, family members, first
responders, or police.
Witnesses or individuals who know the patient may
be helpful in ascertaining the details of the traumatic
event and environment, as well as the patients
normal level of functioning.
It is important to keep the differential diagnoses
broad to avoid making an error of premature closure.

Common or concerning symptoms

Headache
- ask about location, severity, duration and any
associated symptoms, such as visual changes, weakness, or
loss of sensation?
- ask if coughing, sneezing, or sudden movements of
head affect the headache
Dizziness
- ask is the patient lightheaded or feeling faint? Is there
unsteady gait from disequilibrium or perception that room
is spinning or rotating?
Generalized weakness
- are associated symptoms present such as double
vision, difficulty
in forming words, difficulty with balance?
Loss of sensation
- is there any loss of sensation, difficulty in moving limb?
Seizure, confusion
Nausea and vomiting

 Drug or alcohol use

current intoxication: shown to have an
increased association with intracranial
injury detected on CTscan
chronic: associated with cerebral
atrophy, thought to increase risk of
shearing of bridging veins
Past medical history, including any CNS
surgery, past head trauma, haemophilia, or
seizures
Current medications including
anticoagulants

CNS Review

Physical
Examination

Physical Examination
A thorough physical examination must be
performed after the initial ABCDs have been
addressed.
In addition to vigilance for occult injuries, the
physician should perform the physical
examination with careful attention to the
following:
Serial GCS and pupillary examinations should
be performed every 15 minutes until the
patient is stable, to immediately identify
deterioration in neurological function.

Head and Neck

Inspection for cranial nerve deficits, periorbital or
postauricular ecchymoses, CSF rhinorrhoea or otorrhoea,
haemotympanum (signs of base of skull fracture)
Fundoscopic examination for retinal haemorrhage (sign
of abuse) and papilloedema (sign of increased ICP)
Palpation of the scalp for haematoma, crepitance,
laceration, and bony deformity (markers of skull
fractures)
Auscultation for carotid bruits (sign of carotid dissection)
Evaluation for cervical spine tenderness, paraesthesias,
incontinence, extremity weakness, priapism (signs of
spinal cord injury)
Obvious foreign bodies or impaled objects should not be
removed until the dura is opened in the operating room
and the procedure can be performed under direct

 Cardiovascular status requires continuous

cardiac and serial blood pressure
monitoring. Any episodes of hypotension
must be addressed immediately.
Respiratory status requires continuous pulse
oximetry and, in intubated patients,
continuous end-tidal CO2 capnography. Any
episodes of hypoxia must be addressed
immediately.
Extremities should receive motor and
sensory examination (for signs of spinal

GLASCOW COMA SCALE

The GCS is widely used to assess the level of
consciousness in patients with TBI, and provides
fairly good prognostic information (when score
is very low or very high) that allows the
physician to plan for expected diagnostic and
monitoring requirements.
GCS has 3 components: best eye response (E),
best verbal response (V), and best motor
response (M). Scoring for each component
should be documented separately (e.g., GCS 10
= E3 V4 M3).

- GCS of 13 to 15 is
- GCS of with
13 to
15 brain
is
associated
mild
associated with mild
injury
brain injury
- GCS of 9 to 12 is
- GCS of 9 to 12 is
associated with moderate
associated with
brain injury
moderate brain injury
- GCS of <8 is associated
- GCS of <8 is associated
with severe brain injury.
with severe brain injury.

Approach to GCS (Video)

Pupil reflex
Pupillary reflexes function as an indication of both
underlying pathology and severity of injury, and should
be monitored serially.
Pupils should be examined for size, symmetry,
direct/consensual light reflexes, and duration of
dilation/fixation.
Abnormal pupillary reflexes can suggest herniation or
brainstem injury.
Orbital trauma, pharmacological agents, or direct
cranial nerve III trauma may result in pupillary changes
in the absence of increased ICP, brainstem pathology,
or herniation.

Pupil Size
The normal diameter of the pupil is between
2 and 5 mm, and although both pupils
should be equal in size, a 1-mm difference
is considered a normal variant.
Abnormal size is noted by anisocoria
defined as >1 mm difference between
pupils.

Pupil Symmetry
Normal pupils are round, but can be
irregular due to ophthalmological surgeries.
Abnormal symmetry may result from
compression of CNIII can cause a pupil to
initially become oval before becoming
dilated and fixed.

Direct Light Reflex

Normal pupils constrict briskly in response
to light, but may be poorly responsive due
to ophthalmological medications.
Abnormal light reflex may be seen in
sluggish pupillary responses associated with
increased ICP. A non-reactive, fixed pupil
has <1 mm response to bright light and is
associated with severely increased ICP.

CRANIAL NERVE TEST

INVESTIGATI
ON

1. CT Head Scan
For adults who have sustained a head injury and
have any of the following risk factors, perform a
CT head scan within 1 hour of the risk factor
being identified:
GCS less than 13 on initial assessment in the
emergency department.
GCS less than 15 at 2 hours after the injury on
assessment in the emergency department.

 Suspected open or depressed skull fracture.

Any sign of basal skull fracture
(haemotympanum, 'panda' eyes, cerebrospinal
fluid leakage from the ear or nose, Battle's
sign).
Post-traumatic seizure.
Focal neurological deficit.
More than 1 episode of vomiting.

Depressed Skull Fracture

Subdural Hemorrhage

Example of imaging

2. CT Cervical Scan
For adults who have sustained a head injury and
have any of the following risk factors, perform a
CT cervical spine scan within 1 hour of the risk
factor being identified:
GCS less than 13 on initial assessment.
The patient has been intubated.
Plain X-rays are technically inadequate (for
example, the desired view is unavailable).
Plain X-rays are suspicious or definitely abnormal.
A definitive diagnosis of cervical spine injury is
needed urgently (for example, before surgery).

3. MR Imaging
MR imaging is indicated if there are
neurological signs and symptoms referable to
the cervical spine.
If there is suspicion of vascular injury (for
example, vertebral malalignment, a fracture
involving the foramina transversaria or lateral
processes, or a posterior circulation
syndrome), CT or MRI angiography of the neck
vessels may be performed to evaluate for this.

4. Angiogram

An angiogram is a test used to examine blood

vessels. When diagnosing a brain injury, the
test involves injecting dye into an artery that
supplies blood to the brain, usually through a
catheter inserted in the groin.
The dye highlights the blood vessels on x-ray,
and can show any leakage from those vessels.

5. Intracranial pressure (ICP)

monitor
An ICP monitor is a device used to measure
intracranial pressure, or pressure within the
skull. One of the reasons this pressure can
increase is when an injury to the brain causes
swelling.
The ICP monitor consists of a small tube, placed
into or on top of the brain through a small hole
in the skull. This tube is connected to a
transducer that registers the pressure, which is
displayed on a monitor.

6. Blood test
All patients with multiple injuries and those with
severe head injuries, should have blood samples
analysed for baseline estimations - full blood
count, electrolytes and urea, coagulation
screen, blood gases, alcohol level and blood
group (and save).
Electrolyte abnormalities and haemoglobin
deficiencies should be corrected, if present,
whilst clotting disorders should be corrected if
surgery is anticipated.

7. Other diagnostic method

Electroencephalograph (EEG)
Single-photon emission computed tomography
(SPECT)
Positron emission tomography (PET)
Diffusion tensor imaging (DTI)

MANAGEME
NT

1. Transfer to hospital
Patients who have sustained a head injury should be
refered to a hospital emergency department, using
the ambulance service if deemed necessary, if any
of the following are present:
Glasgow coma scale (GCS) score of less than 15 on
initial assessment.
Any loss of consciousness as a result of the injury.
Any focal neurological deficit since the injury.
Any suspicion of a skull fracture or penetrating head
injury since the injury.
Amnesia for events before or after the injury

2. Emergency Management
Remember that the priority for all emergency
department patients is the stabilisation ABCDE
before attention to other injuries.

Airway
Breathing
Circulation
Disability
Exposure

AIRWAY
Handle Neck With Caution: Assume C-spine Injury
Attempt full cervical immobilisation
Avoid Obstruction of Venous Drainage
Do oral intubation if GCS < 8
May Need to Protect Airway Due to Seizures or
Trauma

BREATHING
Even a small rise in PaCO2 causes a significant
rise in ICP
Adequate breathing may not be enough- aim
for PaCO2 of 35-40 mmhg
Hyperventilation is the quickest way to lower ICP
if there are signs of herniation

CIRCULATION
Blood pressure must be optimized to help
maintain adequate CPP (Cerebral perfusion
pressure)
Prevent increased ICP by administering
Mannnitol IV
Only use isotonic fluids for volume expansion
May need inotropic or pressor support
Control bleeding

DISABILITY
Neurological examination begins with
assessment of the patients conscious level
using the GCS.
The severity of the head injury can be based on
this initial GCS score.
A patient with a GCS of 8 or less is in need of
urgent anaesthetic assessment as airway
compromise and/or reduced lung ventilation is
likely.

Assessment of pupil and reaction to

light
Asymmetrical pupil size and reduced reaction to light may
indicate brain injury from either diffuse injury or an intracranial hematoma. It may also, however, indicate an isolated
injury to the orbit and associated with cranial nerves

 Asymmetry of limb movement may help in

diagnosing an underlying intra-cranial
lesion.
Observations on the blood pressure, pulse
and respiratory rate are also essential, not
only to ensure cardio respiratory stability of
the patient, but also to indicate possible
brainstemcompromise.

3. Pain Management
Manage pain effectively because it can lead to a
rise in intracranial pressure.
Provide reassurance, splintage of limb fractures
and catheterisation of a full bladder, where
needed. Treat significant pain with small doses
of intravenous opioids titrated against clinical
response and baseline cardio respiratory
measurements

Indications
for surgery

Indications for surgery

1. Penetrating injuries or blunt injuries with breach of
the calvarium/skull
2. Presence of expanding intracranial hematoma
a) Epidural Hematoma
b) Subdural Hematoma
3. Malignant cerebral edema
Decompressive Craniotomy - Decreases ICP,
improves cerebral perfusion, prevents ischemia

Epidural Hematoma
Surgery is Indicated
If volume > 30 cm3

Clot evacuation with or

without ligation of
bleeding vessel

Subdural Hematoma
Surgery is Indicated If
size > 10 mm on CT or if 5
mm shift
1st line
Irrigation/evacuation via
burr twist drill and burr
hole craniostomy
2nd line Craniotomy

Indications for surgery

New, surgically significant abnormalities on imaging
Persisting coma (GCS 8 or less) after initial resuscitation.
Unexplained confusion which persists for more than 4 hours.
Deterioration in GCS score after admission (greater attention
should be paid to motor response deterioration).
Progressive focal neurological signs.
A seizure without full recovery.
Depressed skull fracture
Definite or suspected penetrating injury.
A cerebrospinal fluid leak.

References
Printed Materials
T. Flannery And N. Buxton (2001) . Modern
management of head injuries. J.R.Coll.Surg.Edinb.,
46, June 2001, 150-15.
http://www.rcsed.ac.uk/RCSEDBackIssues/journal/vol46_
3/4630005.htm
M.Longmore, I.B. Wilkinson, A.Baldwin and E. Wallin
(2014). Oxford Handbook of Clinical Medicine (9th
Edition). Oxford University Press, New York.
Vinay Kumar, Abul K.Abbas, Jon C.Aster (2013). Robbins
Basic Pathology, 9th Edition. Elsevier Saunders.
Parveen Kumar, Michael Clark (2009). Kumar & Clarks
Clinical Medicine, 7th Edition. Elsevier Saunders.

References
Websites
http://biau.org/types-and-levels-of-brain-injury/
http://www.uchospitals.edu/onlinelibrary/content=P00785
http://emedicine.medscape.com/article/248108overview#a7
http://www.mayoclinic.org/diseases-conditions/tr
aumatic-brain-injury/basics/symptoms/con-2002930
2
https://www.traumaticbraininjuryatoz.org/MildTBI/Diagnosing-Mild-TBI-Concussion/Imaging-Tests