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Questions and Answers
Which type of brain injury is classified as a direct consequence of external forces?
What classification separates brain injuries into categories based on the underlying cause?
Which factor is NOT a possible systemic effect following a traumatic brain injury?
What type of brain injury involves localized bruising of the brain tissue?
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Which is an example of a primary brain injury caused by external trauma?
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What is a significant concern when managing a patient with severe brain injury?
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Which of the following is NOT considered a symptom of traumatic brain injury?
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What type of skull injury is likely to be caused by a penetrating object?
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What is the classification for a head injury with a Glasgow Coma Scale (GCS) score of 10?
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Which of the following symptoms is most likely associated with mild head injury?
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What does a fixed and dilated pupil typically indicate?
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What is the main focus of symptomatic treatment in mild head injury management?
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Which of these symptoms indicates a potential intracranial hemorrhage in elderly patients?
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What is the recommended time frame for the initial Glasgow Coma Scale assessment after injury?
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Which type of posturing is characterized by upper extremity flexion and lower extremity extension?
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What symptom is indicative of poor brain perfusion?
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What is the primary cause of epidural hematomas?
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Which symptom is commonly misattributed to other causes in elderly patients following a fall?
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Which of the following symptoms is NOT commonly associated with a concussion?
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Which of the following describes a significant risk factor for intracranial hematoma?
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When analyzing a CT scan for a subdural hematoma, what characteristic shape would it typically present?
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Which group is at an increased risk for developing subdural hematomas?
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What defines the extent of a focal brain injury caused by contusion?
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What is a classic symptom of an epidural hematoma often observed after the initial injury?
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Which of the following symptoms does NOT typically indicate a concussion?
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What differentiates a subdural hematoma from an epidural hematoma in terms of location?
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What is the primary goal in the treatment of skull fractures?
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Which symptom may indicate a more severe brain injury following a concussion?
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Which type of skull fracture is characterized by a sunken portion of the skull that may require surgical intervention?
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What is a common symptom of a basilar skull fracture that might suggest its presence?
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What treatment is generally required for growing fractures in children?
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In which type of skull fracture are the sutures traumatically separated, most commonly at the lambdoidal suture?
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What type of brain injury occurs on the side opposite the impact during a head injury?
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What is the primary mechanism that leads to diffuse axonal injury?
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Which skull fracture type does not typically require specific treatment and usually heals well on its own?
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Which of the following is a common indirect cause of secondary brain injury?
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Which of the following statements is true regarding focal brain injuries?
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What condition is characterized by a mortality rate being doubled in traumatic brain injury patients when present?
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What is a possible consequence of a linear fracture if it develops into a more severe condition?
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What systemic condition was found to be present in 33-35% of traumatic brain injury patients?
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Which symptom is typically associated with a significant skull fracture that may indicate severe underlying injury?
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What commonly occurs after a traumatic brain injury leading to increased intracranial pressure?
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When a skull fracture is suspected, which diagnostic method is most prominently useful?
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Study Notes
Head Injury
- A broad category that may involve damage to other structures such as the scalp and skull.
Traumatic Brain Injury
- An insult to the brain caused by mechanical force.
- Spectrum of Intracranial Injury results from:
- Direct Forces = Object Striking or penetrating cranium
- Indirect Forces = Acceleration/Deceleration or Rotational Mechanism
Traumatic brain injury
- The brain is susceptible to injury by trauma, ischemia, tumours, degenerative processes, and metabolic alterations.
- Brain injuries are classified as:
- Non-traumatic (i.e., stroke, infection, tumour, or seizure).
- Traumatic (i.e., epidural hematoma, subdural haematoma, concussion, or diffuse axonal injury)
- Brain damage can result from the effects of ischemia, excitatory amino acids, oedema, and increased intracranial pressure (ICP).
- Brain injuries can cause a change in the level of consciousness and alterations in cognition, motor, and sensory function
Classification of Traumatic Brain Injury
- Blunt / Penetrating (Closed / Open)
- Severity
- Focal / Diffuse
- Primary / Secondary
Brain injury
-
Primary brain injury
- Primary damage resulting from these external forces
- Diffuse axonal injury
- Focal contusion
- Haematomas, or bleeding, in or around the brain
-
Secondary brain injury
- Occurs hours or days after initial traumatic event.
- Injury may result from impairment or local decline in cerebral blood flow.
-
Systemic effects include:
- Hypotension/hypertension
- Hypoxia
- Anaemia
- CO2 changes
- Electrolyte/glucose/acid-base abnormalities
-
Intracranial effects include:
- Ischemia
- Oedema
- Hydrocephalus
- Infection
- Seizure
- Haemorrhage
Traumatic Brain Injury
- The brain is enclosed in the protective confines of the rigid bony skull.
- Although the skull generally affords protection to the soft tissues of the CNS from external forces, it also imposes risks as a source of injury from internal forces.
- The bony structures of the skull can induce traumatic and ischemic brain injuries when intracranial tissues increase in volume (swelling or bleeding) or shift (swelling or mechanical trauma).
- Focal injury at gray matter closest to the brain surface generates localized brain oedema and disruption of normal neurological function.
- Size of contusion defines the extent of the injury
Concussion
- Symptoms can last for days, weeks, or even longer.
- Common symptoms after a concussive traumatic brain injury are headache, loss of memory (amnesia), and confusion.
- The amnesia usually involves forgetting the event that caused the concussion.
-
Signs and symptoms of a concussion may include:
- Headache or a feeling of pressure in the head
- Temporary loss of consciousness
- Confusion or feeling as if in a fog
- Amnesia surrounding the traumatic event
- Dizziness or "seeing stars"
- Ringing in the ears
- Nausea
- Vomiting
- Slurred speech
- Delayed response to questions
- Appearing dazed
- Fatigue
Haematomas
-
Arise from vascular bleeding/injury.
-
Occur in various compartments depending on the location of the ruptured vessel.
-
Epidural, subdural and subarachnoid spaces and in the brain tissue itself (intracerebral haematoma).
-
Haematomas
- Type | Epidural | Subdural
- Location | Outer layers of the dura mater, | Between dura mater & pia | between the meninges & skull | arachnoid mater. | | Increased risk in elderly and chronic alcohol use due to decreased brain volume
- Vessel involved | Middle Meningeal Artery (36%) | Bridging Veins
- Symptoms | w/ LOC + Lucid Intervals followed | Gradually increasing headache | by deterioration and LOC again | & confusion. Classic presentation = 47% of cases
- CT scan image | Lenticular Shape on CT | Hyperdense crescent shaped lesion
Haematomas
- Epidural hematoma (EDH)
- Subdural hematomas (SDH)
Epidural (extradural) haematoma
- Usually occur in injury where the skull is fractured between in inner bones of the skull and the dura.
- Usually from a tear of an artery (middle meningeal artery).
- Common symptoms of brain injury—such as balance impairment, depression, and cognitive deficits—may be misattributed to other causes, especially when elderly patients experience a non-witnessed fall.
- The frequent use of anticoagulants for comorbid conditions leads to an increased risk of haemorrhage, even with low-velocity head trauma.
- High suspicion for intracranial haemorrhage.
- Some patients may present days or weeks after trauma, such as may occur with subdural haemorrhage.
Assessment
-
Glasgow Coma Scale
- Originally designed for measure 6 hours after injury to provide long-term prognostic information about mortality and disability.
- Now, standardized to measure 30 min after injury and repetitive measurements throughout patient’s stay.
- Should be performed after adequate resuscitation b/c scale is sensitive to hypotension, hypoxia, intoxication, and pharmacologic interventions.
-
Current Classification
- GCS 14-15 - Mild Head Injury
- GCS 9-13 - Moderate Head Injury
- GCS < 9 - Severe Head Injury
Assessment
-
Neurologic Exam
- Pupillary Size + Reactivity
- Fixed Dilated Pupil - Ipsilateral Intracranial Hematoma
- Bilateral Fixed + Dilated - Poor Brain Perfusion, bilateral Uncas herniation or severe hypoxia
- Indicative of very poor neurological outcome
- Neurological Posturing
- Decorticate Posturing - Upper extremity flexion with lower extremity extension
- Cortical Injury above the midbrain
- Decerebrate Posturing - Arm extension and internal rotation with wrist flexion
- Indicative of brainstem injury
- Very poor predictor of outcome
- Decorticate Posturing - Upper extremity flexion with lower extremity extension
- Pupillary Size + Reactivity
Mild head injury
- Clinical features- Signs and symptoms (early/late)
-
Signs and Symptoms of Head Injury
- Cognitive | Somatic | Affective
- Confusion | Headache | Emotional Lability
- Anterograde amnesia | Fatigue | Irritability
- Retrograde amnesia | Disequilibrium | Sadness
- Loss of consciousness | Dizziness |
- Disorientation | Nausea/vomiting |
- Feeling “zoned out” | Visual disturbances |
- Feeling “foggy” | Photophobia |
- Vacant stare | Phonophobia |
- Inability to focus | Difficulty sleeping |
- Delayed verbal/motor | Ringing of the ears |
- response - Slurred or incoherent speech | Excessive Drowsiness |
Mild Head Injury Management
- Symptomatic treatment and prevention of secondary injury.
- Appropriate management depends on an assessment of the risk of neurological decompensation and risk factors for intracranial haematoma.
- A fracture of the bones that form the base of the skull is called a basilar skull fracture.
Fractures in young children
- The skull is flexible, which is why infants and young children often have skull fractures that do not show on x-ray.
Types of skull fractures
- Linear Fractures:
- The most common simple type.
- Seen in the temporal parietal region.
- Often accompanied by an overlying haematoma.
- They require no specific treatment and will heal well.
- A very small minority may develop into a "growing skull fracture".
Types of skull fractures
- Depressed skull fractures
- May be seen with or without a cut on the scalp.
- Part of the skull is actually sunken in from the trauma.
- If the inner part of the skull is pressed against the brain, surgical intervention is needed to help correct the deformity.
Types of skull fractures
- Basal skull Fractures:
- Serious type of skull fracture, involving a break at the base of the skull.
- These may be difficult to see radiologically, although the clinical suspicion should be high if "battle's sign" / "raccoon eyes" or a CSF leak is present.
Types of skull fractures
-
Diastatic Fractures:
- These are caused by the traumatic separation of the sutures most commonly lambdoidal.
-
Growing Fractures:
- Seen in the toddler age group.
- Is generally "diastatic" and it grows as the brain herniates, through the torn dura up into the fracture site.
- Generally present some time after the initial injury, usually as a persistent swelling or pulsatile mass.
- There is almost always underlying parenchymal brain damage, with associated neurological symptoms.
- Requires surgical repair of the dura.
Focal brain injury
- Coup/Contrecoup injury
- In a head injury, a coup injury occurs under the site of impact with an object, and a contrecoup injury occurs on the side opposite the area that was impacted.
Diffuse injuries
- Diffuse axonal injury - Widespread damage to the white matter.
- Results from shaking effect & associated with acceleration and deceleration injury.
- Ischemic brain injury from insufficient blood supply to the brain.
- Is the leading cause of secondary brain injury.
- Vascular injury usually causes death soon after injury.
- Swelling commonly seen after TBI can lead to increased cranial pressure.
Diffuse Axonal Injury
- Rotational Mechanism
- Widespread shearing strain at the deep cerebral white matter that disrupts normal axonal organization resulting in disruption of axonal fibers and myelin sheaths.
- Generalized edema occurs after an injury, typically within 6 hours without any focal lesion on CT imaging.
Secondary Brain Injury
- Indirect result of injury.
- Arises from complications of injury.
- Systemic or Intracranial processes that contribute to the primary brain injury cycle and result in greater tissue injury.
- Ischemia
- Cerebral hypoxia
- Hypotension
- Cerebral oedema
- Alternations in cerebral blood flow
- Raised ICP
- Herniation
- Hypercapnia
- Alterations in the release of neurotransmitters (Excitotoxicity)
- Hydrocephalus
Secondary Brain Injury
-
Systemic Insults
- Hypoxia (PaO2 < 60 mmHg)
- Mortality of TBI pts with hypoxia = doubled.
- 40% of TBI ED patients exhibit hypoxia during the course.
- Hypotension (SBP < 90 mmHg)
- Present in 33-35% of TBI patients.
- Results from hemorrhagic shock, cardiac contusion, tension pneumothorax, etc.
- Hypoxia (PaO2 < 60 mmHg)
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Description
This quiz covers the essentials of traumatic brain injury, including its causes, types, and classifications. Learn about the impact of trauma on brain function and how different injuries are categorized. Ideal for medical students and health professionals.
