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Head Injury


Presentation

The following symptomatology is found in patients suffering in traumatic head injuries:

Pain
  • Drowsiness, high-grade fever, severe headache, left ocular pain with marked periorbital swelling, and paralysis of extraocular eye movements developed.[ncbi.nlm.nih.gov]
  • The most common interventions included repeat CT (42, 21%), antiemetics (26, 13%), and pain medication (29, 14%). Eighty-nine percent were discharged in less than 24 hours.[ncbi.nlm.nih.gov]
  • Third (eye) Vision Problems Fourth (eye) Vision Problems Fifth (face) Trigenial-injury can create an ultra painful condition in the face, usually an electrical type burst of pain on contact with the face.[braininjury.com]
  • The analogy is again chest pain from coronary artery clot but no infarction of heart tissue…[T]he faint and fall caused her head injury and concussion symptoms. I’m leaving it at this for now.[powerlineblog.com]
  • Your child may cry from pain or fright, but this should last no longer than 10 minutes. You may need to apply a cold compress for 20 minutes to help the swelling go down and then watch your child closely for a time.[healthychildren.org]
Fatigue
  • Symptoms may include clumsiness, fatigue, confusion, nausea, blurry vision, headaches, and others. Mild concussions are associated with sequelae.[en.wikipedia.org]
  • […] syndrome may include: Headaches Irritability Feelings of dizziness Restlessness Nausea Impulsivity and self-control problems Sensitivity to light Difficulties with concentration Sensitivity to noise Feeling depressed, tearful, anxious Sleep disturbance Fatigue[headway.org.uk]
  • 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[traumaticbraininjury.com]
  • Other symptoms of mild TBI include headache, confusion, lightheadedness, dizziness, blurred vision or tired eyes, ringing in the ears, bad taste in the mouth, fatigue or lethargy, a change in sleep patterns, behavioral or mood changes, and trouble with[ninds.nih.gov]
  • After an injury, a number of symptoms might be noted including headaches, dizziness/problems walking, fatigue, irritability, memory problems and problems paying attention.[polytrauma.va.gov]
Unconscious State
  • Severe head injury is usually defined as being a condition where the patient has been in an unconscious state for six hours or more, or a post-traumatic amnesia of 24 hours or more.[headway.org.uk]
Vomiting
  • Any vomiting episodes since the injury (clinical judgement should be used in those aged 12 years). Any seizure since the injury. Irritability or altered behaviour, particularly in infants and young children.[patient.info]
  • She developed watery rhinorrhea, progressive headache, fever, nausea, vomiting, and left proptosis with blurred vision, and was admitted to hospital 3 days after injury.[ncbi.nlm.nih.gov]
  • Those who presented with vomiting, triage level of 1 or 2, and GCS score of CONCLUSIONS: Discharging MHI patients who are older or exhibit comorbidities only when symptoms and concerns are relieved completely, providing clear discharge instructions, and[ncbi.nlm.nih.gov]
Ulcer
  • The complications include trauma, nasal septal abscess and inadvertent entry into the cranial cavity and trachea, ulceration, bleeding from varices and perforation.[ncbi.nlm.nih.gov]
Blurred Vision
  • She developed watery rhinorrhea, progressive headache, fever, nausea, vomiting, and left proptosis with blurred vision, and was admitted to hospital 3 days after injury.[ncbi.nlm.nih.gov]
  • vision and sensitivity to light slurred speech or saying things that don't make sense problems concentrating, thinking, or making decisions difficulty with coordination or balance (such as being unable to catch a ball or other easy tasks) feeling anxious[kidshealth.org]
  • Other symptoms of mild TBI include headache, confusion, lightheadedness, dizziness, blurred vision or tired eyes, ringing in the ears, bad taste in the mouth, fatigue or lethargy, a change in sleep patterns, behavioral or mood changes, and trouble with[ninds.nih.gov]
  • Loss of consciousness, confusion, headache, dizziness, and blurred vision are all symptoms that might be experienced.[bisociety.org]
Tinnitus
  • Vision is usually blurred with tinnitus of the ear due to cranial nerve damage. Chest and heart: Tachyarrhythmia may be caused by secondary subarachnoid bleeding due to traumatic brain injury.[symptoma.com]
  • Huffing American Tinnitus Assoc: Ringing in the ears - Information, resources and support. Vestibular Disorders Assoc: Dizziness or Vertigo - Information, resources, and support.[headinjury.com]
  • I suffer with intermittent bouts of depression, varying degrees of anxiety and paranoia, continuous headaches, with extreme light sensitivity, spontaneous loss of balance, motion sickness, and continuous severe tinnitus.[irlen.com]
Aggressive Behavior
  • Difficulty with concentration Short-term memory loss Interference with long-term memory Aggressive behavior Change in sexual interest Persistent talking (damage to right lobe) Difficulty locating objects in environment.[headinjury.com]
  • Aggressive Behaviors Provided a situation does not present a physical threat, various approaches may be used to diffuse hostile behavior: Remain as calm as you can; ignore the behavior.[caregiver.org]
Headache
  • BACKGROUND: Headache is the most frequent symptom following head injury, but long-term follow-up of headache after head injury entails methodological challenges.[ncbi.nlm.nih.gov]
  • The most common recognizable forms of posttraumatic headache in concussion are tension-type headache, cervicogenic headache, migraine, and combined tension-type headache and migraine.[doi.org]
  • Drowsiness, high-grade fever, severe headache, left ocular pain with marked periorbital swelling, and paralysis of extraocular eye movements developed.[ncbi.nlm.nih.gov]
  • They can include nausea, headaches, dizziness, impaired concentration, memory problems, extreme tiredness, intolerance to light and noise, and can lead to anxiety and depression.[headway.org.uk]
  • Individuals with a SSS   7 and headache or pressure in head, or SSS   7 but with a SAC   22 within 48-hours of an injury should undergo further testing.[ncbi.nlm.nih.gov]
Seizure
  • The child was admitted several times with breakthrough seizures. Over time the seizures became refractory to treatment.[ncbi.nlm.nih.gov]
  • Continuous amplitude-integrated EEG monitoring will be one of the useful methods in encephalopathic children in order to estimate seizure burden objectively and to treat seizures appropriately.[ncbi.nlm.nih.gov]
  • Our report highlights nonaccidental head injury as a risk factor for developing infantile spasms following a seizure-free latency period.[ncbi.nlm.nih.gov]
  • He was known to have seizure disorder and was being treated with sodium valproate. CTscan of the brain showed contusion. He was admitted for neurological observations and the patient made complete recovery with conservative treatment.[ncbi.nlm.nih.gov]
  • However, subsequent CT, taken following an episode of seizure, revealed right tentorial subarachnoid hemorrhage and falx hematoma. Conservative management was continued till he started developing recurrent seizures with a decrease in pGCS scores.[ncbi.nlm.nih.gov]
Confusion
  • More than half (56%) screened positive for mTBI, defined as at least one instance in which they experienced a change in consciousness or a period of being dazed and confused as a result of a head injury.[ncbi.nlm.nih.gov]
  • Seems weak or confused, or seems to have problems with coordination, vision, or verbal communication. Can a concussion cause permanent brain damage? Only in rare cases.[babycenter.com]
  • The effects of concussion can leave people with symptoms including dizziness, nausea, confusion or an inability to process or retain information, sensitivity to light, and vision distortion.[headway.org.uk]
  • The following are signs of a more serious injury: A constant headache, particularly one that gets worse Slurred speech or confusion Dizziness that does not go away or happens repeatedly Extreme irritability or other abnormal behavior Vomiting more than[healthychildren.org]
  • Symptoms may include clumsiness, fatigue, confusion, nausea, blurry vision, headaches, and others. Mild concussions are associated with sequelae.[en.wikipedia.org]
Dizziness
  • They can include nausea, headaches, dizziness, impaired concentration, memory problems, extreme tiredness, intolerance to light and noise, and can lead to anxiety and depression.[headway.org.uk]
  • OBJECTIVE: We hypothesised that chronic vestibular symptoms (CVS) of imbalance and dizziness post-traumatic head injury (THI) may relate to: (i) the occurrence of multiple simultaneous vestibular diagnoses including both peripheral and central vestibular[ncbi.nlm.nih.gov]
  • Symptoms can be wide-ranging, from physical effects such as balance problems, headaches and dizziness to cognitive, emotional and behavioural effects such as memory problems and anger.[headway.org.uk]
  • Role of greater occipital nerve blocks and trigger point injections for patients with dizziness and headache. Neurologist. 2011;17:312–7. Google Scholar Cantu RC.[doi.org]
Amnesia
  • Post-traumatic amnesia in a worker presenting with head trauma must be recognised by coworkers, so the cause of injury can be elicited early and the victim gets timely medical help.[ncbi.nlm.nih.gov]
  • Multivariate logistic regression analysis revealed that absence of retrograde amnesia (odds ratio [OR] 4.1, 95% confidence interval [CI] 1.8-9.7) was associated with noncompliance to the CCHR.[ncbi.nlm.nih.gov]
  • OBJECTIVES: It is not currently clear whether all anticoagulated patients with a head injury should receive CT scanning or only those with evidence of traumatic brain injury (eg, loss of consciousness or amnesia).[ncbi.nlm.nih.gov]
  • A moderate head injury is defined as loss of consciousness for between 15 minutes and six hours, or a period of post-traumatic amnesia of up to 24 hours.[headway.org.uk]
  • Patients with GCS 15 multivariable analysis (using imputation) found risk of adverse outcome to increase when reporting at least one associated symptom: vomiting (relative risk (RR) 1.8; 95% CI 1.0 to 3.4), amnesia (RR 3.5; 95% CI 2.1 to 5.7), headache[ncbi.nlm.nih.gov]

Workup

A comprehensive clinical history and a thorough physical and neurologic examination may be all that is needed to diagnose traumatic head injuries. The following laboratories and tests may be helpful in the diagnosis and management of the traumatic brain injuries:

  • Glasgow Coma Scale: A 15 point scale that determines the level of consciousness of patients with head injury
  • Intracranial monitoring device: Inserted in the skull to monitor the actual intracranial pressure
  • Imaging: Computerized tomography can easily visualize skull fractures, intracranial bleeding, brain contusions, brain swelling and hematoma formation. Magnetic resonance imaging can demonstrate a more detailed view of the brain structures.

Treatment

Mild traumatic head injury may not require any treatment. Patients are usually advised adequate rests and may be given pain relievers to treat symptoms of headache. However, patients sustaining severe head injuries with altered state of consciousness and unstable vital signs may need immediate emergency care.

Medical management with osmotic diuretics and anti-seizure drugs may be given to allay the symptoms of severe traumatic head injury. Medical decompression of the CSF using mannitol and vasopressors can maintain cerebral perfusion pressures to at least 70 mmHg ensuring undisrupted blood supply to important cortical structures [10].

Neurosurgical approaches to traumatic head injury include craniotomy and the removal of hematoma, primary repair of skull fractures, or burr hole craniotomy to relieve the pressure in the brain. Rehabilitation treatment with physiatrists, occupational therapists and neuropsychologists are an essential part of post-hospital and post-surgical care of patients.

Prognosis

In general, traumatic head injury prognosis worsens with the relative increase and extent of brain injury. Patients presenting at a Glasgow Coma Score (GCS) of 3 within the first 24 hours carries a 65% mortality rate [8]. The presence of subdural hematoma in patients with head injury varies inversely with the GCS score in terms of prognostic outcome and mortality rate [9]. The clinical condition of patients whether they are conscious and coherent or whether they are in a vegetative state may correlate closely with their prognosis.

Complications

Many complications can occur immediately or a few minutes after the traumatic head injury. The severity of the head injury increases the risk for permanent brain complications and more severe brain complications. The following complications are seen in patients suffering from traumatic head injuries:

Etiology

The following common events may result in traumatic brain injury among patients:

  • Falls: This is the most cause on traumatic head injury in young adults and older patients. This includes falling in a flight of stairs, falling from a ladder, and slipping in a bath. 
  • Vehicular accidents: This usually involves pedestrians colliding with motorcycling, bicycle, and automobiles. 
  • Armed conflict: Domestic violence like gunshot wounds to the head represents 20% of all traumatic head injuries. 
  • Sports injuries: Traumatic head injuries may be caused in certain sports like soccer, boxing, football, baseball, hockey and other high impact sports activities.
  • Explosive blast or combat injuries: This type of injuries affects those in active military service especially those who sustain a grenade shrapnel injury or a blast from an explosive charge that damages the brain cells. 

Epidemiology

In the United States, head injuries numbers to 1.5 million cases annually and three-fourths of which are classified as mild injuries. The relative incidence of head injuries in the Americas has reached 503 cases per 100,000 population with predominance among Native Americans. The incidence of elderly cases of traumatic injury deaths and hospitalizations in the United States has doubled that of the national average in 2003 [2].

In European countries, the rate of head injuries reaches a level of 91 cases per 100,000 cases annually. The exact incidence of traumatic injury may be hard to ascertain because patients who suffer brain dysfunctions with temporal amnesia will have difficulty in recalling the accounts of his head trauma in the emergency room [3].

The Center of Diseases and Control (CDC) has conveyed that more than 50,000 die each year due to traumatic head injuries and almost 100,000 incur permanent disability due to the said injury.

Afro-Americans races have an associated worse outcome of traumatic head injury compared to their white counterparts. There is a male preponderance for traumatic head injury in over two folds the risk compared to females worldwide. More than half of traumatic head injury worldwide is aged 24 years or younger.

Sex distribution
Age distribution

Pathophysiology

The pathophysiology of traumatic head injury is conveniently divided into three brain insults namely: Structural traumatic insults, neurochemical insults, and secondary or indirect insults.

The structural traumatic insult includes incidences associated with the structural deformity of the skull like depressed skull fractures or a displaced skull fragment causing direct damage to the brain matter. The degree and extent of skull deformity may vary directly with the significance of the skull injury. The bridging cerebral vessels may be torn during the trauma which causes a subdural hematoma which may disrupt other cortical vessels in the brain. Trivial brain injuries may cause significant subdural hemorrhages in elderly patients [4].

Neurochemical insults correlates with surge of neurochemicals like catecholamine and hyroxyindole acetic acid (HIAA) in the cerebrospinal fluid (CSF) causing toxic effects to the brain tissues [5]. The initial brain trauma facilitates free radical release breaking down the lipid membranes of the neurons causing intraneuronal calcium accumulation and eventual cell death. Microdialysis of the CSF revealing the presence of excitotoxic aminoacids like glutamate and aspartate correlates with poor prognosis in traumatic head injuries [6]. Hypoxia and hypotension accounts for the majority of secondary insults associated with traumatic head injuries. Severe traumatic injury which halts the breathing centers of the hypothalamus may result to significant long-term or permanent brain injuries if oxygenation is not ensured at the site of the trauma during the rescue and extrication process [7].

Prevention

The following helpful tips are most useful in the prevention of traumatic head injuries:

  • Ensure the wearing of seatbelts when driving and make sure emergency airbags are working properly.
  • Refrain from using alcohol or illegal drugs before driving. 
  • Protective helmets may save one’s life when driving motorcycles and bicycles.
  • Hand rails and nonslip mats may prevent accidents in the bathroom.
  • Clear stairways of clutter and unnecessary obstruction.
  • Install good lighting in the living quarters.
  • Place shock absorbing material in children’s playground.

Summary

Head injury or traumatic brain injury happens when any external mechanical force to the head directly causes a temporal or permanent brain dysfunction. Head injury may also occur after a violent blow or jolt to the head or body part causing a penetrating injury to the skull like a projectile or a bullet.

Cerebral artery vasospasm may ensue as an immediate hemodynamic complication of traumatic brain injury causing intracranial hypertension in almost half of patients [1]. Serious traumatic head injury can result to brain bruising, torn tissues, and bleeding that may result to long standing complications or even death.

Patient Information

Definition

Head injury happens when an external mechanical force jolts the head causing temporary or permanent brain dysfunction.

Cause

Falls, vehicular accidents, armed conflict, sports injury and blast injuries are common causes. 

Symptoms

Altered state of consciousness, difficulty in respiration and rigidity may occur.

Diagnosis

Clinical examination and imaging studies like CT scan and MRI.

Treatment and follow-up

Mild traumatic head injury may not require any treatment. Medical decompression of the CSF pressure and neurosurgical treatment options may be necessary in more severe cases.

References

Article

  1. Anderson P. Hemodynamic Complications Common in Traumatic Brain Injury. Accessed October 5, 2014.
  2. Rutland-Brown W, Langlois JA, Thomas KE, Xi YL. Incidence of traumatic brain injury in the United States, 2003. J Head Trauma Rehabil. Nov-Dec 2006; 21(6):544-8.
  3. Thurman D, Guerrero J. Trends in hospitalization associated with traumatic brain injury. JAMA. Sep 8 1999; 282(10):954-7.
  4. Matsuyama T, Shimomura T, Okumura Y, et al. Acute subdural hematomas due to rupture of cortical arteries: a study of the points of rupture in 19 cases. Surg Neurol. May 1997; 47(5):423-7.
  5. M, Seretis A, Kotsou S, et al. CSF neurotransmitter metabolites and short-term outcome of patients in coma after head injury. Acta Neurol Scand. Aug 1992; 86(2):190-3.
  6. Bullock R, Zauner A, Woodward JJ, et al. Factors affecting excitatory amino acid release following severe human head injury. J Neurosurg. Oct 1998; 89(4):507-18.
  7. Wang HE, Peitzman AB, Cassidy LD, et al. Out-of-hospital endotracheal intubation and outcome after traumatic brain injury. Ann Emerg Med. Nov 2004; 44(5):439-50.
  8. Chestnut R., Ghajar J., Maas A., Marion D, Servadei F., EARLY INDICATORS OF PROGNOSIS 
  9. In Severe Traumatic Brain Injury.
  10. Reale F, Delfini R, Mencattini G: Epidural hematomas. J Neurosurg Sci 28:9-16, 1984
  11. Rosner MJ, Rosner SD, Johnson AH. Cerebral perfusion pressure: management protocol and clinical results.J Neurosurg. Dec 1995; 83(6):949-62.

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Last updated: 2019-07-11 22:27